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Shadow Health Respiratory Subjective Data Collection- Tina Jones
Advanced Health Assessments for Patients and Populations (D028)
Western Governors University
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Jee Sung Kim
Respiratory Results | Turned InD028 -
Advanced Health Assessment - August 2023, D
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Overview Transcript
Subjective Data Collection
Objective Data Collection Education & Empathy Documentation
Subjective Data Collection: 21 of 21
(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.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports increased breathing problems and shortness of breath
(Found)
Example Question:
How long have you had breathing problems?
Finding:
Asked about frequency and duration of SOB episodes
Finding:
Reports exacerbations lasting several minutes
(Found)
Pro Tip: Knowing the duration of an asthma or shortness of breath episode will give you insight into how effective the patient's interventions are, and how severe the episode is.
Example Question:
How long do your asthma episodes last?
Finding:
Reports exacerbated breathing about every 4 hours since original episode
(Found)
Pro Tip: The frequency of asthma episodes or shortness of breath might vary over time. Asking Tina about her recent experience will expound upon her current condition.
Example Question:
How many times have you had breathing problems in the past two days?
Finding:
Reports waking up twice a night with asthma the past 2 nights
(Available)
Pro Tip: Many patients with asthma report trouble sleeping. Asking Tina if she has trouble sleeping can indicate the severity of her asthma.
Example Question:
How many times in the past two nights did asthma wake you up?
Finding:
Asked about severity of symptoms
Finding:
Describes asthma severity as "not full attack," but worse than usual
(Found)
Pro Tip: Asthma severity might change over time for a variety of reasons. Asking Tina about the severity of her asthma will allow her to assess her condition.
Example Question:
How severe is your asthma?
Finding:
Reports asthma has been interfering with activities of daily life
(Available)
What happens when your asthma acts up?
Finding:
Denies chest pain
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences chest pain during an attack will indicate how her individual symptoms manifest.
Example Question:
Are the shortness of breath episodes associated with chest pain?
Finding:
Asked about cough
Finding:
Reports cough
(Found)
Pro Tip: A shallow history of a patient's condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. Soliciting this information from Tina allows her to explain any recent developments with her asthma.
Example Question:
Have you been coughing?
Finding:
Cough has persisted since original asthma exacerbation 2 days ago
(Available)
Pro Tip: Some people who experience chronic asthma may be accustomed to coughing and thus might not volunteer this information. Asking Tina how long she has been coughing illustrates how her asthma is presenting.
Example Question:
How long have you had a cough?
Finding:
Describes cough as "dry"
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe her cough specifies the way her individual symptoms manifest.
Example Question:
How would you describe your cough?
Finding:
Describes cough as "small" and not severe
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe her cough specifies the way her individual symptoms manifest.
Example Question:
How severe is your cough?
Pro Tip: Sometimes a condition will fluctuate during the course of the day. By asking Tina how her asthma differentially impacts her both during the day and at night, you are assessing an important change over time.
Example Question:
Is your asthma worse at night?
Finding:
Reports symptoms increase when lying flat on back
(Found)
Pro Tip: Asthma can be aggravated by movements that constrict the respiratory airways. By asking Tina if lying down causes shortness of breath, you're assessing which positions might cause exacerbation.
Example Question:
Does lying down make your asthma worse?
Finding:
Reports symptoms aggravated by movement
(Available)
Pro Tip: Asthma can be aggravated by movements that constrict the respiratory airways. Inquiring into what activities make Tina short of breath can indicate possible triggers.
Example Question:
Is there anything you can't do because of your asthma?
Medical History
Finding:
Confirmed use of medications
Finding:
Confirms medications (no new medications reported)
(Found)
Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.
Example Question:
What medications do you take?
Finding:
Followed up about inhaler use
Finding:
Uses an inhaler to treat asthma symptoms
(Found)
Pro Tip: It's essential to ask specifically what medications a patient is using to treat her current complaint or any ongoing medical conditions.
Example Question:
Do you use an inhaler for your asthma?
How many times have you used your inhaler in the past two days?
Finding:
Prescribed usage is 2 puffs
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how many puffs of her inhaler she's prescribed will indicate her treatment plan and the degree to which she complies with it.
Example Question:
How many puffs of your inhaler are you prescribed?
Finding:
Reports needing more than 2 puffs to resolve asthma symptoms
(Available)
Pro Tip: Inhaler effectiveness can vary over time for a variety of reasons. Asking Tina about the number on inhaler puffs she needs to resolve symptoms can indicate whether her asthma has worsened or point to potential problems like poor inhaler technique.
Example Question:
How many inhaler puffs do you need?
Finding:
Confirmed allergies
Finding:
Confirms allergies (no new allergies reported)
(Found)
Pro Tip: It's best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.
Example Question:
Do you have any new allergies?
Finding:
Followed up on exposure to allergy and asthma triggers
Finding:
Reports cat allergy triggered recent episodes
(Found)
Pro Tip: Questions about what factors might have caused an illness can point to a patient's environmental stressors, habits, and general wellbeing. Asking Tina what caused her asthma might indicate her health literacy and understanding of what factors impact her breathing.
Example Question:
What started your recent asthma problems?
Finding:
Reports dust as a known trigger
(Found)
Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such trigger.
Pro Tip: For some patients, weather changes can be asthma irritants. Asking Tina if the weather impacts her asthma will indicate if weather is an irritant for Tina's condition.
Example Question:
Do changes in weather make your asthma worse?
Finding:
Reports minimal exposure to asthma triggers at work
(Available)
Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation.
Example Question:
Does anything at work make your asthma worse?
Finding:
Asked detailed questions about asthma history
Finding:
No current asthma doctor
(Available)
Pro Tip: Seeing a specialist, like an asthma doctor, can help patients to manage symptoms. Asking whether Tina is seeing an asthma doctor will allow you to assess her current treatment plan and healthcare access.
Example Question:
Do you have an asthma doctor?
Finding:
Diagnosed with asthma in childhood
(Found)
Pro Tip: By determining the onset of asthma you can get a sense for Tina's asthma history, instance, and frequency of exacerbation.
Example Question:
How long have you had asthma?
Finding:
Age of diagnosis was 2 1/2 years old
(Found)
Pro Tip: By determining the onset of asthma you can get a sense for Tina's asthma history, instance, and frequency of exacerbation.
Example Question:
How old were you when you were diagnosed with asthma?
Finding:
Asked about hospitalizations for asthma
Finding:
Reports prior hospitalizations for asthma
Finding:
Reports she has never been intubated
(Found)
Pro Tip: Intubation for a condition, like asthma, can reveal its severity. By asking Tina if she's been intubated, you are soliciting information about the history and severity of her condition.
Example Question:
Have you ever been put on a breathing tube?
Finding:
Followed up about non-medication forms of asthma management
Finding:
Denies record keeping of asthma exacerbation or shortness of breath episodes
(Found)
Pro Tip: For some patients, keeping records of asthma exacerbation allows them to monitor their conditions. Soliciting this information from Tina will show health literacy.
Example Question:
Do you use a chart to monitor your asthma?
Finding:
Denies using peak flow meter
(Available)
Pro Tip: A peak flow meter measures how well a patient's lungs can expel air. By asking whether Tina uses a peak flow meter, you are asking about her health literacy and what kind of medical tools she uses to manage her asthma.
Example Question:
Do you check your peak flow regularly?
Finding:
Denies nebulizer use
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she uses a nebulizer for her asthma will indicate her treatment plan and the degree to which she complies with it.
Example Question:
Do you use a nebulizer?
Social Determinants of Health
Finding:
Asked about environmental control
Finding:
Reports living situation is tidy and free of dust
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed
Shadow Health Respiratory Subjective Data Collection- Tina Jones
Course: Advanced Health Assessments for Patients and Populations (D028)
University: Western Governors University
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