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Health Assessment - STU - January 2021, nur_418
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Overview
Transcript
Transcript
Started: Jan 12, 2021 | Total Time: 55 min
Subjective Data Collection
All Lines (109) Interview Questions (57) Statements (4) Exam Actions (48)
Objective Data Collection
Documentation Question
Hello!
01/12/21 7:33 PM EST
Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as
a preceptor would in real life. Pay close attention to this information as it will help guide
your exam. At the end of this prebrief, you will answer a short question about the
upcoming assignment. During the simulation, you may return to these instructions at any
time by scrolling to the top of your transcript.
Question
What is the situation?
01/12/21 8:44 PM EST
It's 8 a.m. on Tina Jones' first morning as a patient here at Shadow General Hospital. When
Ms. Jones was admitted at midnight last night for a foot wound, she mentioned a history of
headaches and allergies. Your role in this simulation is that of a healthcare provider who will
perform an examination of Ms. Jones' HEENT systems: Head, Eyes, Ears, Nose, and
Throat. Examination of all of these systems is often necessary to examine any one of them,
given their close proximity and physiological relationships.
Question
What are my objectives in this assessment?
01/12/21 8:44 PM EST
In your interview with Ms. Jones, you will ask about the health of her HEENT systems so
that you can identify any issues and document findings accurately. If you discover any disease
states, ask about symptoms and the patient's experiences of them. Your questioning
should cover a broad array of the symptoms' characteristics. You will also inquire into the
health history of Ms. Jones' family with regards to HEENT systems so you can determine
her genetic predisposition to any diseases. Regardless of whether you have assessed Tina
previously, ask all questions that are medically relevant to her HEENT systems. In addition
to collecting subjective data, you will perform a physical exam on Ms. Jones' HEENT
systems to gather objective data about the systems' health and physiology. While you should
communicate with patients using accessible, everyday language, it is standard practice to
use professional medical terminology everywhere else, such as in documenting
physical findings and nursing notes. You may complete the exam activities in any order and
move between them as needed.
Question
What else will this exam involve?
01/12/21 8:45 PM EST
You will complete nursing tasks to protect the patients safety, privacy, and health. You
can document your findings, including vital signs, in the Electronic Health Record. This
record provides necessary information for healthcare professionals who will continue patient
care. Activities other than Subjective and Objective Data Collection, such as Documentation
and Education and Empathy, provide valuable practice for their real-world counterparts.
However, they are not automatically graded by the simulation.
Support
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, 1/23/2021 HEENT | Completed | Shadow Health
Question
How will I be evaluated?
01/12/21 8:45 PM EST
In this assignment, you will be evaluated on your Subjective and Objective Data
Collection. The evaluation of your interview is dependent on how you word your questions
therapeutically and precisely and explore all relevant topics with comprehensive breadth
and depth. The evaluation of your physical exam is based on how successfully you report on
your physical findings by selecting among clinical terms in the Electronic Health
Record. This assignment on average takes between 60 and 75 minutes. You can pause and
resume the assignment at any time; your work is always saved automatically.
Question
How does this assignment prepare me for the real world?
01/12/21 8:45 PM EST
In this assessment, you will become familiarized with the structure and content of HEENT
exams so that with real-life patients, you can: º ask effective and comprehensive questions
º use therapeutic language º evaluate the patient's risk of disease, infection, injury, and
complications º and obtain and assess objective data.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What
physical exam findings would you look for in a patient with allergies?
Statement
In patients with Allergies I can found nasal congestion, rhinorrhea, sneezing.
01/12/21 8:48 PM EST
Time to begin.
Greet
Hello, my Name is Tania. I will be interviewing you today and conduct a physical examination
01/12/21 8:49 PM EST
Hey.
Could you please help me with your name? (Clarified to Can you please confirm your name Question
and birthday for me?.) 01/12/21 8:49 PM EST
My name's Tina Jones, and my birthday's February 17th. (Clarified to to confirm my name and
date of birth.)
Question
How can I help you today Tina?
01/12/21 8:50 PM EST
I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it's
looking pretty nasty. And the pain is killing me!
Empathize
I am so sorry to hear that
01/12/21 8:50 PM EST
Thanks.
Exam Action
Checked vitals
01/12/21 8:52 PM EST
Could you please help me with you past medical history? (Clarified to Have you had health Question
problems in the past?.) 01/12/21 8:53 PM EST
Yeah. . . I have asthma and diabetes. (Clarified to if I have had past health problems.)
Question
since when do you have asthma? (Clarified to When does your asthma occur?.)
01/12/21 8:54 PM EST
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