FOCUSED EXAM: END OF LIFE RESULTS | TURNED IN | WITH COMPLETE SOLUTIONS
Medical Surgical Nursing: Promoting Wellness in the Older Adult - August 2020, nurs201-la_nurs201_202008fai_vr4
Return to Assignment (/assignments/390495/)
Your Results Lab Pass (/assignment_attempts/7606025/lab_pass.p
Overview
Subjective Data Collection: 52 of 52 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy
below to reveal important available to be found.
QSEN Competencies information, including Pro Tips and
Example Questions.
Documentation
SBAR
Category Scored Items Patient Data
Reflections
Not Scored
Experts selected these topics as essential components A combination of open and closed questions will yie
of a strong, thorough interview with this patient. better patient data. The following details are facts o
patient's case.
Chief Complaint
Established chief complaint Reports pain
Orientation
Established orientation Oriented to person
Oriented to place
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
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 care Reports wanting to be in hospice care
Support
Asked about advanced directives Reports having an advanced directive
, History of Present Illness
Asked about onset and duration of pain Pain became unbearable 2 days ago
Reports pain increasing over the past 2 days
Reports experiencing some pain most of the time
Asked about location of pain Reports bone pain
Reports pain in legs
Reports pain in ribs
Asked about characteristics of pain Describes pain as sharp
Asked about aggravating factors of pain Reports that pain is constant - no periods of relie
or worsening
Asked about treatment and relieving factors of Reports that nothing relieves her current pain
pain Reports prescription pain pill
Asked about severity of pain Reports current pain is a 4/10
Reports pain before medication was a 9/10
Past Medical History
Asked about existing health conditions Reports stage IV breast cancer with liver
metastasis
Reports hypertension diagnosis
Asked about allergies Denies general allergies
Denies latex allergy
Asked specifically about medication allergies Reports allergy to penicillin
Followed up about penicillin allergy Reports last taken in childhood
Reports reaction was a rash
Home Medications
Asked about home medications Reports taking long-acting morphine
Reports taking immediate release morphine
Denies taking vitamins
Denies taking herbal supplements
Followed up on long-acting morphine Reports morphine dosage: 60 mg
Reports morphine frequency: every 12 hours
Reports morphine is typically effective at
reducing overall pain level
Followed up on immediate release morphine Reports morphine dosage: 20 mg
Reports morphine frequency: as needed
Medical Surgical Nursing: Promoting Wellness in the Older Adult - August 2020, nurs201-la_nurs201_202008fai_vr4
Return to Assignment (/assignments/390495/)
Your Results Lab Pass (/assignment_attempts/7606025/lab_pass.p
Overview
Subjective Data Collection: 52 of 52 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy
below to reveal important available to be found.
QSEN Competencies information, including Pro Tips and
Example Questions.
Documentation
SBAR
Category Scored Items Patient Data
Reflections
Not Scored
Experts selected these topics as essential components A combination of open and closed questions will yie
of a strong, thorough interview with this patient. better patient data. The following details are facts o
patient's case.
Chief Complaint
Established chief complaint Reports pain
Orientation
Established orientation Oriented to person
Oriented to place
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
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 care Reports wanting to be in hospice care
Support
Asked about advanced directives Reports having an advanced directive
, History of Present Illness
Asked about onset and duration of pain Pain became unbearable 2 days ago
Reports pain increasing over the past 2 days
Reports experiencing some pain most of the time
Asked about location of pain Reports bone pain
Reports pain in legs
Reports pain in ribs
Asked about characteristics of pain Describes pain as sharp
Asked about aggravating factors of pain Reports that pain is constant - no periods of relie
or worsening
Asked about treatment and relieving factors of Reports that nothing relieves her current pain
pain Reports prescription pain pill
Asked about severity of pain Reports current pain is a 4/10
Reports pain before medication was a 9/10
Past Medical History
Asked about existing health conditions Reports stage IV breast cancer with liver
metastasis
Reports hypertension diagnosis
Asked about allergies Denies general allergies
Denies latex allergy
Asked specifically about medication allergies Reports allergy to penicillin
Followed up about penicillin allergy Reports last taken in childhood
Reports reaction was a rash
Home Medications
Asked about home medications Reports taking long-acting morphine
Reports taking immediate release morphine
Denies taking vitamins
Denies taking herbal supplements
Followed up on long-acting morphine Reports morphine dosage: 60 mg
Reports morphine frequency: every 12 hours
Reports morphine is typically effective at
reducing overall pain level
Followed up on immediate release morphine Reports morphine dosage: 20 mg
Reports morphine frequency: as needed
