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COPD shadow health
Community Health Nursing (NUR 4636C)
Santa Fe College
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Experience Overview
Patient: Debbie O'Connor
Digital Clinical Experience Score
Chapter: Statement
1
Proficiency Level
Beginning
•
Students rated as “beginning” are starting to develop their advanced practice
competencies and clinical reasoning skills. In comparable programs, 50% of students perform at the level of a beginning pra
Subjective Data Collection
30
out of
32
Medication Selection
22
out of
27
Education and Empathy
4
out of
6
Patient Teaching
93%
This score measures your performance on the Student Performance Index in relation to
other students in comparable academic programs. Your instructor has chosen to scale
your Student Performance Index score so that the average score on the index is a
80%. This score may not be your final grade if your instructor chooses to include
additional components, such as documentation or time spent.
Student Performance Index
93
out of
111
Chief Complaint
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. -
####### Finding:
Established chief complaint and reason for admittance
####### Finding:
Reports a bronchospasm three days ago
####### (Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
####### Example Question:
When did your symptoms start?
####### Finding:
Reports increased difficulty breathing
####### (Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
History of Present Illness
####### Example Question:
What are your symptoms?
####### Finding:
Reports desire for smoking cessation aids
####### (Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
####### Example Question:
What can I do for you?
####### Finding:
Asked about additional symptoms
####### Finding:
Reports fatigue and weakness
####### (Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
Do you feel fatigued?
####### Finding:
Asked about onset and duration of symptoms
####### Finding:
Reports most severe fatigue and difficulty breathing began three days ago
####### (Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
When did your fatigue begin?
####### Finding:
Reports purulent sputum production started two weeks ago
####### (Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
When did your productive cough begin?
####### Finding:
Reports respiratory symptoms increased in the last four months
####### (Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
How long have you had your symptoms?
####### Finding:
Followed up on characteristics of respiratory distress
####### Finding:
Reports sputum is mostly clear with occasional yellow, gray, or dark color
####### (Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
What does your sputum look like?
####### Finding:
Reports wheezing
####### (Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
Are you wheezing?
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
When do you have coughing fits?
####### Finding:
Asked about treatment and relieving factors of respiratory symptoms
####### Finding:
Reports trying to hold off on smoking cigarettes as long as possible
####### (Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
How long do you wait between cigarettes?
####### Finding:
Asked about severity of respiratory distress
####### Finding:
Reports breathing difficulty and associated discomfort is a 6/
####### (Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current
Past Medical History
complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
Can you rate your symptoms on a scale of 1 to 10?
####### Finding:
Asked about effects of health on social activity
####### Finding:
Reports low social activity - doesn't feel up to getting out and about
####### (Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
####### Example Question:
How do your symptoms prevent you from social activities?
####### Finding:
Asked about existing health conditions
####### Finding:
Reports chronic bronchitis related to COPD
####### (Found)
####### Finding:
Asked about ER visits or hospitalizations
####### Finding:
Reports hospitalization after miscarriage at age 24
####### (Available)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
####### Example Question:
When were you hospitalized?
####### Finding:
Reports most recent hospitalization was two years ago
####### (Found)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
####### Example Question:
When was your most recent hospitalization?
####### Finding:
Reports most recent hospitalization was for respiratory distress episode
####### (Found)
Home Medications
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
####### Example Question:
What was your recent hospitalization for?
####### Finding:
Asked about home medications
####### Finding:
Reports taking a long-acting beta-agonist (LABA)
####### (Found)
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
Do you take a LABA?
####### Finding:
Followed up on LABA
####### Finding:
Reports the LABA is formoterol inhaler
####### (Found)
####### (Available)
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
When is the last time you used your inhaler?
####### Finding:
Reports the LABA is not very effective
####### (Available)
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
Is the inhaler effective?
####### Finding:
Denies medication side effects
####### (Available)
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
Do you have any side effects from your inhaler?
####### Finding:
Asked about supplements and vitamins
####### Finding:
Denies use of supplements or vitamins
####### (Found)
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
Do you take vitamins?
####### Finding:
Asked about medication regimen adherence
####### Finding:
Denies missing doses
####### (Found)
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
Do you miss doses of your medication?
####### Finding:
Asked about spirometry
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
Do you use oxygen even though you smoke?
####### Finding:
Asked about allergies
####### Finding:
Denies allergies
####### (Found)
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
Do you have any allergies?
####### Finding:
Asked about vaccines
####### Finding:
Denies recent influenza vaccine
####### (Available)
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and
Social History
frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
Have you had a flu shot?
####### Finding:
Denies recent pneumococcal vaccines
####### (Available)
Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.
####### Example Question:
Have you had a pneumonia vaccine?
####### Finding:
Asked about living environment
####### Finding:
Reports she lives with her daughter
####### (Found)
Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives.
####### Example Question:
COPD shadow health
Course: Community Health Nursing (NUR 4636C)
University: Santa Fe College
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