Shadow Health - Health History Tina Jones - Transcript.

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Your Results Lab Pass (/assignment_attempts/12408588/lab_pass.pdf) Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Care Plan Video Tu... torial Hallway Self-Reflection Interview Questions (170) Statements (20) Exam Actions (5) Hello! 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. What is the situation? 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. What are my objectives in this assessment? 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. What else will this exam involve? All Lines (195) Question 06/06/22 12:51 AM EDT Question 06/06/22 12:53 AM EDT Statement 06/06/22 12:59 AM EDT Greet 06/06/22 1:00 AM EDT Exam Action 06/06/22 1:01 AM EDT Exam Action 06/06/22 1:02 AM EDT Exam Action 06/06/22 1:03 AM EDT Question 06/06/22 1:04 AM EDT Question 06/06/22 1:05 AM EDT 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. You will then move onto the Care Plan activity, in which you will synthesize your subjective and objective data to complete the nursing process. You will develop a nursing diagnosis for Ms. Jones's condition, identify a treatment goal, plan your interventions and evaluations, and finally assess if your goal was achieved. The Care Plan is just as important as your assessment, and the patient's well-being will be greatly affected by your diagnosis and interventions. How will I be evaluated? The activities evaluated by the simulation are Subjective Data Collection, Education and Empathy, and the Care Plan activity. Nursing tasks and Documentation, while they provide valuable practice for their real-world counterparts, are not automatically evaluated by the simulation. 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. Your success in the Care Plan activity is based on whether you accurately identify Ms. Jones's nursing diagnosis, select a goal most immediately beneficial to her, select and prioritize the most effective treatments, and accurately evaluate your results. The Care Plan will make up a signficant part of your grade, so be sure to carefully choose your answers based on evidence. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, learners 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. How does this assignment prepare me for the real world? In this assessment, you will familiarize yourself 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 develop a nursing diagnosis º create an effective and expedient care plan º and evaluate your results to determine your goal's achievement. In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient's complete health history? To get a concise understanding of the patient's past and current additions along with any information or factors that may be contributing to the patient's health status. Using this information a diagnosis can be made. Time to begin. Hello Miss Jones I am Alex and I am going to be your nurse today Hello. You closed the curtain for privacy. You washed your hands. You checked the patient's armband. Can you confirm your name? Tina Jones. What brings you to the hospital today Empathize 06/06/22 1:05 AM EDT Question 06/06/22 1:07 AM EDT Question 06/06/22 1:07 AM EDT Empathize 06/06/22 1:11 AM EDT Question 06/06/22 1:12 AM EDT Question 06/06/22 1:14 AM EDT Question 06/06/22 1:15 AM EDT Question 06/06/22 1:16 AM EDT Question 06/06/22 1:17 AM EDT Empathize 06/06/22 1:18 AM EDT Question 06/06/22 1:19 AM EDT 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! I'm sorry you're in so much pain I'm glad you're here so we can help you Aw, thanks. Which foot has a scrape My right foot. How long has this been going on (Clarified to How long have you been in pain?.) Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. (Clarified to how long I have been in pain.) I'm sorry you're in so much pain. I will get you pain medication as soon as possible. I appreciate that. When did the pain start? Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. where Is your pain located It feels like the pain is just centered around the scrape, like around the ball of my foot. That's where it hurts the most, but my whole foot feels some pain. Is the pain constant? Yeah, it's been pretty much around the clock for the last few days. What does the pain feel like It's throbbing and like, sharp if I try to put weight on it. what makes the pain worse Trying to put weight on my foot makes it feel worse... But at this point, it's been killing me all day, non-stop. I'm sorry you're in so much pain That's kind of you. does anything help the pain? Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn't doing much for me -- it would only last a couple of hours. Question 06/06/22 1:25 AM EDT Question 06/06/22 1:25 AM EDT Question 06/06/22 1:25 AM EDT Question 06/06/22 1:26 AM EDT Question 06/06/22 1:32 AM EDT Question 06/06/22 1:33 AM EDT Question 06/06/22 1:35 AM EDT Question 06/06/22 1:38 AM EDT Empathize 06/06/22 1:38 AM EDT Question 06/06/22 1:41 AM EDT Question 06/06/22 1:42 AM EDT Question 06/06/22 1:43 AM EDT Question 06/06/22 1:43 AM EDT How long have you been taking the advil? I started taking Advil two days ago. How much advil were you taking? Well, two per dose, so six every day. What mg were the advil pills? (No matching questions found.) What is the dosage of the advil? (Clarified to Can you tell me the dosage of the ibuprofen?.) I'm not sure. It's just the regular Advil. Not the big extra strength pills. (Clarified to how many milligrams of ibuprofen I take.) Have you tried any treatments? (Clarified to Have you tried treatments at home?.) I made sure to clean it and keep it bandaged. And I put Neosporin on it. (Clarified to if I have tried treatments at home.) Can you rate your current level of pain on a scale of 0 to 10? ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. Can you rate your pain when you came into the emergency department? (Clarified to Can you rate the pain when walking on a scale from 1 to 10?.) Like a 9 or 10. (Clarified to how I would rate my pain when walking.) What additional symptoms have your experienced? 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'm sorry you're in pain Thanks. How did you hurt your foot? I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was! Has your foot been draining any liquids? Yeah, there's definitely pus. What color was the pus? It's... white or maybe off-white. How effective was the neosporin [Show More]

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