Shadow Health: Nursing assessment Study guides, Class notes & Summaries

Chief Complaint - Scrape on foot. It is infected and causing pain(7 out of 10). - Right foot pain, fever, nausea - History of Present Illness - A week ago the scrape startedand the pain got a lot worse in last few days. - 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 ...

Hello Mrs. Jones, my name is Shailee, and I will be taking care of you today. - Can you confirm your name and DOB - On a scale of 0-10 how is your pain? 0 being the no pain. 10 being the most painful. - I am sorry you are going through this pain. Do you know your height? - Do you know your weight? - What brings you to the hospital today? - When did you get the scrape on your foot? - I am sorry about the pain you are going through. We will do our best to help you heal better. What...

Established chief complaint - -Reports pain: Do you have any? -Reports foot wound Asked to rate current pain level on a scale - Can you rate your pain? Asked for details about the pain - -Can you describe your pain? -What is the pain like when you stand on your foot? -how has the pain changed over time? -Does the pain radiate any where else? -Can you bear weight on your foot? Asked location of wound - -which foot is the pain in? -where is the wound? Asked details of the injury - -how d...

Asked about head problems - 1- do you get HAs 2- do you currently have a HA 3- other than headaches, are you experiencing any other health problems? Asked about frequency of headaches - how frequently does your headaches occur Asked about duration of headaches - how long do your headaches last Asked about character and location of headaches - what does your HA feel like? -where do you feel your HAs Asked to rate headache pain on a scale - on a scale of 1-10, how bad are your headaches As...

Relevant Medical History Asked about heart problems - Denies heart problems Asked about heartbeat - Reports normal heartbeat Reports normal heart rate Denies palpitations Denies arrhythmia Asked about high blood pressure - Denies high blood pressure Reports last blood pressure check 140 over 80 or 90 Reports belief that current blood pressure is on the high side of normal range Asked about heart murmur - Denies heart murmur Asked about swelling - Denies swelling other than foot wound ...

Established chief complaint - -reports leg pain -reports leg swelling Established orientation - -oriented to person -oriented to place -oriented to time -oriented to situation Asked about onset and duration of symptoms - -reports fall was 9 am this morning -reports lower leg pain started 2 days ago. Also reports mild constant pain in his knees and hips due to arthritis. -reports leg swelling started 2 days ago -reports pain has been constant since onset -reports pain steadily gets w...

Reason for Visit - Asked about reason for visit Finding: Reports seeking a new primary care provider Culture -Asked about language use Finding: Reports using English Pro Tip: Asking about the client's language use will let you know if you may need to connect them with an interpreter in order to ensure the most appropriate care. Example Question: What language would you like us to use for this visit? -Asked about religious or cultural practices Finding: Reports no religious practices ...

Asked about foot wound - reports swelling has improved reports wound warmth has improved reports wound discharge has improved reports wound is still a little red Asked about history of slow healing wounds - denies history of slow healing wound Asked current wound healing time - reports wound had been getting worse over the past week reports wound has improved with hospital treatment Asked about history of skin conditions - reports acne reports dry skin denies skin cancer denies skin ra...

Asked about reproductive system - Reports last menstrual period was 2 weeks ago Reports menstrual cycle is normal Reports rare cramping Asked about breast health - Reports doing occasional breast exams Denies having a mammogram Denies changes to breasts Denies history of breast cancer Asked about weight changes - Reports recent weight loss Reports weight loss of about 10 pounds Asked about diet - Reports a typical breakfast is smoothie with probiotic yogurt or egg on wheat toast with ...