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Focused Exam: End of Life Results | Turned In
Medical Surgical Nursing: Promoting Wellness in the Older Adult (Los Angeles) - April 2019, NURS 201
Return to Assignment
Your Results Lab Pass
m
er as
Overview
Subjective Data Collection: 52 of 52 (100.0%)
co
Transcript
eH w
Subjective Data Collection Hover To Reveal...
o.
Indicates an item that you found.
Objective Data Collection
rs e Hover over the Patient Data items
below to reveal important information,
Indicates an item that is available to be
found.
ou urc
including Pro Tips and Example
Education & Empathy
Questions.
QSEN Competencies
o
Documentation Category Scored Items Patient Data
aC s
Not Scored
vi y re
SBAR
Experts selected these topics as essential A combination of open and closed questions
Reflections
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
ed d
Chief Complaint
ar stu
Established chief complaint Reports pain
is
Orientation
Th
Established orientation Oriented to person
Oriented to place
sh
Oriented to time
Oriented to situation
Patient Comfort and Status
Asked about fluid intake and hydration Denies current thirst
Reports very little water intake in the past
week
This study source was downloaded by 100000816649994 from CourseHero.com on 04-15-2021 00:17:02 GMT -05:00
https://www.coursehero.com/file/41419828/End-of-Life-Subjective-Datapdf/
, Reports a few sips of ginger ale today
Asked about urinary comfort Reports last urination was around 10 AM
Denies pain or burning with urination
Asked about most recent meal Denies current hunger
Reports no food intake today
Last meal was a few bites of yogurt last
night
Asked about preferences for hospice Reports wanting to be in hospice care
care
Asked about advanced directives Reports having an advanced directive
m
er as
History of Present Illness
co
eH w
Asked about onset and duration of pain Pain became unbearable 2 days ago
Reports pain increasing over the past 2
o.
days
rs e Reports experiencing some pain most of
ou urc
the time
Asked about location of pain Reports bone pain
o
Reports pain in legs
aC s
Reports pain in ribs
vi y re
Asked about characteristics of pain Describes pain as sharp
ed d
Asked about aggravating factors of pain Reports that pain is constant - no periods
ar stu
of relief or worsening
Asked about treatment and relieving Reports that nothing relieves her current
is
factors of pain pain
Reports prescription pain pill
Th
Asked about severity of pain Reports current pain is a 4/10
Reports pain before medication was a 9/10
sh
Past Medical History
Asked about existing health conditions Reports stage IV breast cancer with liver
metastasis
Reports hypertension diagnosis
This study source was downloaded by 100000816649994 from CourseHero.com on 04-15-2021 00:17:02 GMT -05:00
https://www.coursehero.com/file/41419828/End-of-Life-Subjective-Datapdf/
disabled. Thank you for helping us to improve your Shadow Health experience!
Focused Exam: End of Life Results | Turned In
Medical Surgical Nursing: Promoting Wellness in the Older Adult (Los Angeles) - April 2019, NURS 201
Return to Assignment
Your Results Lab Pass
m
er as
Overview
Subjective Data Collection: 52 of 52 (100.0%)
co
Transcript
eH w
Subjective Data Collection Hover To Reveal...
o.
Indicates an item that you found.
Objective Data Collection
rs e Hover over the Patient Data items
below to reveal important information,
Indicates an item that is available to be
found.
ou urc
including Pro Tips and Example
Education & Empathy
Questions.
QSEN Competencies
o
Documentation Category Scored Items Patient Data
aC s
Not Scored
vi y re
SBAR
Experts selected these topics as essential A combination of open and closed questions
Reflections
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
ed d
Chief Complaint
ar stu
Established chief complaint Reports pain
is
Orientation
Th
Established orientation Oriented to person
Oriented to place
sh
Oriented to time
Oriented to situation
Patient Comfort and Status
Asked about fluid intake and hydration Denies current thirst
Reports very little water intake in the past
week
This study source was downloaded by 100000816649994 from CourseHero.com on 04-15-2021 00:17:02 GMT -05:00
https://www.coursehero.com/file/41419828/End-of-Life-Subjective-Datapdf/
, Reports a few sips of ginger ale today
Asked about urinary comfort Reports last urination was around 10 AM
Denies pain or burning with urination
Asked about most recent meal Denies current hunger
Reports no food intake today
Last meal was a few bites of yogurt last
night
Asked about preferences for hospice Reports wanting to be in hospice care
care
Asked about advanced directives Reports having an advanced directive
m
er as
History of Present Illness
co
eH w
Asked about onset and duration of pain Pain became unbearable 2 days ago
Reports pain increasing over the past 2
o.
days
rs e Reports experiencing some pain most of
ou urc
the time
Asked about location of pain Reports bone pain
o
Reports pain in legs
aC s
Reports pain in ribs
vi y re
Asked about characteristics of pain Describes pain as sharp
ed d
Asked about aggravating factors of pain Reports that pain is constant - no periods
ar stu
of relief or worsening
Asked about treatment and relieving Reports that nothing relieves her current
is
factors of pain pain
Reports prescription pain pill
Th
Asked about severity of pain Reports current pain is a 4/10
Reports pain before medication was a 9/10
sh
Past Medical History
Asked about existing health conditions Reports stage IV breast cancer with liver
metastasis
Reports hypertension diagnosis
This study source was downloaded by 100000816649994 from CourseHero.com on 04-15-2021 00:17:02 GMT -05:00
https://www.coursehero.com/file/41419828/End-of-Life-Subjective-Datapdf/
