Download Shadow Health - Tina Jones, Health History and more Exams Nursing in PDF only on Docsity!
Shadow |! Health |! - |! Tina|! Jones, |! Health |!
History
Health |! History |! Tips |! & |! Tricks: |! - |! Student: |! Hello! |! - |! Diana |! Shadow: |! 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. Student: |! What |! is |! the |! situation? |! - |! Diana |! Shadow: |! Your |! patient |! is |! Tina |! Jones:, |! a |! 28-year-old |! African |! American |! woman |! who |! has |! just |! been |! admitted |! to |! Shadow |! General |! Hospital |! for |! a |! painful |! foot |! wound. |! Your |! role |! in |! this |! simulation |! is |! that |! of |! a |! healthcare |! provider |! who |! will |! take |! Ms. |! Jones' |! health |! history, |! a |! key |! component |! of |! her |! admission |! process. Student: |! What |! are |! my |! objectives |! in |! this |! assessment? |! - |! Diana |! Shadow: |! A |! health |! history |! requires |! you |! to |! ask |! questions |! related |! to |! Ms. |! Jones' |! past |! and |! present |! health, |! from |! her |! current |! foot |! wound |! to |! her |! pre-existing |! conditions. |! You |! will |! also |! want |! to |! review |! Ms. |! Jones' |! systems, |! psychosocial |! history, |! and |! family |! medical |! history. |! These |! assessments |! together |! will |! give |! you |! a |! comprehensive |! picture |! of |! Ms. |! Jones' |! overall |! health. |! 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. |! Throughout |! the |! conversation, |! you |! should |! educate |! and |! empathize |! with |! Ms. |! Jones |! when |! appropriate |! to |! increase |! her |! health |! literacy |! and |! sense |! of |! well-being. |! Regardless |! of |! whether |! you |! have |! assessed |! Ms. |! Jones |! previously, |! ask |! all |! questions |! that |! are |! necessary |! for |! obtaining |! a |! complete |! health |! history. |! 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. |! After |! obtaining |! Ms. |! Jones' |! health |! history, |! you |! will |! complete |! an |! information |! processing |! activity. |! You |! will |! identify |! and |! prioritize |! diagnoses, |! then |! create |! a |! plan |! to |! address |! the |! identified |! diagnoses. Student: |! What |! else |! will |! this |! exam |! involve? |! - |! Diana |! Shadow: |! 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. |! Besides |! Subjective |! Data |! Collection, |! and |! Education |! and |! Empathy, |! there |! are |! activities |! within |! the |! simulation |! that |! provide |! valuable |! practice |! for |! their |! real-world |! counterparts, |! but |! they |! are |! not |! automatically |! graded |! by |! the |! simulation. Student: |! How |! will |! I |! be |! evaluated? |! - |! Diana |! Shadow: |! In |! this |! assignment, |! you |! will |! be |! evaluated |! on |! your |! Subjective |! Data |! Collection, |! as |! well |! as |! your |! Education |! and |! Empathy. |! Your |! success |! in |! Education |! and |! Empathy |! is |! based |! on |! whether |! you |! promptly |! respond |! after |! identifying |! a |! moment |! worthy |! of |! therapeutic |! communication. |! 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. |! You |! will |! also |! be |! evaluated |! on |! your |! ability |! to |! collect |! data |! and |! form |! nursing |! diagnoses |! in |! the |! information |! processing |! activity. |! This |! assignment |! takes |! on |! average |! between |! 90 |! and |! 110 |! minutes. |! This |! exam |! may |! take |! longer |! than |! in |! real |! life, |! because |! in |! this |! safe |! simulation, |! students |! of |! all |! experience |! levels |! can |! take |! time |! to |! hone |! and |! review |! their |! skills. |! You |! can |! pause |! and |! resume |! the |! assignment |! at |! any |! time; |! your |! work |! is |! always |! saved |! automatically. Student: |! How |! does |! this |! assignment |! prepare |! me |! for |! the |! real |! world? |! - |! Diana |! Shadow: |! In |! this |! assessment, |! you |! will |! become |! familiarized |! with |! the |! structure |! and |! content |! of |! a |! health |! history |! exam |! so |! that |! with |! real-life |! patients, |! you |! can: |! º |! ask |! effective |! and |! comprehensive |! questions |! º |! obtain |! a |! thorough |! health |! history |! º |! evaluate |! the |! patient's |! risk |! of |! disease, |! infection, |! injury, |! and |! complications |! º |! educate |! and |! empathize |! º |! reflect |! on |! your |! experience |! and |! identify |! areas |! to |! improve |! º |! identify |! and |! prioritize |! nursing |! diagnoses |! º |! and |! develop |! a |! plan |! to |! address |! nursing |! diagnoses.
Student: |! Has |! your |! foot |! been |! draining |! any |! liquids? |! - |! Tina |! Jones: |! Yeah, |! there's |! definitely |! pus. Student: |! What |! color |! was |! the |! pus? |! - |! Tina |! Jones: |! It's... |! white |! or |! maybe |! off- white. Student: |! How |! have |! you |! treated |! the |! wound? |! - |! Tina |! Jones: |! I've |! been |! taking |! Advil |! for |! my |! foot |! for |! a |! few |! days. Student: |! What |! did |! you |! do |! to |! treat |! your |! foot |! after |! your |! accident? |! - |! Tina |! Jones: |! I |! made |! sure |! to |! clean |! it |! and |! keep |! it |! bandaged. |! And |! I |! put |! Neosporin |! on |! it. 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. Student: |! When |! were |! you |! diagnosed |! with |! diabetes? |! - |! Tina |! Jones: |! I |! was |! diagnosed |! when |! I |! was |! 24. Student: |! What |! do |! you |! do |! to |! manage |! your |! asthma? |! - |! Tina |! Jones: |! I |! try |! to |! avoid |! things |! that |! give |! me |! breathing |! problems, |! but |! when |! my |! asthma |! starts |! to |! act |! up, |! I |! just |! use |! my |! inhaler. Student: |! What |! medications |! did |! you |! take |! for |! your |! diabetes? |! - |! Tina |! Jones: |! It |! was |! metformin. 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. 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. Student: |! How |! frequently |! do |! you |! urinate? |! - |! Tina |! Jones: |! I |! don't |! know. |! Every |! hour |! or |! two |! when |! I'm |! awake? Student: |! What |! is |! your |! current |! diet? |! - |! Tina |! Jones: |! It's |! pretty |! good, |! I |! think. |! I'm |! not |! a |! huge |! health |! nut |! or |! anything. Student: |! Have |! you |! had |! any |! change |! in |! appetite? |! - |! Tina |! Jones: |! Yeah, |! lately |! I've |! definitely |! been |! much |! hungrier |! than |! usual. Student: |! Has |! your |! weight |! changed? |! - |! Tina |! Jones: |! Yeah, |! I've |! lost |! some |! weight |! recently. Student: |! Do |! you |! know |! why |! you |! lost |! weight? |! - |! Tina |! Jones: |! I |! don't |! know |! what |! caused |! it, |! I |! just |! lost |! weight. Student: |! How |! often |! do |! you |! have |! asthma |! exacerbations? |! - |! Tina |! Jones: |! I |! haven't |! had |! a |! full |! attack |! in |! years. |! But |! my |! breathing |! definitely |! acts |! up. |!. |! .not |! always. |! Max |! twice |! a |! week. Student: |! What |! asthma |! symptoms |! have |! you |! experienced? |! - |! Tina |! Jones: |! My |! chest |! and |! throat |! get |! tight, |! and |! I |! start |! to |! wheeze. |! It |! feels |! like |! I |! can't |! take |! in |! air, |! like |! I |! can't |! get |! enough |! air |! into |! my |! lungs. 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: |! Do |! you |! have |! a |! family |! history |! of |! psychiatric |! illness? |! - |! Tina |! Jones: |! No. |! They're |! crazy, |! but |! nobody's |! diagnosed |! with |! anything. Student: |! Do |! you |! have |! any |! neck, |! throat |! or |! gland |! problems? |! - |! Tina |! Jones: |! No, |! not |! that |! I |! noticed. Student: |! Do |! you |! have |! any |! problems |! with |! your |! head? |! - |! Tina |! Jones: |! I |! don't |! think |! I |! have |! any |! problems. |! I |! get |! headaches |! sometimes, |! but |! that's |! all. Student: |! Any |! problems |! with |! your |! ears? |! - |! Tina |! Jones: |! No. Student: |! Any |! problems |! with |! your |! eyes |! and |! vision? |! - |! Tina |! Jones: |! I've |! actually |! been |! noticing |! problems |! lately. |! When |! I'm |! reading |! or |! studying |! I'll |! notice |! that |! things |! start |! to |! get |! kind |! of |! blurry. Student: |! Any |! problems |! with |! your |! nose? |! - |! Tina |! Jones: |! My |! nose |! is |! fine |! right |! now. |! Sometimes |! it |! runs, |! but |! not |! very |! often. Student: |! Do |! you |! have |! problems |! with |! your |! mouth? |! - |! Tina |! Jones: |! No. Student: |! Do |! you |! have |! a |! history |! of |! cardiovascular |! problems? |! - |! Tina |! Jones: |! My |! heart's |! fine, |! thank |! God! Student: |! Any |! problems |! with |! your |! heart? |! - |! Tina |! Jones: |! No, |! my |! heart's |! always |! been |! fine. Student: |! Have |! you |! had |! any |! problems |! with |! your |! breasts? |! - |! Tina |! Jones: |! I |! haven't |! noticed |! any |! pain |! there. Student: |! Have |! you |! had |! any |! reproductive |! problems? |! - |! Tina |! Jones: |! I |! don't |! think |! I |! have |! problems |! in |! that |! area. |! I |! just |! get |! really |! bad |! periods, |! that's |! all. Student: |! Have |! you |! had |! any |! neurological |! problems? |! - |! Tina |! Jones: |! No, |! I |! haven't. Student: |! Have |! you |! had |! any |! musculoskeletal |! problems? |! - |! Tina |! Jones: |! No.
Student: |! Do |! you |! have |! a |! history |! of |! skin |! disease? |! - |! Tina |! Jones: |! Um, |! I |! have |! acne, |! if |! that |! counts. Student: |! Does |! your |! paternal |! grandfather |! have |! any |! health |! problems? |! - |! Tina |! Jones: |! Grandpa |! Jones |! had |! colon |! cancer, |! and |! that |! caused |! all |! kinds |! of |! problems |! for |! him. |! Plus, |! he |! had |! high |! blood |! pressure, |! and...I'm |! pretty |! sure |! he |! had |! diabetes. |! And |! high |! cholesterol |! like |! everyone |! else |! in |! my |! family. Student: |! Does |! your |! mother |! have |! any |! health |! problems? |! - |! Tina |! Jones: |! Mom |! has |! high |! cholesterol |! and |! blood |! pressure, |! I |! think. |! She |! seems |! to |! be |! doing |! okay |! though. Student: |! Does |! your |! father |! have |! any |! health |! problems? |! - |! Tina |! Jones: |! Well, |! he |! passed |! away. |! But |! he |! had |! a |! couple |! things... |! Type |! 2 |! diabetes, |! like |! me, |! and |! high |! cholesterol |! and |! blood |! pressure. Student: |! How |! did |! your |! father |! die? |! - |! Tina |! Jones: |! He |! died |! in |! a |! car |! accident. Student: |! Where |! is |! your |! wound |! located? |! - |! Tina |! Jones: |! It's |! on |! the |! ball |! of |! my |! foot. Student: |! Do |! you |! get |! thirsty |! often? |! - |! Tina |! Jones: |! You |! know, |! I |! did |! notice |! lately |! that |! I've |! been |! really |! thirsty. Student: |! What |! happened |! with |! your |! father's |! car |! accident? |! - |! Tina |! Jones: |! It |! was |! last |! year... |! I |! guess |! a |! little |! over |! a |! year |! ago. Student: |! How |! long |! ago |! was |! your |! dad's |! car |! accident? |! - |! Tina |! Jones: |! It |! was |! last |! year... |! I |! guess |! a |! little |! over |! a |! year |! ago. Student: |! How |! did |! you |! cope |! with |! your |! fathers |! death? |! - |! Tina |! Jones: |! Well, |! right |! after |! he |! died, |! after |! the |! funeral |! and |! everything, |! I |! just |! tried |! to |! get |! through |! that. |! Mom |! was |! having |! such |! a |! hard |! time, |! crying |! a |! lot, |! everything |! made |! her |! sad, |! she |! was |! kind |! of |! depressed. |! So, |! I |! guess |! at |! first |! I |! just |! focused |! on |! getting |! things |! done--groceries, |! laundry, |! insurance |! papers |! and |! stuff. |! Knowing |! that |! Mom |! needed |! me |! kind |! of |! helped |! me |! get |! through |! day |! by |! day. |! There |! was |! about |! a |! month |! where |! it |! was |! hard |! for |! us |! to |! get |! to |! church. |! Even |! getting |! up |! and |! ready |!
Student: |! Does |! your |! family |! have |! a |! history |! of |! substance |! abuse? |! - |! Tina |! Jones: |! One |! person |! in |! the |! family, |! my |! dad's |! brother, |! has |! an |! alcohol |! problem, |! but |! we |! never |! see |! him. Student: |! Does |! your |! family |! have |! a |! history |! of |! headaches? |! - |! Tina |! Jones: |! No, |! not |! that |! I |! know |! of. Student: |! How |! much |! alcohol |! do |! you |! drink? |! - |! Tina |! Jones: |! I |! only |! have |! a |! few |! drinks |! when |! I |! go |! out. Student: |! What |! is |! your |! level |! of |! education? |! - |! Tina |! Jones: |! Well, |! I'm |! finishing |! up |! my |! bachelor's |! degree |! right |! now. 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. Student: |! Where |! do |! you |! live? |! - |! Tina |! Jones: |! Right |! now, |! I'm |! living |! at |! my |! mom's |! place, |! which |! is |! out |! in |! the |! suburbs |! a |! bit. |! It's |! like |! a |! half |! hour |! from |! here. Student: |! What |! is |! your |! belief |! system? |! - |! Tina |! Jones: |! I'm |! Baptist. |! My |! faith |! is |! a |! big |! part |! of |! my |! life--when |! things |! get |! hard |! like |! they've |! been |! this |! past |! year, |! I |! know |! I |! can |! trust |! that |! God's |! looking |! out |! for |! me. |! I've |! been |! going |! to |! the |! same |! church |! since |! I |! was |! a |! kid, |! too, |! so |! the |! people |! at |! church |! are |! practically |! part |! of |! my |! family. Student: |! Have |! you |! experienced |! abuse? |! - |! Tina |! Jones: |! I've |! never |! had |! been |! in |! any |! kind |! of |! situation |! like |! that... |! It's |! scary |! to |! think |! about. Student: |! Have |! you |! used |! illicit |! drugs? |! - |! Tina |! Jones: |! Well, |! I |! used |! to |! smoke |! pot. |!. |!. |! but |! I |! don't |! do |! that |! anymore.
Student: |! What |! type |! of |! drugs |! did |! you |! use? |! - |! Tina |! Jones: |! Um...I've |! smoked |! pot |! before. |! In |! high |! school, |! and |! after |! high |! school... |! I |! definitely |! don't |! anymore, |! though. Student: |! Have |! you |! used |! drugs |! other |! than |! marijuana? |! - |! Tina |! Jones: |! No. Student: |! When |! did |! you |! last |! use |! drugs? |! - |! Tina |! Jones: |! I |! haven't |! smoked |! pot |! since |! I |! was |! twenty |! or |! twenty-one. Student: |! Have |! you |! ever |! smoked |! cigarettes? |! - |! Tina |! Jones: |! No. |! I |! think |! it's |! gross. Student: |! Have |! you |! been |! around |! people |! that |! are |! smoking? |! - |! Tina |! Jones: |! Some |! of |! my |! friend's |! smoke |! when |! we |! go |! out |! drinking. |! But |! I |! don't |! smoke, |! and |! nobody |! at |! home |! smokes. Student: |! How |! old |! were |! you |! when |! your |! father |! died? |! - |! Tina |! Jones: |! He |! died |! last |! year, |! so |! I |! was |! 27. Student: |! Did |! your |! father |! die |! from |! any |! disease? |! - |! Tina |! Jones: |! He |! died |! in |! a |! car |! accident. Student: |! Can |! you |! tell |! me |! about |! your |! father's |! health? |! - |! Tina |! Jones: |! He |! had |! high |! blood |! pressure |! and |! cholesterol. |! And |! diabetes |! -- |! we |! have |! diabetes |! in |! common. Student: |! I |! can't |! even |! imagine |! how |! you |! feel |! about |! losing |! your |! father |! - |! Tina |! Jones: |! Thanks. Student: |! Tell |! me |! about |! your |! father. |! - |! Tina |! Jones: |! Dad |! was |! a |! little |! stricter |! than |! Mom |! growing |! up. |!. |!. |! he |! would |! sometimes |! get |! kind |! of |! mad |! at |! us |! when |! we |! did |! something |! wrong. |! But |! he |! never |! hit |! us |! or |! anything. |! He |! would |! just |! get |! really |! calm |! and |! quiet |! and |! tell |! us |! to |! go |! to |! our |! rooms |! without |! supper, |! or |! that |! we |! were |! grounded |! when |! we |! were |! older. |! Or |! like, |! he'd |! make |! us |! rake |! the |! yard |! or |! wash |! his |! car |! or |! something. |! It's |! pretty |! sad |! to Student: |! How |! old |! was |! your |! father |! when |! he |! died? |! - |! Tina |! Jones: |! Last |! year |! when |! Dad |! passed, |! he |! was |! only |! 58.
Finding: |! Reports |! pain |! has |! increased |! in |! the |! past |! 2 |! days |! (Available)Pro |! Tip:Finding |! out |! how |! the |! patient's |! pain |! has |! changed |! will |! give |! you |! insight |! into |! the |! acceleration |! of |! infection. |! - |! Example |! Question: |! How |! has |! the |! pain |! changed |! over |! time? Finding: |! Reports |! feeling |! pain |! radiating |! into |! ankle |! (Available)Pro |! Tip: |! Asking |! about |! where |! else |! the |! patient's |! pain |! radiates |! can |! help |! determine |! the |! progression |! of |! infection. |! - |! Example |! Question: |! Does |! the |! pain |! radiate |! anywhere |! else? Finding: |! Reports |! pain |! prevents |! bearing |! weight |! on |! foot |! (Found)Pro |! Tip: |! Determining |! if |! your |! patient |! can |! bear |! weight |! on |! an |! injury |! is |! important |! to |! determine |! their |! risk |! for |! falls |! while |! in |! your |! care. |! - |! Example |! Question: |! Can |! you |! bear |! weight |! on |! your |! foot? Finding: |! Asked |! location |! of |! wound |! - |! Finding: |! Reports |! right |! foot |! is |! injured |! (Found)Pro |! Tip: |! Confirming |! which |! extremity |! an |! injury |! is |! located |! is |! a |! best |! practice |! for |! your |! patient's |! safety. |! - |! Example |! Question: |! Which |! foot |! is |! in |! pain? Finding: |! Reports |! wound |! is |! on |! the |! plantar |! surface |! of |! her |! foot |! (Found)Pro |! Tip: |! Confirming |! where |! a |! wound |! is |! located |! ensures |! you |! are |! aware |! of |! your |! patient's |! biggest |! complaint. |! - |! Example |! Question: |! Where |! is |! the |! wound? Finding: |! Asked |! details |! of |! the |! injury |! - |! Finding: |! Reports |! she |! scraped |! foot |! on |! bottom |! rung |! of |! a |! step |! stool |! (Found)Pro |! Tip: |! Discovering |! how |! an |! injury |! happened |! helps |! to |! assess |! your |! patient's |! risk |! factors |! for |! injury. |! - |! Example |! Question: |! How |! did |! your |! injury |! happen? Finding: |! Reports |! injury |! occurred |! 1 |! week |! ago |! (Available)Pro |! Tip: |! Discovering |! how |! long |! ago |! the |! pain |! began |! is |! the |! first |! step |! in |! understanding |! whether |! the |! pain |! is |! chronic |! or |! acute. |! - |! Example |! Question: |! When |! did |! your |! injury |! occur?
Finding: |! Denies |! other |! injuries |! besides |! foot |! wound |! (Available)Pro |! Tip: |! Discovering |! additional |! injuries |! can |! reveal |! more |! information |! about |! the |! circumstances |! that |! caused |! the |! presenting |! injury. |! - |! Example |! Question: |! Did |! you |! injure |! anything |! besides |! your |! foot? Finding: |! Reports |! being |! barefoot |! at |! the |! time |! of |! injury |! (Available)Pro |! Tip: |! Asking |! about |! clothing, |! footwear, |! and |! other |! protective |! elements |! being |! worn |! at |! the |! time |! of |! injury |! helps |! you |! discover |! the |! totality |! of |! the |! circumstances. |! - |! Example |! Question: |! Were |! you |! wearing |! shoes |! when |! you |! fell? Finding: |! Denies |! seeing |! a |! healthcare |! provider |! for |! the |! injury |! until |! now |! (Available)Pro |! Tip: |! It's |! crucial |! to |! ask |! whether |! your |! patient |! has |! seen |! another |! provider |! for |! the |! injury, |! because |! any |! previous |! medical |! intervention |! will |! help |! you |! understand |! the |! progression |! of |! the |! wound. |! - |! Example |! Question: |! Have |! you |! seen |! a |! healthcare |! provider |! for |! this |! injury? Finding: |! Asked |! about |! drainage |! from |! the |! foot |! wound |! - |! Finding: |! Reports |! that |! the |! wound |! bled |! a |! little |! after |! sustaining |! the |! injury |! (Available)Pro |! Tip: |! Asking |! about |! bleeding |! helps |! you |! determine |! the |! characteristics |! of |! a |! wound. |! - |! Example |! Question: |! Did |! your |! foot |! bleed? Finding: |! Reports |! seeing |! pus |! draining |! from |! wound |! (Found)Pro |! Tip: |! Asking |! about |! discharge |! helps |! you |! determine |! the |! characteristics |! of |! a |! wound. |! - |! Example |! Question: |! Did |! you |! notice |! any |! discharge |! from |! the |! wound? Finding: |! Reports |! noticing |! pus |! 2 |! days |! ago |! (Available)Pro |! Tip: |! Pinpointing |! exactly |! when |! the |! patient |! noticed |! the |! arrival |! of |! pus |! gives |! you |! an |! important |! data |! point |! for |! when |! an |! active |! infection |! began. |! - |! Example |! Question: |! When |! did |! you |! first |! notice |! the |! pus? Finding: |! Followed |! up |! on |! drainage |! - |! Finding: |! Reports |! pus |! as |! white |! or |! yellow |! (Found)Pro |! Tip: |! The |! color |! of |! discharge |! from |! a |! wound |! can |! provide |! insight |! into |! its |! severity |! and |! characteristics. |! - |! Example |! Question: |! What |! color |! is |! the |! drainage |! from |! your |! wound?
Finding: |! Reports |! swelling |! worsened |! in |! the |! past |! 2 |! days |! (Available)Pro |! Tip:Finding |! out |! how |! long |! swelling |! appeared |! will |! help |! you |! understand |! the |! timeline |! for |! the |! infection |! progression. |! - |! Example |! Question: |! How |! long |! have |! you |! noticed |! swelling |! around |! the |! wound? Finding: |! Reports |! redness |! around |! the |! wound |! (Found)Pro |! Tip: |! Asking |! about |! redness |! will |! help |! you |! understand |! the |! timeline |! for |! the |! infection |! progression. |! - |! Example |! Question: |! Did |! you |! notice |! any |! redness |! around |! the |! wound? Finding: |! Reports |! that |! the |! wound |! feels |! warm |! (Found)Pro |! Tip: |! Asking |! about |! warmth |! will |! help |! you |! understand |! the |! timeline |! for |! the |! infection |! progression. |! - |! Example |! Question: |! Does |! the |! wound |! feel |! warm? Finding: |! Explored |! impact |! of |! patient's |! foot |! injury |! on |! activities |! of |! daily |! living |! - |! Finding: |! Reports |! pain |! affects |! ability |! to |! walk |! (Available)Pro |! Tip: |! Understanding |! the |! impact |! of |! your |! patient's |! wound |! on |! daily |! activities |! helps |! inform |! your |! plan |! for |! care. |! With |! a |! foot |! wound, |! it |! is |! imperative |! to |! discern |! if |! a |! patient |! can |! walk |! or |! not, |! as |! a |! lack |! of |! mobility |! can |! compromise |! quality |! of |! life. |! - |! Example |! Question: |! Does |! your |! injury |! impact |! your |! ability |! to |! walk? Finding: |! Reports |! pain |! affects |! ability |! to |! stand |! at |! work |! for |! long |! periods |! of |! time |! (Available)Pro |! Tip: |! Understanding |! the |! impact |! of |! your |! patient's |! wound |! on |! daily |! activities |! helps |! inform |! your |! plan |! for |! care. |! With |! a |! foot |! wound, |! it |! is |! imperative |! to |! discern |! if |! a |! patient |! can |! stand |! or |! not, |! as |! this |! can |! compromise |! quality |! of |! life |! and |! impact |! job |! performance. |! - |! Example |! Question: |! Does |! your |! foot |! pain |! affect |! your |! work? Finding: |! Reports |! pain |! prevented |! her |! from |! being |! able |! to |! walk |! to |! class |! (Available)Pro |! Tip: |! For |! patients |! who |! are |! also |! students, |! you |! can |! find |! out |! what |! schoolwork |! they |! are |! missing, |! and |! help |! them |! make |! accommodations |! so |! they |! don't |! fall |! behind. |! - |! Example |! Question: |! Has |! your |! injury |! prevented |! you |! from |! going |! to |! class? Past |! Medical |! History |! - |!
Finding: |! Asked |! about |! preexisting |! medical |! conditions |! - |! Finding: |! Reports |! diabetes |! (Found)Pro |! Tip: |! It |! is |! important |! to |! identify |! any |! existing |! medical |! conditions, |! as |! that |! information |! is |! an |! integral |! part |! of |! a |! complete |! health |! history. |! Existing |! conditions |! can |! also |! inform |! your |! treatment |! and |! understanding |! of |! the |! patient's |! current |! health |! issues. |! In |! Tina's |! case, |! it |! is |! important |! to |! identify |! her |! diabetes |! diagnosis |! because |! that |! condition |! has |! a |! direct |! relationship |! with |! her |! current |! foot |! infection. |! - |! Example |! Question: |! Do |! you |! have |! any |! existing |! conditions? Finding: |! Reports |! asthma |! (Found)Pro |! Tip: |! It |! is |! important |! to |! identify |! any |! existing |! medical |! conditions, |! such |! as |! Tina's |! asthma, |! because |! that |! information |! is |! an |! integral |! part |! of |! her |! health |! history. |! Existing |! conditions |! can |! also |! inform |! your |! treatment |! and |! understanding |! of |! the |! patient's |! current |! health |! issues. |! - |! Example |! Question: |! Do |! you |! have |! any |! other |! conditions? Finding: |! Followed |! up |! on |! diabetes |! diagnosis |! - |! Finding: |! Reports |! specific |! age |! of |! diagnosis |! was |! 24 |! (Found)Pro |! Tip: |! Learning |! the |! diagnosis |! date |! of |! your |! patient's |! illness |! is |! an |! essential |! element |! of |! the |! illnesses |! history. |! - |! Example |! Question: |! At |! what |! age |! were |! you |! diagnosed |! with |! diabetes? Finding: |! Reports |! that |! her |! diabetes |! is |! Type |! 2 |! (Available)Pro |! Tip: |! The |! type |! of |! diabetes |! your |! patient |! has |! will |! drastically |! affect |! how |! you |! care |! for |! her. |! - |! Example |! Question: |! Do |! you |! know |! what |! type |! of |! diabetes |! you |! have? Finding: |! Asked |! about |! diabetes |! management |! through |! lifestyle |! changes |! - |! Finding: |! Reports |! staying |! away |! from |! sweets |! (Available)Pro |! Tip: |! Asking |! your |! patient |! specifically |! about |! sugar |! intake |! can |! help |! you |! understand |! the |! history |! of |! her |! diabetes |! as |! well |! as |! her |! health |! literacy. |! - |! Example |! Question: |! Tell |! me |! more |! about |! any |! sugars |! you |! consume. Finding: |! Reports |! drinking |! diet |! coke |! instead |! of |! regular |! (Available)Pro |! Tip: |! Particularly |! for |! diabetic |! patients, |! asking |! about |! intake |! of |! drinks |! that |! contain |! sugar |! can |! reveal |! additional |! sources |! of |! carbohydrates |! that |! the |! patient |! may |! not |! consider. |! - |! Example |! Question: |! Do |! you |! drink |! sugary |! drinks?
patient's |! reaction |! to |! treatment. |! - |! Example |! Question: |! Did |! the |! metformin |! cause |! any |! side |! effects? Finding: |! Reports |! that |! she |! didn't |! like |! checking |! sugar |! and |! taking |! daily |! pills |! (Found)Pro |! Tip: |! Asking |! reasons |! for |! noncompliance |! can |! reveal |! information |! about |! your |! patient's |! health |! literacy, |! side |! effects, |! financial |! situation, |! and |! more. |!
- |! Example |! Question: |! What's |! preventing |! you |! from |! taking |! your |! diabetes |! medication? Finding: |! Asked |! about |! blood |! glucose |! monitoring |! - |! Finding: |! Reports |! infrequent |! blood |! glucose |! monitoring |! (Found)Pro |! Tip: |! Your |! patient's |! blood |! sugar |! monitoring |! habits |! are |! an |! important |! part |! of |! her |! health |! literacy |! and |! home |! treatment. |! - |! Example |! Question: |! Tell |! me |! about |! your |! blood |! sugar |! monitoring. Finding: |! Reports |! she |! last |! checked |! blood |! sugar |! a |! month |! ago |! (Available)Pro |! Tip: |! Your |! patient's |! blood |! sugar |! monitoring |! habits |! are |! an |! important |! part |! of |! her |! health |! literacy |! and |! home |! treatment. |! - |! Example |! Question: |! How |! often |! do |! you |! check |! your |! blood |! sugar? Finding: |! Reports |! confusion |! about |! what |! the |! numbers |! mean |! (Available)Pro |! Tip: |! Your |! patient's |! blood |! sugar |! monitoring |! habits |! are |! an |! important |! part |! of |! her |! health |! literacy |! and |! home |! treatment. |! If |! you |! find |! gaps |! in |! the |! patient's |! literacy, |! that |! is |! your |! opportunity |! to |! provide |! education. |! - |! Example |! Question: |! What |! are |! your |! usual |! blood |! sugar |! levels? Finding: |! Asked |! about |! thirst |! - |! Finding: |! Reports |! increased |! thirst |! (Found)Pro |! Tip: |! Your |! patient's |! thirst |! can |! offer |! insight |! into |! underlying |! medical |! conditions. |! Knowing |! that |! Tina |! is |! diabetic, |! you |! will |! want |! to |! explore |! this |! classic |! symptom |! of |! the |! condition. |! - |! Example |! Question: |! Have |! you |! been |! more |! thirsty |! lately? Finding: |! Reports |! increased |! water |! intake |! (Available)Pro |! Tip: |! Your |! patient's |! fluid |! intake |! can |! offer |! insight |! into |! underlying |! medical |! conditions. |! Knowing |! that |! Tina |!
is |! diabetic, |! you |! will |! want |! to |! explore |! this |! classic |! symptom |! of |! the |! condition. |! - |! Example |! Question: |! Are |! you |! drinking |! more |! water |! than |! normal? Finding: |! Asked |! about |! frequency |! of |! urination |! - |! Finding: |! Reports |! more |! frequent |! urination |! (Found)Pro |! Tip: |! Your |! patient's |! urination |! habits |! can |! offer |! insight |! into |! underlying |! medical |! conditions |! and |! general |! health. |! Knowing |! that |! Tina |! is |! diabetic, |! you |! will |! want |! to |! explore |! this |! classic |! symptom |! of |! the |! condition. |! - |! Example |! Question: |! Have |! you |! been |! urinating |! more |! often |! than |! usual? Finding: |! Reports |! urinating |! every |! hour |! or |! two |! during |! the |! day |! (Found)Pro |! Tip: |! Your |! patient's |! urination |! habits |! can |! offer |! insight |! into |! underlying |! medical |! conditions |! and |! general |! health. |! Knowing |! that |! Tina |! is |! diabetic, |! you |! will |! want |! to |! explore |! this |! classic |! symptom |! of |! the |! condition. |! - |! Example |! Question: |! How |! often |! do |! you |! urinate |! during |! the |! day? Finding: |! Reports |! urinating |! 2 |! to |! 3 |! times |! during |! the |! night |! (Available)Pro |! Tip: |! Discovering |! if |! Tina |! has |! nocturia |! can |! offer |! insight |! into |! underlying |! medical |! conditions |! and |! general |! health. |! - |! Example |! Question: |! How |! often |! do |! you |! wake |! up |! at |! night |! to |! urinate? Finding: |! Asked |! about |! diet |! - |! Finding: |! Reports |! eating |! a |! bowl |! of |! cereal |! for |! breakfast |! yesterday |! (Available)Pro |! Tip: |! In |! a |! health |! history, |! it |! is |! important |! to |! get |! an |! idea |! of |! a |! patient's |! typical |! dietary |! patterns. |! This |! can |! be |! achieved |! by |! asking |! for |! a |! 24-hour |! diet |! recall. |! - |! Example |! Question: |! What |! did |! you |! eat |! for |! breakfast |! yesterday? Finding: |! Reports |! eating |! mac |! and |! cheese |! for |! lunch |! yesterday |! (Available)Pro |! Tip: |! In |! a |! health |! history, |! it |! is |! important |! to |! get |! an |! idea |! of |! a |! patient's |! typical |! dietary |! patterns. |! This |! can |! be |! achieved |! by |! asking |! for |! a |! 24-hour |! diet |! recall. |! - |! Example |! Question: |! What |! did |! you |! eat |! for |! lunch |! yesterday? Finding: |! Reports |! eating |! chicken |! and |! roll |! for |! dinner |! yesterday |! (Available)Pro |! Tip:Finding |! out |! the |! foods |! a |! patient |! last |! ate |! can |! provide |! evidence |! for |! any |! current |! stomach |! upset |! and |! for |! their |! current |! level |! of |! hunger |! and |! blood |! sugar |!
