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Tina jones comprehensive questions to ask
Advanced Health Assessment (NURS 6512)
Walden University
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Subjective Data Collection
Objective Data Collection Documentation Plan My Exam
Subjective Data Collection: 50 of 50
(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.
Category
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:
Confirmed reason for visit
Finding:
Reports needing a pre-employment physical
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.
Example Question:
Can I confirm that you are here for a physical?
Finding:
Reports no current acute health problems
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.
Example Question:
Do you have any current health problems?
Finding:
Asked about last visit to a healthcare provider
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 using a daily 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 use a daily inhaler?
Finding:
Reports taking prescription birth control pills
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.
Example Question:
Are you taking any form of birth control?
Finding:
Followed up about diabetes medication
Finding:
Medication is metformin
(Found)
Pro Tip: Follow up questions about Tina's medication history will help you to understand her treatment plan and recent health history.
Example Question:
What is the name of your diabetes medication?
Finding:
Started taking metformin 5 months ago
(Found)
Pro Tip: Follow up questions about Tina's 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?
Finding:
Reports that eating probiotic yogurt helps with side effects and they have abated over time
Finding:
Asked about asthma medication
Finding:
Reports using Flovent inhaler twice daily
(Found)
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina's been using her inhaler more frequently since exacerbation can indicate how she's been treating her symptoms since exacerbation.
Example Question:
How often do you use your daily inhaler?
Finding:
Has a Proventil rescue inhaler
(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:
Last use of Proventil inhaler was three months ago
(Available)
Pro Tip: Soliciting a shallow history of a patient's medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.
Example Question:
When did you last use your rescue inhaler?
Finding:
Has used Proventil inhaler twice in the last year
(Found)
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina's been using her inhaler more frequently since exacerbation can indicate how she's been treating her symptoms since exacerbation.
Example Question:
How often do you use your rescue inhaler?
Finding:
Followed up about birth control prescription
Finding:
Started taking birth control 4 months ago
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.
Example Question:
How long ago did you start taking birth control?
Finding:
Reason for birth control was to manage PCOS symptoms
(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 take your pill at the same time every day?
Finding:
Reports no skipped days
(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:
Have you missed any days of your birth control pill?
Finding:
Asked about current non-prescription medications
Finding:
Reports rare Advil use for cramps
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes non prescription drugs will indicate her current treatment plan.
Example Question:
Do you take Advil?
Finding:
Reports no OTC herbal products
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan.
Example Question:
Do you use any herbal products?
Finding:
Reports no OTC vitamins
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan.
Example Question:
Do you take any vitamins?
Finding:
Reports no OTC supplements
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan.
Example Question:
Do you take any supplements?
(Found)
Pro Tip: Discerning whether anything is making Tina's asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina's breathing.
Example Question:
Have you been having seasonal allergies?
Finding:
Reports no current medication for allergies
(Available)
Pro Tip: Tina's response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.
Example Question:
Are you taking any medication for your allergies?
Finding:
Asked about diabetes
Finding:
Reports managing diabetes with diet and exercise in addition to medication
(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 are you managing your diabetes?
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:
Checks 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:
Blood sugar number is usually around
(Found)
Reports no recent asthma exacerbations
(Found)
Pro Tip: Asthma severity might change over time for a variety of reasons. Asking Tina about the recent severity of her asthma will allow her to assess her condition.
Example Question:
Have you had recent asthma symptoms?
Finding:
Reports last asthma exacerbation was three months ago
(Found)
Pro Tip: Soliciting a shallow history of a patient's condition can provide a baseline for comparing an attack, exacerbation, and more regular breathing. Asking about breathing problems can elicit a response about recent troubles.
Example Question:
When was your last asthma exacerbation?
Finding:
Asked about headache symptoms
Finding:
Reports no recent headache
(Found)
Pro Tip: Soliciting a shallow history of a patient's condition can provide a timeline for understanding when a patient experiences a condition. Asking Tina if she's had a headache recently will allow you to assess the frequency of her headaches.
Example Question:
Have you had a headache recently?
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:
Optometrist visit 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 prescription eyeglasses
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Pro Tip: Conditions, like palpitations, might change over time. Asking Tina about the frequency and duration of her palpitations recently will allow you to assess the recent severity of her condition.
Example Question:
Are you having heart palpitations?
Finding:
Reports no recent palpitations
(Found)
Pro Tip: Conditions, like palpitations, might change over time. Asking Tina about the frequency and duration of her palpitations recently will allow you to assess the recent severity of her condition.
Example Question:
Have you been having heart palpitations recently?
Finding:
Asked about hypertension treatment
Finding:
Reports that blood pressure responded to diet and exercise changes
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how she has been treating her hypertension will indicate her treatment plan and the degree to which she complies with it.
Example Question:
How have you been treating your hypertension?
Finding:
Asked about GERD
Finding:
Reports no recent GERD symptoms
(Found)
Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.
Example Question:
Have you had heartburn recently?
Finding:
Reports no current GERD symptoms
(Found)
Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.
Example Question:
Are you having any GERD symptoms?
Finding:
Reports no current medication for GERD
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes medication for heartburn will indicate her current treatment plan.
Example Question:
Tina jones comprehensive questions to ask
Course: Advanced Health Assessment (NURS 6512)
University: Walden University
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