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Shadow Health Assessment Assignment Tina Jones Foot Wound

Shadow Health Assessment Assignment Tina Jones Foot Wound - asking que...
Course

advanced health assessment (NR 509)

70 Documents
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Academic year: 2021/2022
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Health History Results | Turned In

Advanced Health Assessment - Chamberlain, NR509-April-

Return to Assignment

Your Results Lab Pass Lab Pass

Started: May 05, 2018 | Patient Exam Time: 181 min

Transcript

Exam Action 05/05/18 11: AM CDT

Exam Action 05/05/18 11: AM CDT

Exam Action 05/05/18 11: AM CDT

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Exam Action 05/05/18 11: AM CDT

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Information Processing

Health History Tips and Tricks

Self-Reflection

Interview Questions (204)Interview Questions (204) Statements (14)Statements (14) Exam Actions (15)Exam Actions (15)

Height: 170 cm Height: 170 cm

Weight: 90 kg Weight: 90 kg

BMI: 31 BMI: 31

Random blood glucose: 238 Random blood glucose: 238

Temperature: 101 F Temperature: 101 F

Blood pressure: 142/82 Blood pressure: 142/

Respiratory rate: 19 Respiratory rate: 19

O2 sat: 99% O2 sat: 99%

All Lines (233)All Lines (233)

Exam Action 05/05/18 11: AM CDT

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Greet 05/05/18 11: AM CDT

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Heart rate: 86 Heart rate: 86

Hello, Tina Jones my name is Sara an FNP student here toHello, Tina Jones my name is Sara an FNP student here to

interview you today you today.

Hey.

What brings you here today?What brings you here today?

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!

Where is the pain on your foot?Where is the pain on your foot?

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.

Can you tell me what foot this is pleaseCan you tell me what foot this is please

It's... [Ms. Jones reports the correct year.] [AUDIO COMING

SOON]

Which foot is the pain located?Which foot is the pain located?

My right foot.

How severe is the pain in your right foot?How severe is the pain in your right foot?

It's really bad.

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what is the pain like when you stand on your foot?what is the pain like when you stand on your foot?

Yes! I mean, I literally can't put weight on my foot, the pain is so

sharp.

when did the pain start?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.

Has the pain changed over time?Has the pain changed over time?

At first, it seemed like it was healing up fine and it didn't give me a

lot of pain. But the last two days, the pain got way worse.

Does your pain radiate?Does your pain radiate?

The pain's worse in my foot, but I feel it moving up into my ankle,

too.

Can you bear weight on your foot?Can you bear weight on your foot?

No, I can't. I can't put any weight on it without like, shooting pain.

I am sorry I understand how you feel am sorry I understand how you feel.

I appreciate you telling me that.

Did you injure anything else beside your foot?Did you injure anything else beside your foot?

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Well, at first I thought my ankle was sprained because it hurt a lot

right after I fell. But, I mean, I guess I was over-estimating it,

because the ankle felt pretty okay the next day and it wasn't a

problem all week.

Did you have any alcoholic drinks before injury?Did you have any alcoholic drinks before injury?

No, I was stone-cold sober. It was the middle of the day.

Where you wearing shoes when you fell?Where you wearing shoes when you fell?

No, I was barefoot.

Always make sure to wear shoes when outside make sure to wear shoes when outside.

OK, I understand.

You went to the ER for your injury?You went to the ER for your injury?

Yeah, right after it happened, I worried I might've sprained my

ankle so mom drove me to the ER.

Did your foot bleed?Did your foot bleed?

Yeah, right when I hurt it.

Did you notice any discharge from the wound?Did you notice any discharge from the wound?

Yeah, there's definitely pus.

When did you first notice pus?When did you first notice pus?

Two days ago.

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Does the wound feel warm?Does the wound feel warm?

Yeah, it feels pretty warm.

Does your foot pain affect your work?Does your foot pain affect your work?

Well, I tried to go in two days ago but I couldn't walk well enough,

so I just went home after a couple hours. And I didn't go in

yesterday. My boss was understanding, but I need to be able to

work!

Has your injury prevented you from going to class?Has your injury prevented you from going to class?

I had a class two days ago, and I skipped it. I haven't missed any

classes before this, and I emailed my professor, so I should be

okay. I don't want to get behind, so I need to get back to it!

Are you feeling feverish right now?Are you feeling feverish right now?

I don't feel feverish right now, but last night I had a high

temperature.

Measured wound: 2 cm x 1 cm, 2 mm deep Measured wound: 2 cm x 1 cm, 2 mm deep

Swabbed wound and sent to lab for C & S Swabbed wound and sent to lab for C & S

Cleansed and irrigated wound with normal saline and applied Cleansed and irrigated wound with normal saline and applied

dry sterile dressing sterile dressing.

Measured wound: 2 cm x 1 cm, 2 mm deep Measured wound: 2 cm x 1 cm, 2 mm deep

Swabbed wound and sent to lab for C & S Swabbed wound and sent to lab for C & S

Exam Action 05/05/18 12: PM CDT

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Cleansed and irrigated wound with normal saline and applied Cleansed and irrigated wound with normal saline and applied

dry sterile dressing sterile dressing.

a culture was taken of your foot and sent to the lab to find outa culture was taken of your foot and sent to the lab to find out

what is going on with the drainagewhat is going on with the drainage

That makes sense.

the wound was also cleaned and placed a sterile dressingthe wound was also cleaned and placed a sterile dressing

Alright, thanks for letting me know.

Do you have any medical conditions?Do you have any medical conditions?

Yeah... I have asthma and diabetes.

When were you diagnosed with diabetes?When were you diagnosed with diabetes?

I was diagnosed when I was 24.

At age 24 you were diagnosed with diabetes? (Clarified to how oldAt age 24 you were diagnosed with diabetes? (Clarified to how old

were you when you were diagnosed with diabetes.)were you when you were diagnosed with diabetes.)

I was diagnosed when I was 24.

Do you know what type of diabetes you have?Do you know what type of diabetes you have?

It's Type 2.

Do you follow a diabetic diet?Do you follow a diabetic diet?

I really try not to worry about what I eat, other than watching my

sugar and trying to make healthy choices.

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Thanks.

Tell me about your blood sugar monitoring me about your blood sugar monitoring.

I don't check it very often, honestly... I think the last time was

about a month ago.

How often do you check your blood sugar?How often do you check your blood sugar?

I don't check it very often, honestly... I think the last time was

about a month ago.

What are your usual blood sugar levels?What are your usual blood sugar levels?

I guess sometimes it's probably high, but I don't know the

numbers. I almost never check it. I don't really get what the

numbers mean.

It is important to check your blood sugars on a regular basis. AIt is important to check your blood sugars on a regular basis. A

diabetic educator will help you with this information in detail if youdiabetic educator will help you with this information in detail if you

are interested interested.

Thanks for telling me.

Have you been thirsty lately?Have you been thirsty lately?

You know, I did notice lately that I've been really thirsty.

Are you drinking more water than normal?Are you drinking more water than normal?

I've definitely been drinking more water lately.

Have you been urinating more often than usual?Have you been urinating more often than usual?

Yeah, but I've been drinking more water.

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How often do you urinate during the day?How often do you urinate during the day?

I don't know. Every hour or two when I'm awake?

How often do you wake up at night to urinate?How often do you wake up at night to urinate?

I probably have to get up two or three times a night.

With your last meal?With your last meal?

I had leftover chicken and mashed potatoes last night.

what is your Typical breakfast?what is your Typical breakfast?

I'll usually have a muffin or pumpkin bread from the cafe near my

house.

what Is your typical lunch?what Is your typical lunch?

Lunch is the meal I usually pick up near campus because of my

schedule. I go to Subway mostly and get a turkey sandwich or

something.

what is your Typical dinner?what is your Typical dinner?

The usual stuff... meatloaf, chicken, casseroles, pasta... stuff like

that.

what Do you typically eat for snacks?what Do you typically eat for snacks?

I try to eat snacks that are kind of healthy like pretzels-sometimes

I'll treat myself and get french fries, but I try not to do that too

often.

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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.

When did you last have issues with asthma?When did you last have issues with asthma?

I was at my cousin's house three days ago, and my asthma acted

up while I was there.

What do your asthma symptoms feel like?What do your asthma symptoms feel like?

My chest and throat get tight, and I start to wheeze. It feels like I

can't take in air, like I can't get enough air into my lungs.

Do you ever wheeze?Do you ever wheeze?

During a full attack, I would wheeze a lot, like I couldn't breathe at

all, but that hasn't happened in years. Now I wheeze a little when I

have breathing problems, but it's not nearly that bad.

When was your last asthma attack?When was your last asthma attack?

It's really rare for me to have an attack now. Three days ago I had

some breathing problems, but I guess probably my last full attack

was in high school.

Have you ever been hospitalized in the past?Have you ever been hospitalized in the past?

Well, I went a week ago on the day I hurt my foot to get it checked

out. That was the first time I've been in the hospital since I was

probably sixteen, though.

Have you ever been hospitalized in the past for your asthma?Have you ever been hospitalized in the past for your asthma?

I went a bunch of times when I was little, for asthma attacks.

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When was your last hospitalization for asthma?When was your last hospitalization for asthma?

I haven't gone to the hospital for asthma since I was sixteen.

Have you been hospitalized for asthma?Have you been hospitalized for asthma?

I went a bunch of times when I was little, for asthma attacks.

How do you manage your asthma?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.

What is the name of the inhaler prescription?What is the name of the inhaler prescription?

It's just a regular Proventil inhaler.

When did you last use your inhaler?When did you last use your inhaler?

I had to use my inhaler three days ago when I was at my cousin's

house.

I'm sorry that I I'm sorry that I sound repetitive but I just want to be accuratesound repetitive but I just want to be accurate

about your medical history your medical history.

Thanks for understanding.

How many puffs of your inhaler are you prescribed?How many puffs of your inhaler are you prescribed?

I usually use two puffs from my inhaler, but lately I sometimes need

three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray

MDI]

What triggers your asthma problems?What triggers your asthma problems?

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I don't remember that well because the last time I had penicillin I

was pretty little... I think I got a rash, like, hives. The doctor told

me not to take it again after that.

Do you have any food allergies?Do you have any food allergies?

Nope, no food allergies that I know of.

Do you have any seasonal allergies?Do you have any seasonal allergies?

No, not really.

Are your immunizations current?Are your immunizations current?

I'm pretty sure they are all taken care of.

Did you receive childhood vaccines?Did you receive childhood vaccines?

I am pretty sure I received all my vaccines as a kid, like before

registering for school.

Did you get a flu shot this year?Did you get a flu shot this year?

No.

When was your last tetanus booster?When was your last tetanus booster?

I got a tetanus booster about a year ago.

Want to inform you that there will be some more repetitiveWant to inform you that there will be some more repetitive

questions.

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Thanks for telling me.

What pain medications have you been taking?What pain medications have you been taking?

It's called tramadol.

How many times a day do you take pain medication?How many times a day do you take pain medication?

I've been taking them morning, noon, and night.

How many pain pills do you take at a time?How many pain pills do you take at a time?

I take two at a time.

What is the dose of the pain medication?What is the dose of the pain medication?

I'm not 100% sure, but I think they're 50 milligrams.

How long does the pain medication last?How long does the pain medication last?

They only help for a few hours at a time.

Do you take any over-the-counter medication?Do you take any over-the-counter medication?

I take Tylenol for a headache sometimes, or Advil for cramps, but

not often.

How often do you take Tylenol for headaches?How often do you take Tylenol for headaches?

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Well, I'm finishing up my Bachelor's degree right now.

What do you study?What do you study?

I'm going to get my bachelor's in accounting.

Can you tell me about your stress level?Can you tell me about your stress level?

I feel pretty worried about my foot right now. I don't like sitting

around, but it's been hard to walk or do anything the last few days.

And I don't like missing school and work. Plus it hurts.

Does anyone live at home with you?Does anyone live at home with you?

Right now I live back at home with my mom and my sister.

Tell me more about living at home me more about living at home.

Things are pretty good between all of us; we're all close. I think

we're a pretty special family, the way we all get along.

Have you ever experimented with drugs?Have you ever experimented with drugs?

Well, I used to smoke pot... but I don't do that anymore.

When did you last smoke marijuana?When did you last smoke marijuana?

I haven't smoked pot since I was twenty or twenty-one.

What happened to cause you to stop smoking pot?What happened to cause you to stop smoking pot?

It just wasn't that fun anymore, plus it started to bother my

asthma.

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You drink alcohol?You drink alcohol?

I do sometimes, yeah, when I go out with my friends.

Who was the last alcoholic drink?Who was the last alcoholic drink?

I haven't had any alcohol in at least three weeks.

How many alcoholic drinks do you have in one sitting?How many alcoholic drinks do you have in one sitting?

I never have more than two or three. If I go over that, I feel like hell

the next day, so I stick to just a few.

How many nights a week do you drink alcohol?How many nights a week do you drink alcohol?

Once or twice a week at most, on the weekend.

How many alcoholic drinks do you have a month?How many alcoholic drinks do you have a month?

Oh, I don't know. Let's see... I might go out every few weeks, so

twice a month... and I maybe have 2 or 3 drinks at a time, so

maybe 6 drinks a month. Even if I go out more than usual, no more

than ten.

Have you ever smoked cigarettes?Have you ever smoked cigarettes?

No. I think it's gross.

Are you ever exposed to second-hand smoke?Are you ever exposed to second-hand smoke?

Some of my friends smoke when we go out drinking. But I don't

smoke, and nobody at home smokes.

Does your mother have health conditions?Does your mother have health conditions?

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Shadow Health Assessment Assignment Tina Jones Foot Wound

Course: advanced health assessment (NR 509)

70 Documents
Students shared 70 documents in this course

University: Chamberlain University

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5/5/2018 Health History | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3485743 1/33
Health History Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results Lab Pass
Lab Pass
Started: May 05, 2018 | Patient Exam Time: 181 min
Transcript
Exam Action
05/05/18 11:43
AM CDT
Exam Action
05/05/18 11:43
AM CDT
Exam Action
05/05/18 11:43
AM CDT
Exam Action
05/05/18 11:43
AM CDT
Exam Action
05/05/18 11:43
AM CDT
Exam Action
05/05/18 11:43
AM CDT
Exam Action
05/05/18 11:43
AM CDT
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Information Processing
Health History Tips and Tricks
Self-Reflection
Interview Questions (204)
Interview Questions (204) Statements (14)
Statements (14) Exam Actions (15)
Exam Actions (15)
Height: 170 cm
Height: 170 cm
Weight: 90 kg
Weight: 90 kg
BMI: 31
BMI: 31
Random blood glucose: 238
Random blood glucose: 238
Temperature: 101.1 F
Temperature: 101.1 F
Blood pressure: 142/82
Blood pressure: 142/82
Respiratory rate: 19
Respiratory rate: 19
O2 sat: 99%
O2 sat: 99%
All Lines (233)
All Lines (233)

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