Week 4 - Assignment 2 - Tina Jones Health Assessment
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Shadow Health - Tina Jones, Health History
Terms in this set (474)
Health History Tips & Tricks: ...
Student: Hello!
Diana Shadow: Hi. I'm Preceptor Diana. I will explain the details of this
assignment and your objectives, just as a preceptor would in real life. Pay
close attention to this information as it will help guide your exam. At the
end of this prebrief, you will answer a short question about the upcoming
assignment. During the simulation, you may return to these instructions at
any time by scrolling to the top of your transcript.
Student: What is the situation?
Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American
woman who has just been admitted to Shadow General Hospital for a
painful foot wound. Your role in this simulation is that of a healthcare
provider who will take Ms. Jones' health history, a key component of her
admission process.
Student: What are my objectives in this
assessment?
Diana Shadow: A health history requires you to ask questions related to
Ms. Jones' past and present health, from her current foot wound to her
pre-existing conditions. You will also want to review Ms. Jones' systems,
psychosocial history, and family medical history. These assessments
together will give you a comprehensive picture of Ms. Jones' overall
health. If you discover any disease states, ask about symptoms and the
patient's experiences of them. Your questioning should cover a broad
array of the symptoms' characteristics. Throughout the conversation, you
should educate and empathize with Ms. Jones when appropriate to
increase her health literacy and sense of well-being. Regardless of
whether you have assessed Ms. Jones previously, ask all questions that
are necessary for obtaining a complete health history. While you should
communicate with patients using accessible, everyday language, it is
standard practice to use professional medical terminology everywhere
else, such as in documenting physical findings and nursing notes. You
may complete the exam activities in any order and move between them
as needed. After obtaining Ms. Jones' health history, you will complete an
information processing activity. You will identify and prioritize diagnoses,
then create a plan to address the identified diagnoses.
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Student: What else will this exam involve?
Diana Shadow: You will complete nursing tasks to protect the patients
safety, privacy, and health. You can document your findings, including
vital signs, in the Electronic Health Record. This record provides
necessary information for healthcare professionals who will continue
patient care. Besides Subjective Data Collection, and Education and
Empathy, there are activities within the simulation that provide valuable
practice for their real-world counterparts, but they are not automatically
graded by the simulation.
Student: How will I be evaluated?
Diana Shadow: In this assignment, you will be evaluated on your
Subjective Data Collection, as well as your Education and Empathy. Your
success in Education and Empathy is based on whether you promptly
respond after identifying a moment worthy of therapeutic
communication. The evaluation of your interview is dependent on how
you word your questions therapeutically and precisely and explore all
relevant topics with comprehensive breadth and depth. You will also be
evaluated on your ability to collect data and form nursing diagnoses in
the information processing activity. This assignment takes on average
between 90 and 110 minutes. This exam may take longer than in real life,
because in this safe simulation, students of all experience levels can take
time to hone and review their skills. You can pause and resume the
assignment at any time; your work is always saved automatically.
Student: How does this assignment prepare
me for the real world?
Diana Shadow: In this assessment, you will become familiarized with the
structure and content of a health history exam so that with real-life
patients, you can: º ask effective and comprehensive questions º obtain
a thorough health history º evaluate the patient's risk of disease,
infection, injury, and complications º educate and empathize º reflect on
your experience and identify areas to improve º identify and prioritize
nursing diagnoses º and develop a plan to address nursing diagnoses.
Diana Shadow: In 1 or 2 sentences, answer
this question to help prepare for the
upcoming exam: Why is it important to
obtain a patient's complete health history?
Student: So that you understand if there are any problems related to
their chief complaint. Also, to help treat their current condition.
Diana Shadow: Time to begin. ...
Patient Exam - Vital Signs:
Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238,
Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90,
Respiratory rate: 18, O2 sat: 98%
Patient Exam - Interview: ...
Student: Hello, my name is Catlain, I am your
nurse today.
Tina Jones: Hey.
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Student: Can you confirm your name? Tina Jones: Tina Jones:.
Student: Why did you come in today? Tina Jones: I got this scrape on my foot a while ago, and it got really
infected. It's killing me.
Student: What additional symptoms have you
experienced?
Tina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it
hurts like hell... It's got all that going on.
Student: Can you rate your current pain level
on a scale of 0 to 10?
Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave
me is helping a little bit.
Student: Please describe the pain. Tina Jones: It's throbbing and like, sharp if I try to put weight on it.
Student: How did you hurt your foot?
Tina Jones: I was changing a light bulb, and I had to use our little
stepstool to reach it. My foot slid off the bottom step and it got all
scraped up. I didn't realize how sharp the edge was!
Student: Has your foot been draining any
liquids?
Tina Jones: Yeah, there's definitely pus.
Student: What color was the pus? Tina Jones: It's... white or maybe off-white.
Student: How have you treated the wound? Tina Jones: I've been taking Advil for my foot for a few days.
Student: What did you do to treat your foot
after your accident?
Tina Jones: I made sure to clean it and keep it bandaged. And I put
Neosporin on it.
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Student: How effective was the Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job.
Student: Can you walk with your foot being
injured?
Tina Jones: No, I can't. I can't put any weight on it without like, shooting
pain.
Student: What preexisting medical conditions
do you have?
Tina Jones: I mean, I have asthma and diabetes, but right I now I just care
about my foot!
Student: I understand your foot hurts, but I
need to know this information to make sure I
take care of the problem correctly.
Tina Jones: Thanks.
Student: When were you diagnosed with
diabetes?
Tina Jones: I was diagnosed when I was 24.
Student: What do you do to manage your
asthma?
Tina Jones: I try to avoid things that give me breathing problems, but
when my asthma starts to act up, I just use my inhaler.
Student: What medications did you take for
your diabetes?
Tina Jones: It was metformin.
Student: Do you currently take medicine for
your diabetes?
Tina Jones: No, I don't take anything for my diabetes anymore.
Student: What made you stop taking
medication for your diabetes?
Tina Jones: I guess I just got sick of feeling sick and gassy all the time,
and it was overwhelming, remembering to take pills and check my sugar.
I feel a lot better now that I'm just eating healthier than I did when I was
taking the pills.
Student: Do you monitor your blood
glucose?
Tina Jones: I have a monitor at home, but to be honest I don't really use it
that often.
Student: How frequently do you urinate? Tina Jones: I don't know. Every hour or two when I'm awake? Shadow Health - Tina Jones, Health History
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Student: What is your current diet? Tina Jones: It's pretty good, I think. I'm not a huge health nut or anything.
Student: Have you had any change in
appetite?
Tina Jones: Yeah, lately I've definitely been much hungrier than usual.
Student: Has your weight changed? Tina Jones: Yeah, I've lost some weight recently.
Student: Do you know why you lost weight? Tina Jones: I don't know what caused it, I just lost weight.
Student: How often do you have asthma
exacerbations?
Tina Jones: I haven't had a full attack in years. But my breathing definitely
acts up. . .not always. Max twice a week.
Student: What asthma symptoms have you
experienced?
Tina Jones: 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.
Student: How many puffs do you take when
using your asthma inhaler?
Tina Jones: I usually use two puffs from my inhaler, but sometimes I need
three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]
Student: What are some things that trigger
your asthma?
Tina Jones: Being around cats is the worst, but dust and running up stairs
can make my breathing bad, too.
Student: What allergies do you have? Tina Jones: I'm allergic to cats.
Student: When did you realize you were
allergic to cats?
Tina Jones: For as long as I've been around.
Student: How effective was your pain
medication at home?
Tina Jones: Whatever pain medication the ER gave me is helping. Before I
came in, I was just taking Advil. For the past few days, the Advil wasn't
doing much for me -- it would only last a couple of hours.
Student: What medication allergies do you
have?
Tina Jones: I'm allergic to penicillin.
Student: What food allergies do you have? Tina Jones: I don't have any food allergies that I know of.
Student: Are you allergic to dust, mold, or
pollen?
Tina Jones: Well. . . I don't know if it's allergies, but sometimes my asthma
acts up around dust.
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Student: What immunizations have you
received?
Tina Jones: I got a tetanus booster for work about a year ago. For the
other kinds, I got all the required ones when I was a kid, and for
college...I'm sure I have a record somewhere at home.
Student: Have you received a flu vaccine? Tina Jones: No.
Student: Have you had any prior
hospitalizations?
Tina Jones: Well, before this I went a bunch of times when I was little, for
asthma attacks. This is the first time I've been in the hospital since I was
probably sixteen, though.
Student: Have you had any gastrointestinal
problems?
Tina Jones: No. I've never really had stomach or bowel problems.
Student: Do you have a family history of
psychiatric illness?
Tina Jones: No. They're crazy, but nobody's diagnosed with anything.
Student: Do you have any neck, throat or
gland problems?
Tina Jones: No, not that I noticed.
Student: Do you have any problems with
your head?
Tina Jones: I don't think I have any problems. I get headaches sometimes,
but that's all.
Student: Any problems with your ears? Tina Jones: No.
Student: Any problems with your eyes and
vision?
Tina Jones: I've actually been noticing problems lately. When I'm reading
or studying I'll notice that things start to get kind of blurry.
Student: Any problems with your nose? Tina Jones: My nose is fine right now. Sometimes it runs, but not very
often.
Student: Do you have problems with your
mouth?
Tina Jones: No.
Student: Do you have a history of
cardiovascular problems?
Tina Jones: My heart's fine, thank God!
Student: Any problems with your heart? Tina Jones: No, my heart's always been fine. Shadow Health - Tina Jones, Health History
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Student: Have you had any problems with
your breasts?
Tina Jones: I haven't noticed any pain there.
Student: Have you had any reproductive
problems?
Tina Jones: I don't think I have problems in that area. I just get really bad
periods, that's all.
Student: Have you had any neurological
problems?
Tina Jones: No, I haven't.
Student: Have you had any musculoskeletal
problems?
Tina Jones: No.
Student: Do you have a history of skin
disease?
Tina Jones: Um, I have acne, if that counts.
Student: Does your paternal grandfather
have any health problems?
Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of
problems for him. Plus, he had high blood pressure, and...I'm pretty sure
he had diabetes. And high cholesterol like everyone else in my family.
Student: Does your mother have any health
problems?
Tina Jones: Mom has high cholesterol and blood pressure, I think. She
seems to be doing okay though.
Student: Does your father have any health
problems?
Tina Jones: Well, he passed away. But he had a couple things... Type 2
diabetes, like me, and high cholesterol and blood pressure.
Student: How did your father die? Tina Jones: He died in a car accident.
Student: Where is your wound located? Tina Jones: It's on the ball of my foot.
Student: Do you get thirsty often? Tina Jones: You know, I did notice lately that I've been really thirsty.
Student: What happened with your father's
car accident?
Tina Jones: It was last year... I guess a little over a year ago.
Student: How long ago was your dad's car
accident?
Tina Jones: It was last year... I guess a little over a year ago.
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Student: How did you cope with your fathers
death?
Tina Jones: Well, right after he died, after the funeral and everything, I
just tried to get through that. Mom was having such a hard time, crying a
lot, everything made her sad, she was kind of depressed. So, I guess at
first I just focused on getting things done--groceries, laundry, insurance
papers and stuff. Knowing that Mom needed me kind of helped me get
through day by day. There was about a month where it was hard for us to
get to church. Even getting up and ready for church was too
overwhelming. But our church family helped us out and gave us rides to
church and brought meals and all that, so they really helped build us
back up. Things were only hard like that for a few months.
Student: What caused your dads accident? Tina Jones: He was driving to work, and it was raining...and his car
hydroplaned. And hit a tree. So, it was really sudden.
Student: How is your paternal grandmother's
health?
Tina Jones: Granny's doing good. She's still living on her own. She's
slowing down, but we help her out. She lives down the street from us,
and she gets around okay. I think she takes some pills, maybe for blood
pressure? She might have high cholesterol too. She seems happy.
Student: How is your paternal grandfather's
health?
Tina Jones: Grandpa Jones passed away when I was really little.
Student: How is your maternal grandfather's
health?
Tina Jones: Well, Poppa died about five years ago.
Student: How is your maternal grandmother's
health?
Tina Jones: Nana was 73 when she died of a stroke about five years ago. I
think she had high blood pressure and cholesterol, too.
Student: How is your brother's health? Tina Jones: He's a healthy guy. Kind of big like me.
Student: How is your sister's health? Tina Jones: She's pretty healthy. She has asthma too, but she almost never
has attacks.
Student: Does your family have a history of
obesity?
Tina Jones: No, I don't think so. My brother and my dad are kind of big,
but I wouldn't say they were obese or anything.
Student: Does your family have a history
thyroid issue?
Tina Jones: No, I don't think so.
Student: Does your family have a history of
substance abuse?
Tina Jones: One person in the family, my dad's brother, has an alcohol
problem, but we never see him.
Student: Does your family have a history of
headaches?
Tina Jones: No, not that I know of.
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Student: How much alcohol do you drink? Tina Jones: I only have a few drinks when I go out.
Student: What is your level of education? Tina Jones: Well, I'm finishing up my bachelor's degree right now.
Student: What are stressors?
Tina Jones: I feel really stressed out right now! Honestly, I didn't realize
that I'd be admitted to the hospital for my foot. I don't want to miss work
or school but now it looks like I'll have to. And I want my foot to stop
hurting. I know I need sleep, too.
Student: We are going to take care of
everything as quickly as possible.
Tina Jones: Thanks.
Student: Where do you live? Tina Jones: Right now, I'm living at my mom's place, which is out in the
suburbs a bit. It's like a half hour from here.
Student: What is your belief system?
Tina Jones: I'm Baptist. My faith is a big part of my life--when things get
hard like they've been this past year, I know I can trust that God's looking
out for me. I've been going to the same church since I was a kid, too, so
the people at church are practically part of my family.
Student: Have you experienced abuse? Tina Jones: I've never had been in any kind of situation like that... It's scary
to think about.
Student: Have you used illicit drugs? Tina Jones: Well, I used to smoke pot. . . but I don't do that anymore.
Student: What type of drugs did you use? Tina Jones: Um...I've smoked pot before. In high school, and after high
school... I definitely don't anymore, though.
Student: Have you used drugs other than
marijuana?
Tina Jones: No.
Student: When did you last use drugs? Tina Jones: I haven't smoked pot since I was twenty or twenty-one.
Student: Have you ever smoked cigarettes? Tina Jones: No. I think it's gross.
Student: Have you been around people that
are smoking?
Tina Jones: Some of my friend's smoke when we go out drinking. But I
don't smoke, and nobody at home smokes.
Student: How old were you when your father
died?
Tina Jones: He died last year, so I was 27.
Student: Did your father die from any
disease?
Tina Jones: He died in a car accident.
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Student: Can you tell me about your father's
health?
Tina Jones: He had high blood pressure and cholesterol. And diabetes --
we have diabetes in common.
Student: I can't even imagine how you feel
about losing your father
Tina Jones: Thanks.
Student: Tell me about your father.
Tina Jones: Dad was a little stricter than Mom growing up. . . he would
sometimes get kind of mad at us when we did something wrong. But he
never hit us or anything. He would just get really calm and quiet and tell
us to go to our rooms without supper, or that we were grounded when
we were older. Or like, he'd make us rake the yard or wash his car or
something. It's pretty sad to
Student: How old was your father when he
died?
Tina Jones: Last year when Dad passed, he was only 58.
Subjective Data Collection -
Checklist:
...
Chief Complaint ...
Finding: Established chief complaint ...
Finding: Reports pain (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 pain?
Finding: Reports foot wound (Found)Pro Tip:
If a patient mentions pain, it's important to
determine what specifically is causing her
pain, if she knows.
Example Question: What's causing your pain?
History of Presenting Illness ...
Finding: Asked to rate current pain
level on a scale
...
Finding: Reports current pain is 7/10
(Found)Pro Tip: Asking your patient to rate
her pain on a scale of 0 to 10 is important to
gauge how it ebbs and flows while she is in
your care.
Example Question: Can you rate the pain on a scale of 0 to 10?
Shadow Health - Tina Jones, Health History
