NR 509 Comprehensive_Assessment_transcript_Chamberlain College of Nursing | NR509 Comprehensive_Assessment_transcript

NR 509 Comprehensive_Assessment_transcript_Chamberlain College of Nursing NR509 Comprehensive_Assessment_transcript Comprehensive Assessment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-20 ...

NR 509 Comprehensive_Assessment_transcript_Chamberlain College of Nursing NR509 Comprehensive_Assessment_transcript Comprehensive Assessment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Transcript Greet 06/10/18 3:17 PM CDT Question 06/10/18 3:17 PM CDT Question 06/10/18 3:17 PM CDT Question 06/10/18 3:18 PM CDT Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Self-Reflection I In nt te er rv viie ew w Q Qu ue es st tiio on ns s ( (2 25 56 6) ) S St ta at te em me en nt ts s ( (3 33 3) ) E Ex xa am m A Ac ct tiio on ns s ( (4 44 45 5) ) Hello my name is Sara and FNP student I will be conducting your interview today Hey. What is your name Tina Jones. Your date of birth? February 17th. And how old are you? I'm 28. A Allll L Liin ne es s ( (7 73 34 4) )6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 2/36 Question 06/10/18 3:23 PM CDT Question 06/10/18 3:23 PM CDT Question 06/10/18 3:26 PM CDT Empathize 06/10/18 3:27 PM CDT Question 06/10/18 3:28 PM CDT Question 06/10/18 3:28 PM CDT Question 06/10/18 3:29 PM CDT What brought you into the clinic today? I came in because I'm required to have a recent physical exam for the health insurance at my new job. Do you have any current health problems? I don't have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I'm taking good care of my health these days. Where is your new job? (Clarified to what is your new job.) I'm going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I'll be helping a more experienced accountant with her clients, and then eventually I'll get more responsibility, and build my own client list. I start in two weeks--I'm really excited! That is great that you are excited Thanks. When was your last physical? 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. And what did your kind of gynecologist say? She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things. How much birth control are you taking? (Clarified to How often do you take birth control.)6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 3/36 Question 06/10/18 3:29 PM CDT Question 06/10/18 3:30 PM CDT Empathize 06/10/18 3:32 PM CDT Question 06/10/18 3:32 PM CDT Question 06/10/18 3:32 PM CDT Empathize 06/10/18 3:33 PM CDT Question 06/10/18 3:33 PM CDT I take it every morning, with breakfast. What is the name of your birth control? (Clarified to what was the name of the birth control pill you took.) They're called Yaz. Has your menstrual cycle improved since TAKING YAZ? Now that I'm on the pill I'm getting my period every month. That's great I am really glad that you are having your period every month Thanks. How long have you had asthma? I've had asthma a long time. . . since I was really little. What age were you diagnosed with asthma? My doctor told me when I was pretty little... I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. That sounds frightening Thanks. How do you manage your asthma? I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 4/36 Question 06/10/18 3:33 PM CDT Question 06/10/18 3:34 PM CDT Question 06/10/18 3:34 PM CDT Question 06/10/18 3:34 PM CDT Question 06/10/18 3:35 PM CDT Question 06/10/18 3:35 PM CDT Question 06/10/18 3:37 PM CDT Question 06/10/18 3:38 PM CDT 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. What happens when you're around DUST? I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn't happened since I got my daily inhaler. What daily inhaler do you use? It's Flovent. How much fLOVENT do you use a day (No matching questions found.) How much flovent do you use? (No matching questions found.) How often do you use flovent? Twice a day. [Nurse confirmed: fluticasone propionate 88 mcg b.i.d./spray MDI] When was your last dose of flovent? Probably. . . well, not for my last period. Maybe for the one before? So six weeks ago? when you last use flovent? (Clarified to when did you last use your inhaler.)6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 5/36 Question 06/10/18 3:40 PM CDT Question 06/10/18 3:40 PM CDT Question 06/10/18 3:41 PM CDT Question 06/10/18 4:14 PM CDT Question 06/10/18 4:15 PM CDT Question 06/10/18 4:15 PM CDT Empathize 06/10/18 4:15 PM CDT I used my Flovent inhaler this morning--I have to take it twice a day. My albuterol. . . I've maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too. How much Albuterol do you use? I do two puffs when I need it, but that rarely happens. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] How much metformin do you take ? (Clarified to how many milligrams of metformin did you take.) It's 850 mg. And I take one pill, twice a day. When did you last take Metformin? I took it this morning. When were you diagnosed with asthma? My doctor told me when I was pretty little... I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. Are you taking any other medication? Um, I take a lot now, so let me list everything I take... I'm taking Yaz for birth control, metformin, and my daily inhaler. And I have the albuterol inhaler that I don't seem to need anymore. That's good to hear (No matching questions found.) That's good to hear Thanks.6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 6/36 Question 06/10/18 4:16 PM CDT Question 06/10/18 4:16 PM CDT Empathize 06/10/18 4:17 PM CDT Question 06/10/18 4:17 PM CDT Question 06/10/18 4:17 PM CDT Question 06/10/18 4:17 PM CDT Question 06/10/18 4:18 PM CDT Question 06/10/18 4:20 PM CDT Are you using PEAK AND FLOW? I haven't heard that term. Do you feel like your asthma is well controlled? Yeah, ever since I started using my daily inhaler and keeping track of my peak flow I've felt much more in control of my breathing. great Thanks. How often do you use your Peak flow meter Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart. What are your Peak flow meter results? Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart. what are your peak flow averages? (Clarified to Do you check your peak flow regularly?.) Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart. What are your Peak flow meter results? Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart. When was your last asthma attack - - - - - - - - - - - - - -- - - - - - - - - - - - - - - Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 33/36 Question 06/11/18 1:05 PM CDT Question 06/11/18 1:05 PM CDT Question 06/11/18 1:08 PM CDT Question 06/11/18 1:08 PM CDT Question 06/11/18 1:08 PM CDT Question 06/11/18 1:08 PM CDT Question 06/11/18 1:08 PM CDT I haven't had any problems with diarrhea. Excessive flatulence I haven't been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. Any food intolerances? I can eat just about anything. Any burning when you urinate No, it doesn't burn when I pee. You get up in the middle of the night to pee (Clarified to How often do you wake up at night to urinate?.) Only once, if at all. Are you peeing multiple times a day I think I pee a normal amount. . . maybe five times during the day, and then once at night? In blood in your urine No! That doesn't sound like it would be good. flank pain? (No matching questions found.) amy flank pain (No matching questions found.)6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 34/36 Question 06/11/18 1:09 PM CDT Question 06/11/18 1:09 PM CDT Question 06/11/18 1:09 PM CDT Question 06/11/18 1:10 PM CDT Question 06/11/18 1:10 PM CDT Question 06/11/18 1:11 PM CDT Question 06/11/18 1:11 PM CDT Question 06/11/18 1:11 PM CDT are you having pain to flank area? (Clarified to are you having pain right now.) I don't have any pain anywhere. Any vaginal discharge? My discharge is normal, I think. . . I have a little, and it's kind of clear, sometimes white-ish. Vaginal itching? No, it feels normal. Are you having any problems with your breasts, My breasts feel fine. Have you noticed any lumps in your breast? No. Any pain in your breast? No, my breasts feel fine. Are you having any dizziness I haven't been getting dizzy at all.6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 35/36 Question 06/11/18 1:11 PM CDT Question 06/11/18 1:12 PM CDT Question 06/11/18 1:12 PM CDT Question 06/11/18 1:12 PM CDT Question 06/11/18 1:12 PM CDT Question 06/11/18 1:13 PM CDT Question 06/11/18 1:14 PM CDT Question 06/11/18 1:14 PM CDT Any lightheadedness No, I don't really get lightheaded. Any tingling Nope, no tingling. Loss of coordination No. I mean, I'm clumsy, but it's not that bad. Loss of sensation (Clarified to Have you had changes in sensation?.) I haven't noticed any changes. any seizures No, I've still never had problems with seizures, fortunately. Any problems with your equilibrium? (Clarified to do you have memory problems.) I think my memory has been fine. any muscle pain My muscles have felt great, especially since I started exercising more. joint pain6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 36/36 Question 06/11/18 1:14 PM CDT Question 06/11/18 1:14 PM CDT Exam Action 06/11/18 1:16 PM CDT Exam Action 06/11/18 1:16 PM CDT Show more My joints always seem fine. Any muscle weakness? No, I haven't felt weak at all. Any swelling? Nothing is swollen. Performed pulse oximetry Performed spirometry Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2018