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Tina Jones Health History
Course: Nursing Nclex review (Nur003)
61 Documents
Students shared 61 documents in this course
University: Chicago School of Professional Psychology
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Tina Jones Health History
Shift Assessment
Student Documentation Model Documentation
Chief Complaint
The patient states that she got and scrape on
her foot a while ago and it got really infected.
Right foot pain, fever, nausea
History of Present Illness
Patient states she got the wound on her foot a
week ago while she was changing a light bulb.
The wound is located on the ball of her right
foot, and it's red and swollen. Patient refers a
whitish drainage from the wound. Patient states
she used Neosporin on her wound with not
relieve. Patient states a pain level 7 in the scale
of pain. Patient refers some relief after takin
Advil at home. Patient states she is unable of
performing her activities of daily living because
of the wound on her foot
Ms. Jones is a pleasant 28-year-old African
American woman who presented to the
emergency department for evaluation of a
right foot injury and was admitted for IV
antibiotics. She is a good historian. She hurt
the ball of her right foot by scraping it on the
edge of a metal step while changing a light
bulb. The injury occurred about one week
ago. Her pain has worsened, and the swelling
has persisted. She tried ibuprofen, but it didn't
work well. The foot feels better when she
rests, and it hurts more when she walks on it.
Her pain is a 9 when she tries to ambulate.
She took her temperature at home and
reports it was 102. She has not been eating
much and has been staying in bed the last few
days, per patient report. The scrape is red and
swollen with exudate and has no odor; she
reports the swelling and exudate started two
days ago. She reports diarrhea overnight. Pain
improved with oxycodone. Stomach upset.
Pain Assessment
Patient refers a pain level of 7 in the pain scale.
Patient states the pain is continuous and
throbbing. She says the pain is sharp if she tries
to put weight on it
Pain is rated as 7. Pain is localized to ball of
foot related to wound. Dull and constant ache.
Patient has tried ibuprofen, but reports it does
not work well. Patient states there is relief
when foot is elevated, not walking on it.
Patient answers questions clearly and
consistently. Offers information without
hesitation. Vital signs are within range.
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