Virginia Commonwealth University - NURS 261Focused Exam_ Pain Transcript Shadow Health. Fully Explained
Focused Exam: Pain Results | Turned In
GeHealth, including the Technical Support team will be closed on Memorial
...
Virginia Commonwealth University - NURS 261Focused Exam_ Pain Transcript Shadow Health. Fully Explained
Focused Exam: Pain Results | Turned In
GeHealth, including the Technical Support team will be closed on Memorial Day Monday, 5/25/2020. We will resume normal business on Tuesday, 5/
9 AM EDT. Your success is extremely important to us, so be assured that we will respond to your calls and/or emails ASAP on Tuesday.
Transcript
Your Results Reopen (/assignment_attempts/6932397/reopen
Lab Pass (/assignment_attempts/6932397/lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
SBAR
Reflections
Interview Questions (123) Statements (0) Exam Actions (81)
Hi Mr Carter, I am Jessica, your nurse caring for you today.
Hello.
Can you verify your identity please?
Yes -- I'm Edward Carter.
what is your date of birth?
January 1 . . . [Mr. Carter reports the correct birth year.]
I am horried that this just going to get worse.
(Clarified to if I am in pain right now.)
can you rate your current pain from 0 to 10?
Right now, it's more of a 1. Thank God for the medication.
is the pain constant?
Yes, it was constant from the time I woke up this morning until I came to the ER.
What medicine were you administered in the ER?
They gave me OxyContin when I was in the ER.
Do you know the dosage? (Clarified to What is the dosage of your medication?.)
Let's see -- the Hyzaar is a combination drug -- I know it's 100 milligram of one of the drugs in
there, and ... 25 milligram of the other. I'm afraid I don't know what those two drugs ARE,
though. (Clarified to what the dosage of my medication is.)
how did the injury happen? (Clarified to How did you hurt your back?.)
Well, my back is a bit sore from hitting it on the bed frame this morning. (Clarified to how I hurt
my back.)
uilding you are in? (Clarified to Do you know why you are here today?.)
Well, I'm in the hospital because I was in a lot of pain this morning and I fell. (Clarified to if I
know why I am here.)
what is the day and year? (Clarified to What is the date and year?.)
It's . . . [Mr. Carter says the correct date and year.] (Clarified to what is the date and the year.)
doele.
Does anything make the pain worse?
I have had a little pain every morning for the past month or so -- just walking around seemed to
trigger it. I chalked it up to morning stiffness, getting old, that kind of thing. Sometimes it even
feels like weather changes causes it. This morning was a game changer though. I fell in my
bedroom and hit my back on the bed frame.
do you use any cold therapy?
I havoarthritis/
It was a couple of years ago... I must have been about 66.
Are you diagnosed with other health conditions?
You mean aside from the fall? I've got chronic kidney disease, atrial fib, plus my osteoarthritis
and high blood pressure.
h conditions?
I didn't take anything before I came to the ER, but I know the ER nurse gave me something for
pain.
wheago for a check-up. The doctor said it was around 130
over 85 -- that's in the right range for me.
how does your diet look like?
I try and eat right. I've been cutting back on salt and sugar as much as I can. But I like to have
something sweet now and then.
Have you had any surgeries before?
I've had procedures in the hospital, such as the time I had that damn kidney stone, but I've
never had surgery exactly
Is there a history of kidney stones in the family?
No, I'm the only one who has had them.
is there a history of osteoarthritis in the family?Questio
Questio
mother and father both had.
Do you have any allergies?
No, I don't have any allergies.
Do you have any seasonal allergies?
No, I don't have any allergies like that.
do you have any medication allergies?
me kind -- Kenalog, that's it.
what medications do you take for your atrial fibrillation?
I take warfarin, and verapamil.
what is the dosage on the warfarin?
My doctor's got me on 2.5 milligrams.
what is the dosage of the verapamil?
I take an 80 milligram pill each time.
do you take any medication for your hypertension?
Yes, I take a combo drug for blood pressure.
tell me more about the combo drug
I would say my sleep has been good. I usually feel rested in the morning. I suppose I get about
eight hours.
what medicine do you take for your hypertension?
It's called Hyzaar.
what is the dosage on the Hyzaar?
Let's see -- the Hyzaar is a combination drug -- I know it's 100 milligram of one of the drugs in
there, and ... 25 milligram of the other. I'm afraid I don't know what those two drugs ARE,
though.
do you take any medication for your chronic kidney disease? (Clarified to Do you take
medication for chronic kidney disease?.)
No, my doctor says I don't need to take any medications for it. (Clarified to if I take medication
for chronic kidney disease.)
do you take any pain medication?
I didn't take anything before I came to the ER, but I know the ER nurse gave me something for
do you take other supplements?
No, I don't.
how do you organize your medications?
Well, I see my doctor pretty often to make sure everything's on track. I keep everything in a pill
box and take my medications with my meals so I take them on time. It's not rocket science.
have you noticed any adverse effects of your medicine? (No matching questions found.)
have you noticed any adverse effects of your medication? (No matching questions found.)
have you noticed any adverse effects? (No matching questions found.)
Do you have any side effects from your medications?
Not that I recall.
how often do you take verapamil?
I take it three times a day. I never miss a dose.
how often do you take warfarin?
Once a day.
what medication have you taken last?
I haven't taken any of my regular medications yet today.
how often do you take Hyzaar?
Once a day.
how often do you take naproxen?
I typically take it twice a day for joint pain, that sort of thing.
what is the dosage on the naproxen?
I believe it's 220 mg. That's what it says on the box.
I want to say they are -- 10 mg/mL. That's what I remember my doctor telling me anyway.
when was your last kenalog injection?
Oh, it was at least 3 months ago.
do you consume any alcohol?
I almost never drink these days. It's not good for my kidneys.
do you have any history of drug use?
No. I never once tried drugs.
do you smoke?
No, never.
Have you been hospitalized before?
The last time I was in the hospital was three years ago. I had an awful kidney stone that
wouldn't pass.
how do you view your own health?
Weletite?
I haven't been particularly hungry with this pain. In general, I eat like I always have.
do your health conditions affect your social life?
I wouldn't say that. Though I do need to sit through some family events. Admittedly, I've been
worried that it will get even worse as I age.Questio
have you noticed any issues with confusion?
No, I'd say I'm very alert.
Do you live alone?
I live with my wife, Cynthia. It's been just us for a long while.
do you feel safe at home?
Yes, absolutely. I feel very safe.
do you require assistance with daily activities? (Clarified to Have you required assistance in
performing daily activities?.)
I'm still pretty independent . . . but I'm sure that if I needed help, Cynthia and Randi would take
care of me. (Clarified to if I have needed help with daily activities.)
do you have any trouble bathing?
I can still do that myself.
Do you have any issues clothing yourself? (Clarified to Do you have trouble pulling clothes on
over your head?.)
I've not had any issues dressing myself. (Clarified to if I have trouble pulling clothes over my
head.)
Do you have any issues getting out of bed independently? (Clarified to Do you have trouble
getting in and out of bed?.)
I usually have to use some support to get out of bed with this damn arthritis, but this morning
the pain was so unbearable that I collapsed. (Clarified to if I have trouble getting in and out of
bed.)
do you use a walker?
Well, sometimes I'll use furniture or a cane for some extra support when my arthritis is really
acting up.
do you require assistance going to the bathroom?
No, I don't need help going to the bathroom right now.
have you had a bowel movement today?
Everything's been normal in that department.
when was your last bowel movement?Questio
05/23/20 12:29 AM ED
Oh, it was sometime earlier this morning.
can you tell me how your stool looked like?
I haven't noticed anything alarming or out of the ordinary about it.
how is your usual diet?
I try and eat right. I've been cutting back on salt and sugar as much as I can. But I like to have
something sweet now and then.
do you have difficulty sleeping?
No, I wouldn't say I've had any sleep issues.
do you have any history of falls?
I've never fallen like I did this morning. It was really very startling.
have you noticed any changes in weight lately?
I don't really think about it. I've always managed to maintain what I consider a healthy weight.
do you have any problems with your teeth?
No, I haven't had any problems with my mouth . . . or my teeth for that matter.
Do you have any issues with your gums?
No, I haven't had any problems with my mouth . . . or my teeth for that matter.
are you fully continent? (No matching questions found.)
are you continent?
Everything's been normal in that department.
Do you require assistance toileting? (No matching questions found.)
can you go to the toilet independently? (Clarified to Have you been able to get to the toilet by
yourself?.)
I don't have any problem with doing *that* myself. (Clarified to if I can go to the bathroom
without help.)
do you ever get any accidents?Questio
do you ever get chest pain? (Clarified to Have you ever had chest pain?.)
No, I'd be pretty concerned if I did. (Clarified to if I have ever had chest pain.)
Have you noticed any edema?
My knees feel a bit swollen, probably from my arthritis acting up, but I don't typically have
s
do you have any trouble hearing?
My hearing is still pretty good, I'd say.
Have you noticed any memory problems?
My memory has always been pretty sharp.
do you get headaches often?
I don't typically get headaches.
have you noticed any mood changes?Questio
05/23/20 12:35 AM ED
Questio
0
05/23/20 12:38 AM ED
Exam Actio
05/23/20 12:39 AM ED
Exam Actio
05/23/20 12:39 AM ED
Have you ever suffered from depression?
No, I haven't had much cause for that.
Mr Carter, I will examine you now
Thank you. I'm ready. [AUDIO COMING SOON]
Inspected head and face
Inspected mouth
Inspected front of hips: visible edema
Inspected left hip: visible edema
Inspected back of hips: visible edema
Inspected right hip: visible edemaExam Actio
05/23/20 12:40 AM ED
Exam Actio
05/23/20 12:40 AM ED
Exam Actio
05/23/20 12:40 AM ED
Exam Actio
Exam Actio
05/23/20 12:41 AM ED
Exam Actio
05/23/20 12:41 AM ED
Exam Actio
05/23/20 12:41 AM ED
Exa
Inspected left thigh
Inspected back of thighs
Inspected front of knees: Valgus deformity
Inspected left knee: visible swelling
Inspected back of knees: Valgus deformity
Inspected front of lower legs
Exam Actio
05/23/20 12:42 AM ED
Exam Actio
05/23/20 12:43 AM ED
Exam Actio
05/23/20 12:43 AM ED
Exam Actio
05/23/20 12:43 AM ED
Exam Actio
05/23/20 12:43 AM ED
Exam Actio
ness
Inspected left hand palm
Inspected right hand palm
Inspected back of legs
Inspected heels
Inspected right shoulder and right side of neck
Inspected top of right hand
Inspected right leg
Inspected right side of right foot
Auscultated carotids
05/23/20 12:47 AM ED
Auscultated breath sounds in posterior right upper lobe
Au
Palpated right knee: reported tenderness, effusion, bony swelling, and crepitus, popping, or
clicking
Palpated left knee: reported tenderness, effusion, bony swelling, and crepitus, popping, or
clicking
Palpated posterior tibial pulse
Palpated dorsalis pedis pulse
Tested fine motor skills
repeat and remember apple, penny, table
Apple, penny, and table.
can you repeat the three words I asked you to remember earlier?
Apple, penny, and table.
Tested cognition
Tested strength of hips - no resistance: Active movement against gravityExam Actio
05/23/20 12:47 AM ED
Exam Actio
05/23/20 12:49 AM ED
Exam Actio
05/23/20 12:49 AM ED
Exam Actio
05/23/20 12:50 AM ED
Exam Actio
05/23/20 12:50 AM ED
Questio
05/23/20 12:51 AM ED
Exam Actio
05/23/20 12:52 AM ED
Tested strength of knees against gravity: Active movement against gravity
Tested skin turgor
Tested capillary refill
Tested gait: Hesitancy, steps clear floor, and greater than 12 seconds to complete
Tested gait: Hesitancy, steps clear floor, and greater than 12 seconds to complete
thank you mr carter
You're welcome. [AUDIO COMING SOON]
Assessed vitals
Comments
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