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Gerontologic Nursing - NRSE 4560 - Summer 2020, NRSE_4560_SEM_SUM1_2019-20
Return to Assignment (/assignments/322167/)
Your Results Reopen (/assignment_attempts/6872134/reopen)
Lab Pass (/assignment_attempts/6872134/lab_pass.pdf)
Overview
Transcript
Transcript
Started: May 14, 2020 | Total Time: 120 min
Subjective Data Collection
All Lines (250) Interview Questions (180) Statements (17) Exam Actions (53)
Objective Data Collection
Education & Empathy Greet
Hi my name is Crystal I will be your nurse today. Can you tell me your name and date of birth
05/14/20 3:52 PM EDT
QSEN Competencies
Documentation Hello, hello.
SBAR
Question
Reflections can you tell me your name
05/14/20 3:53 PM EDT
Student Survey
Robert Hall
Question
Can you tell me your date of birth Mr. Hall
05/14/20 3:53 PM EDT
That would be December 28th . . . [Mr. Hall reports correct birth year.]
Question
Thank you. Can you tell me why you are here Mr. Hall
05/14/20 3:53 PM EDT
Well, long story short, I fell this morning. Right when I got out of my car I was hit with this wave
of dizziness. The whole garage started spinning around me and next thing I knew, I was hitting
the ground. Luckily my daughter found me after a while. On top of that is this wild pain that
started in my leg. I don't know if the two are connected but it's been swelling up and hurting
bad.
Question
Can you tell me what time it was you fell? (Clarified to Can you tell me how you fell?.)
05/14/20 3:54 PM EDT
It was this morning, around about nine when I was getting out of my car. When I stood up,
everything started spinning around and down I went. I didn't bump anything too bad on the way
down, but I couldn't get back up, so I had to wait there till my daughter found me lying there.
(Clarified to how I fell.)
Question
Do you know how long you laid there? (No matching questions found.)
05/14/20 3:55 PM EDT
Can you tell me when your daughter found you (Clarified to How long after your fall were you Question
found by your daughter?.) 05/14/20 3:55 PM EDT
,I was laying there in my garage for a quite a while, but my daughter found me after a few hours
and helped me up. We came right to the ER afterwards. (Clarified to how long after my fall I
was found by my daughter.)
Question
have you been having any pain prior to the fall
05/14/20 3:56 PM EDT
It doesn't hurt too bad right now. The meds they gave me in the ER helped with that.
Question
can you describe the pain
05/14/20 3:56 PM EDT
It's like a sharp, nagging feeling. Kind of like someone's been jabbing my leg over and over
again.
Question
can you tell me where the pain is
05/14/20 3:56 PM EDT
In my lower left leg, around the calf. It was getting hard to bear... I was thinking of coming here
even before I fell this morning.
Question
Any stingy or burning (No matching questions found.)
05/14/20 3:56 PM EDT
Question
have you notice any burning sensation in leg (Clarified to Have you had burning sensations?.)
05/14/20 3:57 PM EDT
No, but my leg does seem a bit warmer than usual. (Clarified to if I have had burning
sensations.)
Question
Does anything make the pain worse
05/14/20 3:57 PM EDT
Even if I do nothing, it gets more painful but I definitely can't walk on it without a whole lot of
pain.
Question
What treatments have you tried to help with pain
05/14/20 3:58 PM EDT
Well, I tried resting the leg and taking some Advil but nothing seemed to work. It just kept on
hurting.
Question
Have you tried heat or ice? (Clarified to Have you tried a heating pad for the pain?.)
05/14/20 3:58 PM EDT
I usually use a heating pad for my arthritis pain, but it didn't seem like it would do any good
earlier today, so my daughter just brought me straight here. (Clarified to if I have tried a heating
pad for the pain.)
Question
Did you use any ice?
05/14/20 3:58 PM EDT
No, I didn't think of it at the time.
Can you rate your pain now on a scale 0-10? (Clarified to Can you rate your current pain level Question
on a scale of 0 to 10?.) 05/14/20 3:58 PM EDT
Right now, I'd call the pain a 2. I know it's there, but it feels much milder than it did. (Clarified to
how I would rate my pain on a scale.)
Empathize
I am sorry you are uncomfortable. Lets see what I can do to make you feel better
05/14/20 4:00 PM EDT
, Much appreciated.
Question
Do you have any existing health condition's?
05/14/20 4:00 PM EDT
A few, but nothing too exciting: just some osteoarthritis, high blood pressure, and an enlarged
prostate.
how old were you when diagnosed with high blood pressure (Clarified to How old were you Question
when you were diagnosed with hypertension?.) 05/14/20 4:01 PM EDT
Hmm, gotta think on that one... I was 57. (Clarified to how old I was when I was diagnosed with
hypertension.)
Question
Is your hypertension well controlled
05/14/20 4:01 PM EDT
Yes, I'd say it's OK. I usually just get it checked every few months when I go to my doctor.
Question
What does your blood pressure usually run
05/14/20 4:01 PM EDT
Oh, you got me on that one... I'm not sure, but I do know that the first number hasn't ever been
higher than 140.
Question
Do you check it at home (No matching questions found.)
05/14/20 4:02 PM EDT
Question
Do you check your blood pressure at home
05/14/20 4:02 PM EDT
I don't really check it at home, but a month ago at my doctor's appointment, it was just fine.
Question
Do you check your blood pressure before taking your medication
05/14/20 4:02 PM EDT
Eh, no, I don't.
Question
Is it ok for me to take your vitals?
05/14/20 4:03 PM EDT
Please go ahead.
Exam Action
Assessed vitals
05/14/20 4:03 PM EDT
Educate
Your blood pressure looks good
05/14/20 4:04 PM EDT
Thanks a lot for the tip.
Exam Action
Assessed blood pressure after lying for 5 minutes
05/14/20 4:04 PM EDT
Exam Action
Assessed blood pressure after standing for 1 minute
05/14/20 4:05 PM EDT
We are going to take a three sets of vitals. First, after 5 minutes of lying down, then standing Educate
after 1 and 3 minutes 05/14/20 4:06 PM EDT
Gerontologic Nursing - NRSE 4560 - Summer 2020, NRSE_4560_SEM_SUM1_2019-20
Return to Assignment (/assignments/322167/)
Your Results Reopen (/assignment_attempts/6872134/reopen)
Lab Pass (/assignment_attempts/6872134/lab_pass.pdf)
Overview
Transcript
Transcript
Started: May 14, 2020 | Total Time: 120 min
Subjective Data Collection
All Lines (250) Interview Questions (180) Statements (17) Exam Actions (53)
Objective Data Collection
Education & Empathy Greet
Hi my name is Crystal I will be your nurse today. Can you tell me your name and date of birth
05/14/20 3:52 PM EDT
QSEN Competencies
Documentation Hello, hello.
SBAR
Question
Reflections can you tell me your name
05/14/20 3:53 PM EDT
Student Survey
Robert Hall
Question
Can you tell me your date of birth Mr. Hall
05/14/20 3:53 PM EDT
That would be December 28th . . . [Mr. Hall reports correct birth year.]
Question
Thank you. Can you tell me why you are here Mr. Hall
05/14/20 3:53 PM EDT
Well, long story short, I fell this morning. Right when I got out of my car I was hit with this wave
of dizziness. The whole garage started spinning around me and next thing I knew, I was hitting
the ground. Luckily my daughter found me after a while. On top of that is this wild pain that
started in my leg. I don't know if the two are connected but it's been swelling up and hurting
bad.
Question
Can you tell me what time it was you fell? (Clarified to Can you tell me how you fell?.)
05/14/20 3:54 PM EDT
It was this morning, around about nine when I was getting out of my car. When I stood up,
everything started spinning around and down I went. I didn't bump anything too bad on the way
down, but I couldn't get back up, so I had to wait there till my daughter found me lying there.
(Clarified to how I fell.)
Question
Do you know how long you laid there? (No matching questions found.)
05/14/20 3:55 PM EDT
Can you tell me when your daughter found you (Clarified to How long after your fall were you Question
found by your daughter?.) 05/14/20 3:55 PM EDT
,I was laying there in my garage for a quite a while, but my daughter found me after a few hours
and helped me up. We came right to the ER afterwards. (Clarified to how long after my fall I
was found by my daughter.)
Question
have you been having any pain prior to the fall
05/14/20 3:56 PM EDT
It doesn't hurt too bad right now. The meds they gave me in the ER helped with that.
Question
can you describe the pain
05/14/20 3:56 PM EDT
It's like a sharp, nagging feeling. Kind of like someone's been jabbing my leg over and over
again.
Question
can you tell me where the pain is
05/14/20 3:56 PM EDT
In my lower left leg, around the calf. It was getting hard to bear... I was thinking of coming here
even before I fell this morning.
Question
Any stingy or burning (No matching questions found.)
05/14/20 3:56 PM EDT
Question
have you notice any burning sensation in leg (Clarified to Have you had burning sensations?.)
05/14/20 3:57 PM EDT
No, but my leg does seem a bit warmer than usual. (Clarified to if I have had burning
sensations.)
Question
Does anything make the pain worse
05/14/20 3:57 PM EDT
Even if I do nothing, it gets more painful but I definitely can't walk on it without a whole lot of
pain.
Question
What treatments have you tried to help with pain
05/14/20 3:58 PM EDT
Well, I tried resting the leg and taking some Advil but nothing seemed to work. It just kept on
hurting.
Question
Have you tried heat or ice? (Clarified to Have you tried a heating pad for the pain?.)
05/14/20 3:58 PM EDT
I usually use a heating pad for my arthritis pain, but it didn't seem like it would do any good
earlier today, so my daughter just brought me straight here. (Clarified to if I have tried a heating
pad for the pain.)
Question
Did you use any ice?
05/14/20 3:58 PM EDT
No, I didn't think of it at the time.
Can you rate your pain now on a scale 0-10? (Clarified to Can you rate your current pain level Question
on a scale of 0 to 10?.) 05/14/20 3:58 PM EDT
Right now, I'd call the pain a 2. I know it's there, but it feels much milder than it did. (Clarified to
how I would rate my pain on a scale.)
Empathize
I am sorry you are uncomfortable. Lets see what I can do to make you feel better
05/14/20 4:00 PM EDT
, Much appreciated.
Question
Do you have any existing health condition's?
05/14/20 4:00 PM EDT
A few, but nothing too exciting: just some osteoarthritis, high blood pressure, and an enlarged
prostate.
how old were you when diagnosed with high blood pressure (Clarified to How old were you Question
when you were diagnosed with hypertension?.) 05/14/20 4:01 PM EDT
Hmm, gotta think on that one... I was 57. (Clarified to how old I was when I was diagnosed with
hypertension.)
Question
Is your hypertension well controlled
05/14/20 4:01 PM EDT
Yes, I'd say it's OK. I usually just get it checked every few months when I go to my doctor.
Question
What does your blood pressure usually run
05/14/20 4:01 PM EDT
Oh, you got me on that one... I'm not sure, but I do know that the first number hasn't ever been
higher than 140.
Question
Do you check it at home (No matching questions found.)
05/14/20 4:02 PM EDT
Question
Do you check your blood pressure at home
05/14/20 4:02 PM EDT
I don't really check it at home, but a month ago at my doctor's appointment, it was just fine.
Question
Do you check your blood pressure before taking your medication
05/14/20 4:02 PM EDT
Eh, no, I don't.
Question
Is it ok for me to take your vitals?
05/14/20 4:03 PM EDT
Please go ahead.
Exam Action
Assessed vitals
05/14/20 4:03 PM EDT
Educate
Your blood pressure looks good
05/14/20 4:04 PM EDT
Thanks a lot for the tip.
Exam Action
Assessed blood pressure after lying for 5 minutes
05/14/20 4:04 PM EDT
Exam Action
Assessed blood pressure after standing for 1 minute
05/14/20 4:05 PM EDT
We are going to take a three sets of vitals. First, after 5 minutes of lying down, then standing Educate
after 1 and 3 minutes 05/14/20 4:06 PM EDT
