Shadow Health - Tina Jones, Health History
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Terms in this set (351)
Subjective Data Collection - Checklist:
Chief Complaint
Finding: Established chief complaint
Finding: Reports pain (Found)Pro Tip: Initially
Example Question: Do establishing a chief complaint allows the patient to
you have any pain? express their reason for seeking care, primary
concerns, or condition they are presenting with.
Finding: Reports foot wound (Found)Pro Tip: If a
Example Question: What's
patient mentions pain, it's important to determine
causing your pain?
what specifically is causing her pain, if she knows.
History of Presenting Illness
Finding: Asked to rate current pain level on a scale
Finding: Reports current pain is 7/10 (Found)Pro Tip:
Example Question: Can
Asking your patient to rate her pain on a scale of 0 to
you rate the pain on a
10 is important to gauge how it ebbs and flows while
scale of 0 to 10?
she is in your care.
Finding: Asked for details about the pain
Finding: Reports pain is throbbing (Found)Pro Tip:
Example Question: Can
Determining how your patient describes the
you please describe the
characteristics of the pain can be important data to
pain?
support the cause of the pain.
, Finding: Reports pain is sharp when she attempts to
stand (Found)Pro Tip: Determining what physical
Example Question: What is
activities and movements exacerbate the patient's
the pain like when you
pain can help you better understand the problems
stand on your foot?
and assess treatment needs. This can also alert you if a
patient's activities of daily living are hindered.
Finding: Reports pain has increased in the past 2 days
Example Question: How
(Available)Pro Tip:Finding out how the patient's pain
has the pain changed over
has changed will give you insight into the acceleration
time?
of infection.
Finding: Reports feeling pain radiating into ankle
Example Question: Does
(Available)Pro Tip: Asking about where else the
the pain radiate anywhere
patient's pain radiates can help determine the
else?
progression of infection.
Finding: Reports pain prevents bearing weight on foot
Example Question: Can
(Found)Pro Tip: Determining if your patient can bear
you bear weight on your
weight on an injury is important to determine their risk
foot?
for falls while in your care.
Finding: Asked location of wound
Finding: Reports right foot is injured (Found)Pro Tip:
Example Question: Which
Confirming which extremity an injury is located is a
foot is in pain?
best practice for your patient's safety.
Finding: Reports wound is on the plantar surface of
Example Question: Where her foot (Found)Pro Tip: Confirming where a wound is
is the wound? located ensures you are aware of your patient's
biggest complaint.
Finding: Asked details of the injury
Finding: Reports she scraped foot on bottom rung of
Example Question: How a step stool (Found)Pro Tip: Discovering how an injury
did your injury happen? happened helps to assess your patient's risk factors
for injury.
, Finding: Reports injury occurred 1 week ago
Example Question: When (Available)Pro Tip: Discovering how long ago the pain
did your injury occur? began is the first step in understanding whether the
pain is chronic or acute.
Finding: Denies other injuries besides foot wound
Example Question: Did
(Available)Pro Tip: Discovering additional injuries can
you injure anything
reveal more information about the circumstances that
besides your foot?
caused the presenting injury.
Finding: Reports being barefoot at the time of injury
Example Question: Were (Available)Pro Tip: Asking about clothing, footwear,
you wearing shoes when and other protective elements being worn at the time
you fell? of injury helps you discover the totality of the
circumstances.
Finding: Denies seeing a healthcare provider for the
injury until now (Available)Pro Tip: It's crucial to ask
Example Question: Have
whether your patient has seen another provider for
you seen a healthcare
the injury, because any previous medical intervention
provider for this injury?
will help you understand the progression of the
wound.
Finding: Asked about drainage from the foot wound
Finding: Reports that the wound bled a little after
Example Question: Did sustaining the injury (Available)Pro Tip: Asking about
your foot bleed? bleeding helps you determine the characteristics of a
wound.
Example Question: Did Finding: Reports seeing pus draining from wound
you notice any discharge (Found)Pro Tip: Asking about discharge helps you
from the wound? determine the characteristics of a wound.
Finding: Reports noticing pus 2 days ago
Example Question: When (Available)Pro Tip: Pinpointing exactly when the
did you first notice the patient noticed the arrival of pus gives you an
pus? important data point for when an active infection
began.
Finding: Followed up on drainage
, Example Question: What Finding: Reports pus as white or yellow (Found)Pro
color is the drainage from Tip: The color of discharge from a wound can provide
your wound? insight into its severity and characteristics.
Finding: Denies odor from the wound (Available)Pro
Example Question: Does
Tip: The odor of discharge from a wound can provide
the wound have an odor?
insight into its severity and characteristics.
Finding: Asked about home treatment of foot wound
Finding: Reports wound care regimen of bandaging
Example Question: How (Available)Pro Tip: Asking specifically how often a
often do you change your patient changed a bandage will let you know if an
bandage? infection spread through improper hygiene, or for
other reasons such as uncontrolled blood sugar.
Finding: Reports cleaning wound twice a day
Example Question: How (Available)Pro Tip: Asking specifically how often a
often did you clean the patient cleaned a wound will let you know if an
wound? infection spread through improper hygiene, or for
other reasons such as uncontrolled blood sugar.
Finding: Reports applying bacitracin, neomycin and
Example Question: Did polymyxin B (Neosporin) (Found)Pro Tip: Determining
you use any ointment on what products a patient used to sterilize or treat a
the wound? wound establishes home care routines and health
literacy.
Finding: Followed up on effectiveness of ointment
Finding: Reports bacitracin, neomycin and polymyxin
B (Neosporin) was ineffective (Found)Pro Tip:
Understanding the effect of a home medication can
Example Question: Did the
help you determine the severity of the wound. Tina's
ointment help?
diabetes diagnosis will have a large impact on her
body's healing ability, which should be taken into
consideration during your exam.
Finding: Asked about other foot wound symptoms
Save
Terms in this set (351)
Subjective Data Collection - Checklist:
Chief Complaint
Finding: Established chief complaint
Finding: Reports pain (Found)Pro Tip: Initially
Example Question: Do establishing a chief complaint allows the patient to
you have any pain? express their reason for seeking care, primary
concerns, or condition they are presenting with.
Finding: Reports foot wound (Found)Pro Tip: If a
Example Question: What's
patient mentions pain, it's important to determine
causing your pain?
what specifically is causing her pain, if she knows.
History of Presenting Illness
Finding: Asked to rate current pain level on a scale
Finding: Reports current pain is 7/10 (Found)Pro Tip:
Example Question: Can
Asking your patient to rate her pain on a scale of 0 to
you rate the pain on a
10 is important to gauge how it ebbs and flows while
scale of 0 to 10?
she is in your care.
Finding: Asked for details about the pain
Finding: Reports pain is throbbing (Found)Pro Tip:
Example Question: Can
Determining how your patient describes the
you please describe the
characteristics of the pain can be important data to
pain?
support the cause of the pain.
, Finding: Reports pain is sharp when she attempts to
stand (Found)Pro Tip: Determining what physical
Example Question: What is
activities and movements exacerbate the patient's
the pain like when you
pain can help you better understand the problems
stand on your foot?
and assess treatment needs. This can also alert you if a
patient's activities of daily living are hindered.
Finding: Reports pain has increased in the past 2 days
Example Question: How
(Available)Pro Tip:Finding out how the patient's pain
has the pain changed over
has changed will give you insight into the acceleration
time?
of infection.
Finding: Reports feeling pain radiating into ankle
Example Question: Does
(Available)Pro Tip: Asking about where else the
the pain radiate anywhere
patient's pain radiates can help determine the
else?
progression of infection.
Finding: Reports pain prevents bearing weight on foot
Example Question: Can
(Found)Pro Tip: Determining if your patient can bear
you bear weight on your
weight on an injury is important to determine their risk
foot?
for falls while in your care.
Finding: Asked location of wound
Finding: Reports right foot is injured (Found)Pro Tip:
Example Question: Which
Confirming which extremity an injury is located is a
foot is in pain?
best practice for your patient's safety.
Finding: Reports wound is on the plantar surface of
Example Question: Where her foot (Found)Pro Tip: Confirming where a wound is
is the wound? located ensures you are aware of your patient's
biggest complaint.
Finding: Asked details of the injury
Finding: Reports she scraped foot on bottom rung of
Example Question: How a step stool (Found)Pro Tip: Discovering how an injury
did your injury happen? happened helps to assess your patient's risk factors
for injury.
, Finding: Reports injury occurred 1 week ago
Example Question: When (Available)Pro Tip: Discovering how long ago the pain
did your injury occur? began is the first step in understanding whether the
pain is chronic or acute.
Finding: Denies other injuries besides foot wound
Example Question: Did
(Available)Pro Tip: Discovering additional injuries can
you injure anything
reveal more information about the circumstances that
besides your foot?
caused the presenting injury.
Finding: Reports being barefoot at the time of injury
Example Question: Were (Available)Pro Tip: Asking about clothing, footwear,
you wearing shoes when and other protective elements being worn at the time
you fell? of injury helps you discover the totality of the
circumstances.
Finding: Denies seeing a healthcare provider for the
injury until now (Available)Pro Tip: It's crucial to ask
Example Question: Have
whether your patient has seen another provider for
you seen a healthcare
the injury, because any previous medical intervention
provider for this injury?
will help you understand the progression of the
wound.
Finding: Asked about drainage from the foot wound
Finding: Reports that the wound bled a little after
Example Question: Did sustaining the injury (Available)Pro Tip: Asking about
your foot bleed? bleeding helps you determine the characteristics of a
wound.
Example Question: Did Finding: Reports seeing pus draining from wound
you notice any discharge (Found)Pro Tip: Asking about discharge helps you
from the wound? determine the characteristics of a wound.
Finding: Reports noticing pus 2 days ago
Example Question: When (Available)Pro Tip: Pinpointing exactly when the
did you first notice the patient noticed the arrival of pus gives you an
pus? important data point for when an active infection
began.
Finding: Followed up on drainage
, Example Question: What Finding: Reports pus as white or yellow (Found)Pro
color is the drainage from Tip: The color of discharge from a wound can provide
your wound? insight into its severity and characteristics.
Finding: Denies odor from the wound (Available)Pro
Example Question: Does
Tip: The odor of discharge from a wound can provide
the wound have an odor?
insight into its severity and characteristics.
Finding: Asked about home treatment of foot wound
Finding: Reports wound care regimen of bandaging
Example Question: How (Available)Pro Tip: Asking specifically how often a
often do you change your patient changed a bandage will let you know if an
bandage? infection spread through improper hygiene, or for
other reasons such as uncontrolled blood sugar.
Finding: Reports cleaning wound twice a day
Example Question: How (Available)Pro Tip: Asking specifically how often a
often did you clean the patient cleaned a wound will let you know if an
wound? infection spread through improper hygiene, or for
other reasons such as uncontrolled blood sugar.
Finding: Reports applying bacitracin, neomycin and
Example Question: Did polymyxin B (Neosporin) (Found)Pro Tip: Determining
you use any ointment on what products a patient used to sterilize or treat a
the wound? wound establishes home care routines and health
literacy.
Finding: Followed up on effectiveness of ointment
Finding: Reports bacitracin, neomycin and polymyxin
B (Neosporin) was ineffective (Found)Pro Tip:
Understanding the effect of a home medication can
Example Question: Did the
help you determine the severity of the wound. Tina's
ointment help?
diabetes diagnosis will have a large impact on her
body's healing ability, which should be taken into
consideration during your exam.
Finding: Asked about other foot wound symptoms
