Shadow Health Tina Jones Health History

Health History Results | Turned In Health Assessment Laboratory - Fall 2019, NUR 305L Return to Assignment Your Results LLaabb PPaassss Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports pain Reports foot wound History of Presenting Illness Asked to rate current pain level on a scale Reports current pain is 7/10 Asked for details about the pain Reports pain is throbbing Reports pain is sharp when she attempts to stand Reports pain has increased in the past 2 days Reports feeling pain radiating into ankle Subjective Data Collection: 52 of 88 (59.1%) Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Self-Reflection Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Reports pain prevents bearing weight on foot Asked location of wound Reports right foot is injured Reports wound is on the plantar surface of her foot Asked details of the injury Reports she scraped foot on bottom rung of a step stool Reports injury occurred 1 week ago Denies other injuries besides foot wound Reports being barefoot at the time of injury Denies seeing a healthcare provider for the injury until now Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the injury Reports seeing pus draining from wound Reports noticing pus 2 days ago Followed up on drainage Reports pus as white or yellow Denies odor from the wound Asked about home treatment of foot wound Reports wound care regimen of bandaging Reports cleaning wound twice a day Reports applying bacitracin, neomycin and polymyxin B (Neosporin) Followed up on effectiveness of ointment Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective Asked about other foot wound symptoms Reports swelling around foot wound Reports swelling worsened in the past 2 days Reports redness around the wound Reports that the wound feels warm Explored impact of patient's foot injury on activities of daily living Reports pain affects ability to walk Reports pain affects ability to stand at work for long periods of time Reports pain prevented her from being able to walk to class Past Medical Histor