Shadow Health - Tina Jones, Health History
1. Acute pain - ANS -Priority: High Priority Pro Tip: Managing acute pain is an immediate high priority, because other
health concerns cannot be effectively addressed while a patient experiences severe pain. Evidence - Relevant: "...Like a
7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit." "It's throbbing and like, sharp if I try to put
weight on it." Evidence Pro Tip: Tina expresses pain, which is the strongest evidence for this problem. She reports intense
pain on a numerical scale and describes pain characteristics. The presence of a physical injury supports her susceptibility
to acute pain. Planning - Relevant: Assess - Pain: Assess the patient's pain at regular intervals and with each assessment
of vital signs. Assess - Pain: Assess the patient's response to pain medication. Educate - Medication: Educate the patient
on medications used for pain relief. Educate - Pain: Educate the patient on non-pharmaceutical methods to reduce pain
intensity. Intervene - Pain: Administer non-pharmacologic interventions to reduce pain. Intervene - Pain: Administer
prescribed analgesics to provide optimal pain relief. Planning Pro Tip: To reduce the patient's pain, assess her current
rating. Provide an appropriate intervention (pharmaceutical or otherwise) and educate the patient. After an appropriate
time interval, assess pain levels again to see how the intervention affected the pain.
\1.Expression of pain Followed Up - ANS -Description: Tina expresses frustration about her level of pain. Student: How
effective was the Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job. Student: Can you walk with your
foot being injured? Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain. Student: What
preexisting medical conditions do you have? Tina Jones: I mean, I have asthma and diabetes, but right I now I just care
about my foot! Student: I understand your foot hurts, but I need to know this information to make sure I take care of the
problem correctly. Tina Jones: Thanks. Model Statement: "I'm sorry to hear that your pain is returning. We want you to be
in as little pain as possible. I can give you some Advil at this time, and in a few hours, you can have more tramadol. I can
also walk through some pain management exercises with you that don't involve medication, if you are interested."
\2. Impaired skin integrity - ANS -Priority: High Priority Pro Tip: This is a high priority. The infection is the most immediate
threat to the patient's health, and the wound is at risk for delayed healing because of the patient's uncontrolled blood
glucose. Evidence - Relevant: Evidence Pro Tip: As Tina discusses symptoms of her wound, including symptoms such as
discharge, redness, warmth, and swelling, she reports strong evidence of impaired skin integrity. Planning - Relevant:
Planning Pro Tip: Because wound infections impact the patient's overall health, it's important to assess perfusion,
,hydration, and swelling. Assess the status of the wound itself and ensure proper cleaning and dressing per the physician's
order. Prevent worsening infection by educating the patient about wound care and self-monitoring.
\2.Impact of injury on daily life Followed Up - ANS -Description: Tina brings up her pain and frustration at how being
unable to bear weight on her foot impacts her life. Student: What are stressors? Tina Jones: I feel really stressed out right
now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it
looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too. Student: We are going to take care of
everything as quickly as possible. Tina Jones: Thanks. Model Statement: "This sounds like a challenging time for you. I
understand your frustration at having your life interrupted by foot pain. Please let me know if there is anything I can help
you with, such as contacting your employer or asking a family member to bring your schoolwork. We'll do our best to get
you feeling better and, on your way, home as soon as possible."
\3. Impaired walking - ANS -Priority - High Priority Pro Tip: This is a high priority. The patient is unable to bear weight on
her affected leg, which prevents walking. This impacts her daily life and increases her risk for falls and deep-vein
thrombosis. Evidence - Relevant: "I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all
that going on." "I got this scrape on my foot a while ago, and it got really infected. It's killing me." "No, I can't. I can't put
any weight on it without like, shooting pain." Evidence Pro Tip: The strongest evidence of impaired walking is that Tina
directly reports she can't bear weight or walk on her affected foot. Other supporting data points are the presence of her
foot wound and her general reports of pain. Planning - Relevant: Assess - Musculoskeletal: Assess the patient's ability to
bear weight and gait. Assess - Musculoskeletal: Assess the patient's mobility. Consult / Refer: Consult with physical
therapist to develop a plan to improve the patient's mobility. Intervene - Mobility: Assist the patient as needed with mobility.
Intervene - Mobility: Provide assistive devices to facilitate mobility (crutches, therapeutic boot to minimize pressure on
plantar surface, wheelchair). Planning Pro Tip: Assess how well the patient can bear weight and walk. While the patient is
in your care, work with other healthcare professionals to keep the pain managed and improve the patient's mobility.
Provide assistance with activities such as toileting and ensure that the patient can access and use assistive devices.
\3.Gaps in health literacy around diabetic diet Not Encountered - ANS -Description: Tina describes controlling her diabetes
by avoiding "sweets." Model Statement: "Staying away from sugar is a great start. I can give you some more information
on what a balanced diet looks like for someone with diabetes. For example, many starchy foods break down into glucose
in the body, like pasta, and so you can eat those in moderation, too. Most people with diabetes feel better when they limit
all starches, eat protein, and take regular medication."
,\4. Ineffective diabetes management - ANS -Priority - High Priority Pro Tip: Poorly managed diabetes and uncontrolled
blood glucose complicate wound healing. As the underlying cause for delayed healing and infection, they must be
addressed. Evidence - Relevant: "No, I don't take anything for my diabetes anymore." "I guess I just got sick of feeling
sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now
that I'm just eating healthier than I did when I was taking the pills." "I have a monitor at home, but to be honest I don't
really use it that often." Evidence Pro Tip: Tina directly reports ineffective diabetes management when discussing her lack
of treatment. She expresses gaps in health literacy about the risk of ceasing prescribed medication and blood glucose
monitoring. Supporting evidence comes from her inability to incorporate meaningful dietary changes or increase her
exercise. Planning - Relevant: Assess - Health Literacy and Patterns: Assess the patient's knowledge related to diabetic
disease process, assess personal/social supports. Assess - Health Literacy and Patterns: Assess the patient's perceived
barriers to adherence to the prescribed regimen (cost, adverse effects, lack of knowledge). Assess - Health Literacy and
Patterns: Assess the patient's readiness for change/education. Educate - Disease Process: Educate the patient on
diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. Planning Pro Tip: To gain a deep
understanding of your patient's situation, determine her level of health literacy, her feelings and beliefs about the disease,
and the motivation behind her choices. Educate the patient about what risks are, and what good diabetes care looks like.
Most importantly, ask about her goals and changes she may be willing to make.
\4.Lack of treatment with diabetes medication Not Followed Up - ANS -Description: Tina reveals that she does not treat
her diabetes with medication. Student: Do you currently take medicine for your diabetes? Tina Jones: No, I don't take
anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? Tina Jones: I
guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check
my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Model Statement: "I
understand that it can be challenging to keep up with daily medication. But it's important to keep your blood sugar under
control to prevent long-term damage to your health, and medication can really help. I'd like to talk with you more about
getting back onto a prescription. We could start you at a low dose, which reduces the side effects."
\5. Lack of blood glucose monitoring Not Followed Up - ANS -Description: Tina reveals that she does not check her blood
sugar. Student: Do you monitor your blood glucose? Tina Jones: I have a monitor at home, but to be honest I don't really
use it that often. Model Statement: "I understand how it can feel like a frustrating chore to check your sugar every day. But
it is important to keeping your diabetes under control. When you monitor your sugar, it helps you understand what foods,
activities, and times of day contribute to you feeling your best. And keeping your sugar down will help your foot wound
, heal quickly, too. If you would like, I can help you find a monitor that is as painless as possible. I can also teach you more
about what the numbers mean."
\5. Risk for falls - ANS -Priority - High Priority Pro Tip: The patient's foot wound impairs her walking, which in turn
increases her risk for falls while she is an admitted patient. Her past history of injury also adds to this risk. Evidence -
Relevant: Evidence Pro Tip: The strongest evidence of Tina's fall risk is reports of being unable to bear weight or walk on
her foot. Other supporting evidence is her recent injury caused by falling. Planning - Relevant: Planning Pro Tip: Protect
your patient by taking all fall precautions, and educate your patient about how to be safe as she goes through her daily
activities at the hospital. Make sure that the patient feels comfortable asking for your assistance.
\6. Gaps in health literacy around asthma control Not Followed Up - ANS -Description: Tina describes increased inhaler
use and decreased effectiveness, indicating that her asthma is uncontrolled. Student: How many puffs do you take when
using your asthma inhaler? Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse
confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are some things that trigger your asthma? Tina
Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: What
allergies do you have? Tina Jones: I'm allergic to cats. Model Statement: "It sounds like your asthma is giving you some
problems, and you're not getting full relief from your inhaler. I would like to talk with you about changing your medication
and your regimen, to reduce your frequent breathing problems, so that you feel better day-to-day. Most patients find that
using a daily inhaler is an easy way to reduce your asthma symptoms even more."
\6. Risk for unstable blood glucose level - ANS -Priority - High Priority Pro Tip: Uncontrolled blood glucose levels delay or
prevent wound healing, and must be addressed to resolve the infection. Unstable blood glucose levels could increase the
patient's risk for falls. Evidence - Relevant: "Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent blood
glucose monitoring and a general lack of diabetes management, which increases her risk for fluctuating blood glucose
levels. Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are
significantly higher than her baseline. Planning - Relevant: Assess - Vitals: Assess the patient's blood glucose levels
according to orders. Educate - Disease Process: Educate the patient on the signs and symptoms of hyper- and
hypoglycemia. Intervene - Diet: Provide the patient a diet without concentrated sweets. Intervene - Hypoglycemia:
Administer insulin and/or oral hypoglycemics, per physician orders. Planning Pro Tip: First, gauge your patient's current
status by checking hydration, vital signs, and perfusion. Measure the patient's blood glucose and provide medication as
per the physician's orders. While the patient is in your care, ensure that their meals align with a low glycemic diet, and
educate the patient on monitoring her own health status.
1. Acute pain - ANS -Priority: High Priority Pro Tip: Managing acute pain is an immediate high priority, because other
health concerns cannot be effectively addressed while a patient experiences severe pain. Evidence - Relevant: "...Like a
7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit." "It's throbbing and like, sharp if I try to put
weight on it." Evidence Pro Tip: Tina expresses pain, which is the strongest evidence for this problem. She reports intense
pain on a numerical scale and describes pain characteristics. The presence of a physical injury supports her susceptibility
to acute pain. Planning - Relevant: Assess - Pain: Assess the patient's pain at regular intervals and with each assessment
of vital signs. Assess - Pain: Assess the patient's response to pain medication. Educate - Medication: Educate the patient
on medications used for pain relief. Educate - Pain: Educate the patient on non-pharmaceutical methods to reduce pain
intensity. Intervene - Pain: Administer non-pharmacologic interventions to reduce pain. Intervene - Pain: Administer
prescribed analgesics to provide optimal pain relief. Planning Pro Tip: To reduce the patient's pain, assess her current
rating. Provide an appropriate intervention (pharmaceutical or otherwise) and educate the patient. After an appropriate
time interval, assess pain levels again to see how the intervention affected the pain.
\1.Expression of pain Followed Up - ANS -Description: Tina expresses frustration about her level of pain. Student: How
effective was the Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job. Student: Can you walk with your
foot being injured? Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain. Student: What
preexisting medical conditions do you have? Tina Jones: I mean, I have asthma and diabetes, but right I now I just care
about my foot! Student: I understand your foot hurts, but I need to know this information to make sure I take care of the
problem correctly. Tina Jones: Thanks. Model Statement: "I'm sorry to hear that your pain is returning. We want you to be
in as little pain as possible. I can give you some Advil at this time, and in a few hours, you can have more tramadol. I can
also walk through some pain management exercises with you that don't involve medication, if you are interested."
\2. Impaired skin integrity - ANS -Priority: High Priority Pro Tip: This is a high priority. The infection is the most immediate
threat to the patient's health, and the wound is at risk for delayed healing because of the patient's uncontrolled blood
glucose. Evidence - Relevant: Evidence Pro Tip: As Tina discusses symptoms of her wound, including symptoms such as
discharge, redness, warmth, and swelling, she reports strong evidence of impaired skin integrity. Planning - Relevant:
Planning Pro Tip: Because wound infections impact the patient's overall health, it's important to assess perfusion,
,hydration, and swelling. Assess the status of the wound itself and ensure proper cleaning and dressing per the physician's
order. Prevent worsening infection by educating the patient about wound care and self-monitoring.
\2.Impact of injury on daily life Followed Up - ANS -Description: Tina brings up her pain and frustration at how being
unable to bear weight on her foot impacts her life. Student: What are stressors? Tina Jones: I feel really stressed out right
now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it
looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too. Student: We are going to take care of
everything as quickly as possible. Tina Jones: Thanks. Model Statement: "This sounds like a challenging time for you. I
understand your frustration at having your life interrupted by foot pain. Please let me know if there is anything I can help
you with, such as contacting your employer or asking a family member to bring your schoolwork. We'll do our best to get
you feeling better and, on your way, home as soon as possible."
\3. Impaired walking - ANS -Priority - High Priority Pro Tip: This is a high priority. The patient is unable to bear weight on
her affected leg, which prevents walking. This impacts her daily life and increases her risk for falls and deep-vein
thrombosis. Evidence - Relevant: "I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all
that going on." "I got this scrape on my foot a while ago, and it got really infected. It's killing me." "No, I can't. I can't put
any weight on it without like, shooting pain." Evidence Pro Tip: The strongest evidence of impaired walking is that Tina
directly reports she can't bear weight or walk on her affected foot. Other supporting data points are the presence of her
foot wound and her general reports of pain. Planning - Relevant: Assess - Musculoskeletal: Assess the patient's ability to
bear weight and gait. Assess - Musculoskeletal: Assess the patient's mobility. Consult / Refer: Consult with physical
therapist to develop a plan to improve the patient's mobility. Intervene - Mobility: Assist the patient as needed with mobility.
Intervene - Mobility: Provide assistive devices to facilitate mobility (crutches, therapeutic boot to minimize pressure on
plantar surface, wheelchair). Planning Pro Tip: Assess how well the patient can bear weight and walk. While the patient is
in your care, work with other healthcare professionals to keep the pain managed and improve the patient's mobility.
Provide assistance with activities such as toileting and ensure that the patient can access and use assistive devices.
\3.Gaps in health literacy around diabetic diet Not Encountered - ANS -Description: Tina describes controlling her diabetes
by avoiding "sweets." Model Statement: "Staying away from sugar is a great start. I can give you some more information
on what a balanced diet looks like for someone with diabetes. For example, many starchy foods break down into glucose
in the body, like pasta, and so you can eat those in moderation, too. Most people with diabetes feel better when they limit
all starches, eat protein, and take regular medication."
,\4. Ineffective diabetes management - ANS -Priority - High Priority Pro Tip: Poorly managed diabetes and uncontrolled
blood glucose complicate wound healing. As the underlying cause for delayed healing and infection, they must be
addressed. Evidence - Relevant: "No, I don't take anything for my diabetes anymore." "I guess I just got sick of feeling
sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now
that I'm just eating healthier than I did when I was taking the pills." "I have a monitor at home, but to be honest I don't
really use it that often." Evidence Pro Tip: Tina directly reports ineffective diabetes management when discussing her lack
of treatment. She expresses gaps in health literacy about the risk of ceasing prescribed medication and blood glucose
monitoring. Supporting evidence comes from her inability to incorporate meaningful dietary changes or increase her
exercise. Planning - Relevant: Assess - Health Literacy and Patterns: Assess the patient's knowledge related to diabetic
disease process, assess personal/social supports. Assess - Health Literacy and Patterns: Assess the patient's perceived
barriers to adherence to the prescribed regimen (cost, adverse effects, lack of knowledge). Assess - Health Literacy and
Patterns: Assess the patient's readiness for change/education. Educate - Disease Process: Educate the patient on
diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. Planning Pro Tip: To gain a deep
understanding of your patient's situation, determine her level of health literacy, her feelings and beliefs about the disease,
and the motivation behind her choices. Educate the patient about what risks are, and what good diabetes care looks like.
Most importantly, ask about her goals and changes she may be willing to make.
\4.Lack of treatment with diabetes medication Not Followed Up - ANS -Description: Tina reveals that she does not treat
her diabetes with medication. Student: Do you currently take medicine for your diabetes? Tina Jones: No, I don't take
anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? Tina Jones: I
guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check
my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Model Statement: "I
understand that it can be challenging to keep up with daily medication. But it's important to keep your blood sugar under
control to prevent long-term damage to your health, and medication can really help. I'd like to talk with you more about
getting back onto a prescription. We could start you at a low dose, which reduces the side effects."
\5. Lack of blood glucose monitoring Not Followed Up - ANS -Description: Tina reveals that she does not check her blood
sugar. Student: Do you monitor your blood glucose? Tina Jones: I have a monitor at home, but to be honest I don't really
use it that often. Model Statement: "I understand how it can feel like a frustrating chore to check your sugar every day. But
it is important to keeping your diabetes under control. When you monitor your sugar, it helps you understand what foods,
activities, and times of day contribute to you feeling your best. And keeping your sugar down will help your foot wound
, heal quickly, too. If you would like, I can help you find a monitor that is as painless as possible. I can also teach you more
about what the numbers mean."
\5. Risk for falls - ANS -Priority - High Priority Pro Tip: The patient's foot wound impairs her walking, which in turn
increases her risk for falls while she is an admitted patient. Her past history of injury also adds to this risk. Evidence -
Relevant: Evidence Pro Tip: The strongest evidence of Tina's fall risk is reports of being unable to bear weight or walk on
her foot. Other supporting evidence is her recent injury caused by falling. Planning - Relevant: Planning Pro Tip: Protect
your patient by taking all fall precautions, and educate your patient about how to be safe as she goes through her daily
activities at the hospital. Make sure that the patient feels comfortable asking for your assistance.
\6. Gaps in health literacy around asthma control Not Followed Up - ANS -Description: Tina describes increased inhaler
use and decreased effectiveness, indicating that her asthma is uncontrolled. Student: How many puffs do you take when
using your asthma inhaler? Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse
confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are some things that trigger your asthma? Tina
Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: What
allergies do you have? Tina Jones: I'm allergic to cats. Model Statement: "It sounds like your asthma is giving you some
problems, and you're not getting full relief from your inhaler. I would like to talk with you about changing your medication
and your regimen, to reduce your frequent breathing problems, so that you feel better day-to-day. Most patients find that
using a daily inhaler is an easy way to reduce your asthma symptoms even more."
\6. Risk for unstable blood glucose level - ANS -Priority - High Priority Pro Tip: Uncontrolled blood glucose levels delay or
prevent wound healing, and must be addressed to resolve the infection. Unstable blood glucose levels could increase the
patient's risk for falls. Evidence - Relevant: "Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent blood
glucose monitoring and a general lack of diabetes management, which increases her risk for fluctuating blood glucose
levels. Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are
significantly higher than her baseline. Planning - Relevant: Assess - Vitals: Assess the patient's blood glucose levels
according to orders. Educate - Disease Process: Educate the patient on the signs and symptoms of hyper- and
hypoglycemia. Intervene - Diet: Provide the patient a diet without concentrated sweets. Intervene - Hypoglycemia:
Administer insulin and/or oral hypoglycemics, per physician orders. Planning Pro Tip: First, gauge your patient's current
status by checking hydration, vital signs, and perfusion. Measure the patient's blood glucose and provide medication as
per the physician's orders. While the patient is in your care, ensure that their meals align with a low glycemic diet, and
educate the patient on monitoring her own health status.
