Focused Exam: Mobility Results Medical Surgical Nursing: Promoting Wellness in the Older Adult.

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Focused Exam: Mobility Results | Turned In Medical Surgical Nursing: Promoting Wellness in the Older Adult (Los Angeles) - April 2019, NURS 201 Return to Assignment Your Results Lab Pass ... Overview Transcript Subjective Data Collection: 54 of 54 (100.0%) Subjective Data Collection Objective Data Collection Education & Empathy QSEN Competencies Documentation SBAR Reflections Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Indicates an item that you found. Indicates an item that is available to be found. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports leg pain Reports leg swelling Orientation Established orientation Oriented to person Oriented to place Oriented to time Oriented to situation History of Present Illness Asked about onset and duration of symptoms Reports fall was 9 am this morning Reports lower leg pain started 2 days ago. Also reports mild constant pain in his knees and hips due to arthritis. Reports leg swelling started 2 days ago Reports pain has been constant since onset Reports pain steadily gets worse Asked about location of pain Reports pain in left lower calf Asked about characteristics of pain Describes pain as "nagging" Describes pain as sharp Denies stinging or burning pain Reports sensation of warmth Asked about aggravating factors of pain Reports pain is worse with walking Asked about treatment and relieving factors of pain Reports taking Advil Reports Advil did not relieve leg pain Denies home treatments such as heating or icing for pain today Asked about severity of pain Current pain level is 2/10 Pain level arriving at ER was 10/10 Past Medical History Asked about existing health conditions Reports hypertension Reports osteoarthritis Reports prostate enlargement Followed up about hypertension diagnosis Hypertension diagnosed at age 57 Reports belief that hypertension is "okay" (well-controlled) Reports that typical number in the doctor's office is "never above 140 for the first number" Reports that he doesn't check BP at home Reports that he only checks BP at doctor's office every few months Denies checking BP before taking medication Followed up about osteoarthritis diagnosis Arthritis diagnosed at age 57 Reports hip pain Reports knee pain Reports morning stiffness Reports using heat to relieve pain Reports doing exercises to help symptoms Followed up about prostate enlargement diagnosis Diagnosed at age 69 Asked about allergies Denies general allergies Denies environmental allergies Denies latex allergy Asked specifically about medication allergies Denies medication allergies Home Medications Asked about home medications Reports medication for hypertension Reports medication for prostate enlargement Reports occasionally taking a sleep aid Denies taking vitamins Denies taking herbal supplements Asked about medication regimen adherence Reports using a pillbox to organize medications Denies missing doses of medication Denies missing doses of medication because of side effects Denies difficulty obtaining medications because of finances Denies difficulty obtaining medications because of transportation Followed up on last dose of home medications Reports taking hypertension medication this morning Reports last dose of medication for prostate enlargement yesterday Reports last dose of sleep aid was earlier this week Followed up on medication for hypertension Reports taking metoprolol Reports metoprolol dosage: 25 mg Reports metoprolol frequency: 1x daily Denies metoprolol side effects Followed up on medication for prostate enlargement Reports taking Proscar (finasteride) Reports Proscar dosage: 5 mg Reports Proscar frequency: 1x daily Denies Proscar side effects Followed up on sleep aid Reports taking Benadryl to make him drowsy Reports Benadryl dosage: Isn't sure Reports Benadryl frequency: once or twice a week Denies Benadryl side effects Family History Asked about relevant family history Reports father died of colon cancer Reports mother died of heart failure Social History Asked about substance use Reports occasional alcohol use Denies illicit drug use Reports past cigarette smoking Followed up on alcohol use Reports occasional beer or cocktails Reports drinking only at gatherings Reports drinking less than 1 drink per week Reports that drinking often gives heartburn so he tends to avoid alcohol Followed up on cigarette smoking Reports started smoking age 20 Reports quitting smoking age 60 (20 years ago) Reports smoking 1 pack a day when actively smoking Asked about exercise Reports occasional exercise Reports enjoying walking, but only short distances, as he does not have the energy any more to walk long distances. Reports that dizziness has interfered with walking Review of Systems Asked about general symptoms Denies feeling feverish Denies chills Denies night sweats Asked about review of systems for HEENT Reports hearing loss Reports wearing a hearing aid Reports vision problems Reports wearing glasses for reading and watching TV Asked about review of systems for respiratory Denies shortness of breath Denies cough Denies dyspnea on exertion Denies wheezing Asked about review of systems for cardiovascular Denies history of blood clots Denies history of DVT Denies chest pain Denies palpitations Reports claudication Asked about review of systems for gastrointestinal Denies abdominal pain Denies difficulty swallowing Denies nausea Denies vomiting Denies constipation Denies diarrhea Denies changes in stool or bowel patterns Asked about review of systems for musculoskeletal Reports occasional joint pain from arthritis Reports erythema of joints Reports edema of joints Asked about review of systems for neurological Reports overall weakness Denies frequent headaches Reports numbness and tingling in left lower leg Denies numbness / tingling elsewhere in body Asked about review of systems for psychological Denies anxiety Denies recent mood changes Denies suicidal thoughts Functional Status & Geriatric Syndromes Asked about depression Asked about living environment Reports living in a house Reports living alone Reports some loneliness Reports visits from one of his daughters every few days Asked about feeling safe at home Reports feeling safe at home Asked about bathing Reports being able to bathe independently Reports being able to reach all parts of his body Reports being able to get out of shower safely Reports that his daughter installed a bar in the shower Asked about dressing Reports being able to retrieve clothing Reports being able to put on clothes Denies difficulty with buttons and zippers Denies difficulty tying shoes Asked about toileting Reports being able to get up from the toilet with support (uses cane) Reports being able to arrange clothing during toileting Reports being able to clean genital area without help Asked about transferring Reports difficulty getting out of bed in the morning Reports some difficulty getting out of chairs Reports occasional use of cane to transfer Asked about continence Reports full control over bowels Reports occasional urinary incontinence from prostate enlargement Asked about ability to eat independently Reports being fully able to eat and feed himself Reports being fully able to get food from plate to mouth Reports being able to prepare food Asked about sleeping habits Reports poor sleep Reports occasional insomnia Reports frequent waking Denies oversleeping Asked about confusion Denies confusion Asked about evidence of falls Reports recent fall Reports history of falls Reports falling twice in the last 6 months Reports recent dizziness Reports increased dizziness the past 2 weeks Reports dizziness gets worse when he stands Asked about gait and ambulatory aids Reports some gait impairment Denies bedrest Denies use of wheelchair Reports occasionally using cane to walk Reports balance problems Asked about skin breakdown Reports thin skin Denies open wounds Denies rashes or lesions Reports Bruising Denies pruritus, itching or scratching Asked about weight changes Reports weight loss Reports 10 lbs weight loss Reports weight loss occurred over the last 6 months Reports weight loss was unintentional Asked about oral or dental problems Denies tooth problems and dental pain Denies issues with mouth, jaw, or gums Reports no issues with being able to chew food Asked about appetite changes Reports anorexia Reports anorexia for the last few months Reports feeling full quickly Asked about effects of health on social activity Reports that health sometimes prevents him from engaging in social activity Denies that emotional problems prevent him from engaging in social activity Asked about patient's perception of health Reports poor health Asked about tiredness, energy levels, and fatigue Reports fatigue Reports activity increases fatigue Reports some fatigue most days Asked about recent ER visits or hospitalizations Reports ER visit in the last 3 months Denies hospitalization in the last 3 months Reports going to the ER after a fall Reports getting a hip x-ray Reports x-ray revealed no fracture Denies being admitted to hospital © Shadow Health® 2018 [Show More]

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