NUR 325 Transcript Comprehensive Assessment _ Completed _ Shadow Health( Complete Solution Rated A)

Transcript Question 02/12/19 12:39 PM EST Question 02/12/19 12:39 PM EST Question 02/12/19 12:39 PM EST Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam ...

Transcript Question 02/12/19 12:39 PM EST Question 02/12/19 12:39 PM EST Question 02/12/19 12:39 PM EST Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Self-Reflection IInntteerrvviieeww QQuueessttiioonnss ((225533)) SSttaatteemmeennttss ((1122)) EExxaamm AAccttiioonnss ((336633)) Hello! Hi. Im 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? Six months have passed since Tina Jones was admitted to Shadow General Hospital, and her foot wound has healed. Your role in this simulation is that of a healthcare provider who will perform a comprehensive assessment on Ms. Jones to demonstrate your clinical competency. What are my objectives in this assessment? AAllll LLiinneess ((662288)) Question 02/12/19 12:40 PM EST Question 02/12/19 12:40 PM EST Question 02/12/19 12:41 PM EST At the beginning of this assignment, you will be asked to identify and organize the steps of your comprehensive exam. Having a clear plan is essential to maximizing efficiency and obtaining a full picture of the patients current health. Then you will collect subjective data from Ms. Jones: inquire into her current health status, body systems, mental health, and psychosocial history. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to understanding her current health status. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones systems to gather objective data about her overall health. Ms. Jones has no new abnormal findings, so after you complete an exam task, you do not need to make selections in the Electronic Health Record, though you may document your findings if you like. 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? You will complete nursing tasks to protect the patients safety, privacy, and health. While it is not required for this assignment, 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. How will I be evaluated? 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 requires you only to complete all exam actions. Documentation of the exam is optional, though encouraged, as it can provide you valuable realworld experience. This assignment takes on average between 140 and 170 minutes. 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? Statement 02/13/19 11:41 AM EST Question 02/13/19 12:39 PM EST Question 02/13/19 12:39 PM EST Question 02/13/19 12:40 PM EST Question 02/13/19 12:40 PM EST In this assessment, you will become familiarized with the structure and content of comprehensive assessments so that with real-life patients, you can: º develop a mental model for sequencing a comprehensive exam º ask effective and comprehensive questions º evaluate the patients risk of disease, infection, injury, and complications º and document data with professional terminology. In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: How does interviewing a healthy patient differ from interviewing a patient with a known health condition? In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: How does interviewing a healthy patient differ from interviewing a patient with a known health condition? A health assessment is individualized to each patient based on any known health conditions, current condition and acuity. Knowing a patient has an existing condition enables the nurse to custom tailor the assessment, adding additional depth to the interview and assessment customized to the given disease state to seek additional information about effective management, symptoms, medication compliance and patient perceptions of disease state while further enabling the identification of knowledge gaps and facilitating the provision of additional education. Time to begin. Hello, I'm Kathleen. I'm your nurse today. Hi. Can you please confirm your name and date of birth? My name's Tina Jones, and my birthday's February 17th. Hi Tina. How old are you? (Clarified to How old are you?.) I'm 28. (Clarified to what is my age.) What brought you into the clinic today? Empathize 02/13/19 12:40 PM EST Question 02/13/19 12:41 PM EST Question 02/13/19 12:41 PM EST Empathize 02/13/19 12:58 PM EST Question 02/13/19 12:58 PM EST Question 02/13/19 12:58 PM EST Question 02/13/19 12:59 PM EST I came in because I'm required to have a recent physical exam for the health insurance at my new job. Congrats on the new job. Thanks. What is your new job? Well, I'm starting my new job in two weeks, and I'm really excited about that. I'm going to be an Accounting Clerk at this really nice accounting firm. Are you excited or nervous about your new job? I'm so excited about my new job. I think it's going to be a great experience, and I can't wait to learn how to do a bunch of new things. Are you having any health problems right now? Thanks. Are you having any health issues currently? I don't have any new problems--still just the old asthma and diabetes. Can you list all of your current medications? I'm taking metformin now, that's every day. And I take Yaz, the birth control pill. And then my inhaler is the same, but that's not every day. What is your dose and frequency of metformin? It's 850 mg. And I take one pill, twice a day. Question 02/13/19 1:00 PM EST Question 02/13/19 1:00 PM EST Question 02/13/19 1:00 PM EST Question 02/13/19 1:01 PM EST Question 02/13/19 1:01 PM EST Question 02/13/19 1:02 PM EST Question 02/13/19 1:02 PM EST Question 02/13/19 1:02 PM EST Do you monitor your blood sugars? Yeah, I check it once a day, in the morning. Can you give me a range of your morning blood sugars? (No matching questions found.) What are normal blood sugars for you ? My blood sugar's usually around 90. Do you check your blood sugar before eating or drinking? Yeah, I check it once a day, in the morning. which inhalers do you use? It's an albuterol inhaler. How many puffs do you use, and how frequently do you use it? It's usually a couple puffs--sometimes 3 if I need it. The prescription says I can do that. How often do you need your albuterol? Never more than twice a week, I'd say. It depends on the week. Sometimes I don't use it at all. What are your triggers for asthma? Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven't had a full asthma attack in years, though. Question 02/13/19 1:03 PM EST Question 02/13/19 1:03 PM EST Question 02/13/19 1:04 PM EST Question 02/13/19 1:04 PM EST Question 02/13/19 1:05 PM EST Question 02/13/19 1:05 PM EST Question 02/13/19 1:06 PM EST Question 02/13/19 1:06 PM EST Question 02/13/19 1:07 PM EST How many years has it been since your last full asthma attack? I had a small exacerbation yesterday from running up the stairs which only lasted a minute, really--just used my inhaler and I was fine. Do you use other medications for you asthma? It's an albuterol inhaler. How long have you been taking the birth control pill Yaz? About four months ago. I went to the gynecologist, and she prescribed it. Are you using Yaz for birth control or another reason? (No matching questions found.) Do you have any medical conditions besides asthma and diabetes? (Clarified to Do you have medical problems other than your diabetes and asthma?.) I found out recently that I had PCOS, too. (Clarified to if I have other medical problems besides diabetes and asthma.) Are you taking Yaz to treat pcos? (No matching questions found.) Are you using Yaz as birth control? Yeah. The gynecologist said I have PCOS, and I should be on birth control. How often do you take Yaz? I take it every morning, with breakfast. Have you noticed any changes since taking Yaz? (No matching questions found.) Question 02/13/19 1:07 PM EST Question 02/13/19 1:08 PM EST Question 02/13/19 1:08 PM EST Question 02/13/19 1:08 PM EST Question 02/13/19 1:08 PM EST Question 02/13/19 1:09 PM EST Question 02/13/19 1:09 PM EST Question 02/13/19 1:10 PM EST What symptoms do you associate with polycystic ovarian syndrome? Yeah. The gynecologist said I have PCOS, and I should be on birth control. Prior to starting Yaz, were your menstrual cycles irregular? (No matching questions found.) Are your menstrual cycles regular? Now that I'm on the pill I'm getting my period every month. When was your last period? Um. . . about two weeks ago. Do you have any problems when you have your period? Being on the pill has really helped the problems I was having with my period. Do you have any pain with your period? (Clarified to Do you have pain during your menstrual cycle?.) They used to be pretty bad. I would have to take three or four Advil, and use a heating pad and everything. They're much better now. (Clarified to if I have pain during menstruation.) Have you had any unusual hair issues? Actually, I think I have a little less body hair than I used to. Have you noticed any hair loss on your head? Nope. Question 02/13/19 1:10 PM EST Question 02/13/19 1:10 PM EST Question 02/13/19 1:10 PM EST Question 02/13/19 1:11 PM EST Question 02/13/19 1:11 PM EST Question 02/13/19 1:11 PM EST Question 02/13/19 1:12 PM EST Question 02/13/19 1:13 PM EST Are you taking any vitamins? I don't take any vitamins. Do you use any over the counter medications? I don't take anything over the counter really. . . except Advil for cramps, but I don't need it that much anymore. Do you take any herbal supplements? I don't take any herbal supplements. Have you missed any doses of medication? No, I'm pretty careful with my medications. Have you missed any doses of Yaz? (Clarified to Have you missed any days of your birth control pill?.) I'm really careful to take it every day. (Clarified to if I have missed days of my birth control pill.) Do you take it at the same time every day? I take it every morning, with breakfast. Do you use any inhaled steroids for your asthma? Yeah, I have a rescue inhaler. When was your last visit to a healthcare provider? Question 02/13/19 1:13 PM EST Question 02/13/19 1:13 PM EST Question 02/13/19 1:15 PM EST Educate 02/13/19 1:18 PM EST Question 02/13/19 1:18 PM EST Question 02/13/19 1:18 PM EST Question 02/13/19 1:19 PM EST Question 02/13/19 1:19 PM EST Let's see... I had two doctor's appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear. What were the results of your pap smear? I think they were all fine. Are you currently sexually active? It's been a while, but I actually have a boyfriend now. We haven't had sex yet, but we probably will soon. How do you plan to protect yourself from sexually transmitted infections when you have sex? I used condoms. . . some of the time. I was on the pill. It is important to use condoms consistently in any new sexual relationship to protect yourself and your partner. I recommend that each of you are screened for sexually transmitted infections before becoming intimate and again six months into the relationship, and continue condom use until after that six month exam. Thanks for telling me. Please tell me about any hospitalizations you've experienced. (No matching questions found.) Will you tell me about any hospitalizations you've experienced? (No matching questions found.) Have you been hospitalized? Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I've been in the hospital since I was probably sixteen, though. What brought you to the hospital?