Basic Patient Case Results John Larsen ShadowHealth Patient Assessment

Finding: Asked for patient identification (Found) Pro Tip: Proper identification is critical for the protection of your patient. It is recommended to check two identifiers before interacting with the patient. Example Question: Can you confirm your name? Finding: Checked vitals before giving medication (Found) Pro Tip: Assessing the patient's vitals may impact your care plan and the safe administration of ordered medications. Example Question: Finding: Asked current breathing status (Available) Pro Tip: Difficulty breathing is one of the adverse effects of enoxaparin, a medication the patient received prior to this assessment. Example Question: How is your breathing? Finding: Asked about medication allergies (Found) Pro Tip: Patients may have allergies that are not included in their documentation, so asking for verbal confirmation can prevent serious adverse events. Example Question: Do you have any allergies to medications? Finding: Asked about current pain (Found) Pro Tip: This patient has been ordered pain medication. Assessing for pain is vital to determining the efficacy of prior treatment and the need for further analgesic intervention. Example Question: Are you having pain right now? Finding: Ask about allergic reaction to codeine (Available) Pro Tip: Assessing the reaction type and severity of a stated allergy may help inform your care plan and determine which medications are appropriate to administer. Example Question: What is your reaction to codeine? Finding: Asked about general experience with side effects (Available) Pro Tip: When administering routine medications, understanding the side effects that the patient generally experiences can shape your care plan to ensure patient safety and comfort. Example Question: Have you experienced medication side effects before? Finding: Asked about thirst (Available) Pro Tip: Thirst can be an important indicator of the patient's general comfort and recent intake. Excessive thirst may be an indicator of dehydration, which is a symptom of rhabdomyolysis, a potentially life-threatening adverse effect associated with atorvastatin. Example Question: Are you thirsty? Finding: Checked intake and output before giving medication (Found)