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Comprehensive Assessment Tina Jones Shadow Health

Comprehensive Assessment Tina Jones Shadow Health. Subjective and obje...

Course

Nursing Clinical Experience LAB (11-63-272)

24 Documents

Students shared 24 documents in this course

University

University of Windsor

Academic year: 2020/2021

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Herzing heath assessment comprehensive assessment

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Comprehensive Assessment

Patient: Tina Jones

Subjective Data Collection: 33 of 33

(100%)

Hover To Reveal...

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

 Found:

Indicates an item that you found.

 Available:

Indicates an item that is available to be found.

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

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.

Current Health Status



Finding:

Asked about current health problems



Finding:

Denies current acute health problems

(Found)

Pro Tip: Determining if the patient has any current acute health problems is essential in conducting a productive exam and prioritzing the patient's needs.

Example Question:

Are you having any health problems?



Finding:

Reports diabetes

(Found)

Pro Tip: Confirming a patient's medical conditions, such as diabetes, will enable you to provide the best care possible.

Example Question:

Can you confirm your diabetes?



Finding:

Reports asthma

(Found)

Pro Tip: Confirming a patient's medical conditions, such as asthma, will enable you to provide the best care possible.

Example Question:

Can you confirm your asthma?

Example Question:

When was your last physical exam?



Finding:

Asked about current prescription medications



Finding:

Reports taking diabetes medication

(Found)

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.

Example Question:

Have you been taking medication for your diabetes?



Finding:

Reports having an inhaler

(Found)

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.

Example Question:

Do you have an inhaler?



Finding:

Reports taking prescription birth control pills

(Found)

Pro Tip: A patient's use of birth control can impact the care plan, such as which medications are prescribed. Understanding a patient's history of birth control can be an indicator of health literacy.

Example Question:

Are you taking any form of birth control?



Finding:

Followed up about diabetes medication



Finding:

Reports diabetes medication is metformin

(Found)

Pro Tip: Follow up questions about Tina's diabetes medication will help you to understand her treatment plan and recent health history.

Example Question:

What is the name of your diabetes medication?



Finding:

Reports starting taking diabetes medication 5 months ago

(Available)

Pro Tip: Follow up questions about Tina's diabetes medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question:

How long have you been taking metformin?



Denies adverse effects of diabetes medication

(Available)

Pro Tip: Determining if Tina has experienced any adverse effects of her diabetes medication will help you determine the efficacy and appropriateness of her medication.

Example Question:

Are you experiencing adverse effects from your diabetes medication?



Finding:

Asked about asthma medication



Finding:

Reports asthma medication has not changed

(Found)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.

Example Question:

Has your asthma medication changed?



Finding:

Reports inhaler is albuterol (Proventil)

(Found)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.

Example Question:

Do you have a rescue inhaler?



Finding:

Reports using inhaler no more than 2 times per week

(Available)

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking how frequently Tina uses her inhaler can indicate how she's been treating her symptoms.

Example Question:

How often do you use your inhaler?



Finding:

Reports recommended dose is 1-3 puffs as needed

(Found)

Pro Tip: Asking Tina about the recommended dose of her inhaler can help you determine if the treatment is effective and appropriate for her health needs.

Example Question:

What is the recommended dosage for your inhaler?



Finding:

Reports typically taking 2 puffs

(Found)

Pro Tip: Asking Tina about how many puffs of her inhaler she typically takes can help you determine if the treatment is effective and appropriate for her health needs.

Example Question:

How many puffs of your inhaler do you typically take?



How long ago did you start taking birth control?



Finding:

Reports reason for birth control was to manage PCOS symptoms

(Available)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.

Example Question:

What reason did you decide to start taking birth control?



Finding:

Reports birth control is drospirenone and ethinyl estradiol (Yaz)

(Found)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina's birth control pill will solicit information about her health history and current treatment plan.

Example Question:

What type of birth control do you use?



Finding:

Reports taking birth control pill daily

(Available)

Pro Tip: Follow up questions about Tina's birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question:

How often do you take your birth control pill?



Finding:

Reports taking birth control pill at the same time every day

(Available)

Pro Tip: Follow up questions about Tina's birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question:

Do you take your pill at the same time every day?



Finding:

Denies adverse side effects from birth control

(Found)

Pro Tip: Follow up questions about Tina's birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question:

Do you have side effects from your birth control?



Finding:

Asked about current non-prescription medications



Finding:

Reports occasional ibuprofen use

(Found)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes ibuprofen will indicate her current treatment plan.

(Found)

Pro Tip: Discovering the reason a patient has been taking pain medication is a crucial part of the history of her condition or injury.

Example Question:

Why do you take ibuprofen?



Finding:

Reports ibuprofen is regular strength

(Available)

Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan.

Example Question:

What strength ibuprofen do you take?



Finding:

Reports ibuprofen is effective

(Available)

Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient's individual response to pain medication is an important factor in your overall treatment plan.

Example Question:

Does ibuprofen help your cramps?



Finding:

Reports last use of ibuprofen was six weeks ago

(Available)

Pro Tip: Discovering the last time your patient has taken pain medication is a crucial part of the history of her condition or injury.

Example Question:

When was the last time you took ibuprofen?



Finding:

Asked about allergies



Finding:

Reports allergies have not changed

(Found)

Pro Tip: In a comprehensive assessment, it is important to determine if any allergies have changed for the patient and determine how best to address those changes.

Example Question:

Can you confirm your allergies?



Finding:

Reports penicillin allergy

(Found)

Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient's safety while she is in your care, as it affects what medications will be safe and appropriate.

Example Question:

Are you allergic to penicillin?



Finding:



Finding:

Reports recently beginning exercising to manage diabetes

(Found)

Pro Tip: Tina's response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.

Example Question:

Have you been exercising?



Finding:

Asked about blood glucose monitoring



Finding:

Reports checking blood sugar once a day

(Found)

Pro Tip: Tina's response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.

Example Question:

How often do you monitor your blood glucose?



Finding:

Reports checking sugar in the morning

(Found)

Pro Tip: Tina's response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.

Example Question:

When do you check your blood glucose?



Finding:

Reports using glucometer

(Available)

Pro Tip: Tina's response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.

Example Question:

Do you use a glucometer?



Finding:

Reports blood sugar number is usually around 90

(Available)

Pro Tip: Tina's response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.

Example Question:

What is your average blood sugar number?



Finding:

Reports having adequate supplies

(Available)

Pro Tip: Tina's response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.

Example Question:

Pro Tip: It is important to solicit information about Tina's current asthma symptoms, as this will allow you gain an up-to-date picture of her condition.

Example Question:

Do you have any difficulty breathing?



Finding:

Reports last use of Proventil inhaler was yesterday

(Available)

Pro Tip: Determining the last time Tina used her inhaler will help you gain an up-to-date picture of her condition and determine the efficacy of her current medication.

Example Question:

When was the last time you used your inhaler?



Finding:

Asked about vision



Finding:

Reports optometrist visit

(Found)

Pro Tip: Asking Tina if she has been to an eye doctor will indicate the degree to which she's seen her vision as something that has needed medical attention.

Example Question:

Have you been to an eye doctor?



Finding:

Reports last optometrist visit was 3 months ago

(Found)

Pro Tip: Asking Tina when she last saw an eye doctor will indicate the degree to which she's seen her vision as something that has needed medical attention.

Example Question:

When did you go to the eye doctor?



Finding:

Reports recently prescribed eyeglasses

(Found)

Pro Tip: Determining any outcomes from Tina's last optometrist visit is important, as it may reveal treatments that you should follow-up on.

Example Question:

Did you get prescription eyeglasses?



Finding:

Reports that glasses improve overall vision

(Found)

Pro Tip: Once you uncover that Tina has recently been prescribed eyeglasses, it is important to follow-up on any effects, both positive and negative, that she may have noticed.

Example Question:

How do you like your glasses?



Finding:

Asked about reproductive system

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Comprehensive Assessment Tina Jones Shadow Health

Course: Nursing Clinical Experience LAB (11-63-272)

24 Documents

Students shared 24 documents in this course

University: University of Windsor

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Comprehensive Assessment

Patient: Tina Jones

Subjective Data Collection: 33 of 33

(100.0%)

Hover To Reveal...

Hover over the Patient Data items below to reveal important information, including Pro

Tips and Example Questions.

Found:

Indicates an item that you found.

Available:

Indicates an item that is available to be found.