Planning - Relevant: Planning Pro Tip: Take a general survey of the patient for changes in skin color, and assess respiratory rate, rhythm, depth, and quality to confirm there are no acute breathing issues. Asking Tina if any of her family members had cancer is essential for understanding her risks. Finding: Denies problems with balance or disequilibrium (Available)Pro Tip: Problems with balance can indicate neurological problems, or issues with the inner ear. First, gain a deep understanding of your patient's situation. Finding: Reports asthma triggered by dust (Found)Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. This assignment takes on average between 90 and 110 minutes. Higher levels of pain have been associated with thoughts of self-harm. Shortness of breath. ", 7. Finding: Reports infrequent sinus problems (Available)Pro Tip: Asking about symptoms, such as frequent sinus issues, is one possible component of a review of systems interview. Tina Jones: I haven't smoked pot since I was twenty or twenty-one. Example Question: When did you first notice the pus? The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. She has asthma too, but she almost never has attacks. Example Question: Can you please describe the pain? Finding: Reports taking ibuprofen (Advil) for 2 days (Found)Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury. Example Question: Can you rate the pain on a scale of 0 to 10? The patient's response to these questions may uncover additional problems, such as nerve damage. Finding: Denies circulation problems (Available)Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Exam includes checking weight and height, and listening to heart and lungs. Student: How did you cope with your fathers death? 0000011389 00000 n
Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. A potential pregnancy impacts important parts of the patient's care plan, including which medications are administered. Finding: Asked about number of puffs when using asthma inhaler. Finding: Asked about constitutional health. It's good to hear that you no longer smoke pot. Example Question: Does your paternal grandmother have health conditions? Planning Pro Tip: To help your patient address her obesity, which is often a sensitive topic, use therapeutic communication techniques. Finding: Asked about paternal grandfather's health. Example Question: Does your maternal grandmother have health conditions? Try to think of all the questions you can related to the presenting problem and what kind of problems they might experience in each system. 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. Even getting up and ready for church was too overwhelming. Diana Shadow: Hi. Please note, this is an average time. Example Question: Do you ever get headaches? Example Question: Does it hurt when you urinate? Example Question: What color is the drainage from your wound? Finding: Denies easy bruising (Available)Pro Tip: Asking if a patient bruises easily is one possible component of a review of systems interview. 0000405948 00000 n
Example Question: Do you have muscle swelling? Dress neatly—clean and unwrinkled clothes, combed hair, and shoes in clean, unscuffed shape. Finding: Reports last use of inhaler was 3 days ago (Available)Pro Tip: Determining the patient's last use of an inhaler clues you in to any recent breathing problems. In case you have a concern or query regarding gynaecological issues, you can consult a gynaecologist online & get the answers to your questions through online … Evidence - Relevant: Evidence Pro Tip: The strongest evidence of Tina's fall risk is reports of being unable to bear weight or walk on her foot. Assess - Health Literacy and Patterns: Assess the patient's readiness for change/education. There was about a month where it was hard for us to get to church. Tina Jones: No, I can't. Welcome to Midwifery and Obstetrical Nursing Blog! A history of pain during urination could be a symptom of genitourinary problems. 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 … Example Question: Do you remember what you were prescribed for diabetes? Example Question: Do you have circulation problems? And hit a tree. Example Question: Do you have any throat problems? The narrowing and broadening of scope in a health history interview occurs in the contexts of: an organized progression through topics related to patient health. Asking Tina if her father had diabetes can reveal generational patterns. Student: Do you have any neck, throat or gland problems? I would like to talk with you about changing your medication and your regimen, to reduce your frequent breathing problems, so that you feel better day-to-day. Student: How often do you have asthma exacerbations? Example Question: Have you had gum problems? Student: Have you used illicit drugs? Example Question: Does the pain radiate anywhere else? Priority - High Priority Pro Tip: This is a high priority. For the past few days, the Advil wasn't doing much for me -- it would only last a couple of hours. Finding: Asked to rate current pain level on a scale. Finding: Denies muscle swelling (Available)Pro Tip: Asking about muscle swelling is one possible component of a review of systems interview. It's better for your asthma and your overall health.". Student: What preexisting medical conditions do you have? Example Question: Have you ever smoked cigarettes? The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Finding: Asked about review of systems for mouth and jaw. Example Question: Have you noticed an increase in appetite? A history of incontinence could be a symptom of genitourinary or pelvic problems. Student: How many puffs do you take when using your asthma inhaler? Finding: Reports applying bacitracin, neomycin and polymyxin B (Neosporin) (Found)Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy. And I want my foot to stop hurting. This numerical evidence is required to establish obesity. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. Medication Strength Frequency Taken Health Maintenance: Test Date Result (Please Circle) And I put Neosporin on it. It is useful to confirm the gestational age, gravidity and parityearly on in the consultation, as this will assist you in determining which questions are most relevant and what conditions are most likely. If the patient reports a history of gas, it could be a symptom of dietary or gastrointestinal problems. Educate - Exercise: Educate the patient about the benefits of exercise. Finding: Followed up on coping with father's death. Finding: Asked if patient has experienced abuse. Finding: Denies taking herbals (Available)Pro Tip: Finding out about your patient's use of herbals will help you get a complete health history and avoid unwanted drug interactions. Finding: Reports she stopped because of health reasons and waning interest (Available)Pro Tip: Communicating about why a patient stopped or started drug use gives insight into their attitudes and dependencies on a substance. Example Question: Do you have muscle pain? Symptoms like these could indicate a yeast or sexually transmitted infection. Example Question: Have you seen a healthcare provider for this injury? At the end of this prebrief, you will answer a short question about the upcoming assignment. Example Question: What's preventing you from taking your diabetes medication? Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Example Question: Have you had any family members with cancer? Tina Jones: Um...I've smoked pot before. Finding: Denies seasonal allergies (Available)Pro Tip: Asking about seasonal allergies can help you understand a patient's complete set of allergies over the course of a year. Kind of big like me. A completed history is usually only a few pages in length, although it contains a great deal of information. If you discover any disease states, ask about symptoms and the patient's experiences of them. Example Question: Have you had watery eyes? Finding: Reports recommended dose is 1-3 puffs as needed (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. If the patient reports a history of vomiting, it could be a symptom of a recurring gastrointestinal problem. Counseling around past drug use Not Followed Up, Description: Tina discusses her past history of marijuana smoking. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are some things that trigger your asthma? Example Question: Are you ever exposed to secondhand smoke? Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are significantly higher than her baseline. It looks like your browser needs an update. 0000405107 00000 n
I've never really had stomach or bowel problems. Finding: Asked about use of pain medication. Example Question: Did you injure anything besides your foot? Student: I can't even imagine how you feel about losing your father, Tina Jones: Dad was a little stricter than Mom growing up. Finding: Reports father was diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. Example Question: Do you have seasonal asthma triggers? Student: Do you have any problems with your head? Tina Jones: No. In Tina's case, it is important to identify her diabetes diagnosis because that condition has a direct relationship with her current foot infection. Example Question: When was your last penicillin reaction? You may also need to provide further support and resources to the patient. You should assess her needs to determine if providing any addition resources or support is appropriate. She might have high cholesterol too. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Student: Do you know why you lost weight? Finding: Reports maternal grandfather diagnosed with high blood pressure (Available)Pro Tip: Family histories might indicate a genetic predisposition. Example Question: Have you ever had a urinary infection? 0000406728 00000 n
Example Question: Does the wound have an odor? While the patient is in your care, work with other healthcare professionals to keep the pain managed and improve the patient's mobility. Most importantly, ask about her goals and changes she may be willing to make. Asking your patient about this can inform your care plan. Example Question: When was your last tetanus booster? I can't put any weight on it without like, shooting pain. Finding: Reports about 5 total hospitalizations for asthma as a child and teen (Available)Pro Tip: Finding out the number of Tina's previous hospitalizations is important for understanding the history of her asthma. Tina Jones: No, I don't think so. Finding: Reports occasional tiredness or fatigue (Available)Pro Tip: Asking about tiredness or fatigue is one possible component of a review of systems interview. Update From Lybrate: Buy Vitamins and Supplements from Lybrate’s Goodkart and keep your metabolic activities on track. Example Question: Do you have a rash on your breasts? We'll do our best to get you feeling better and, on your way, home as soon as possible. Finding: Asked about patient's level of education. Finding: Asked about maternal grandfather's health. Finding: Asked review of systems for skin, hair and nails. Student: Can you walk with your foot being injured? Finding: Reports disliking diabetes medication side effects (Found)Pro Tip: Asking about side effects from medication can provide information about your patient's reaction to treatment. Assess - Musculoskeletal: Assess the patient's mobility. Asking Tina if her paternal grandfather had high cholesterol can reveal generational patterns. Tina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. Evidence - Relevant: "Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent blood glucose monitoring and a general lack of diabetes management, which increases her risk for fluctuating blood glucose levels. Tina Jones: I've been taking Advil for my foot for a few days. Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Finding: Reports chest tightness during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness. �d��M�j���pTwC��@�?8��`W�Kk^s��&��=D�����Z��@�O� ���G�յ�Q�J���&�w��S͕�b�:?,; Finding: Reports that she used to take diabetes medication (Found)Pro Tip: Asking about Tina's medication history for asthma will provide a timeline of treatment. .Hx�ߩ���dY�/�['���N;=�� *o��� Q)=��OZ�#40���̤�������9��������F Student: Does your family have a history of headaches? Example Question: What's the most puffs you ever take? Planning - Relevant: Planning Pro Tip: Protect your patient by taking all fall precautions, and educate your patient about how to be safe as she goes through her daily activities at the hospital. Finding: Denies nausea (Available)Pro Tip: Currently presenting nausea can be caused by changes in blood sugar, a reaction to medication, stress, or even spreading infection. Finding: Reports changes to neck skin (Available)Pro Tip: Asking about changes in skin color is one possible component of a review of systems interview. Tina Jones: I don't think I have problems in that area. Tina Jones: Whatever pain medication the ER gave me is helping. The following questions will help in the care of your pregnancy. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. Tina Jones: No. Finding: Denies night sweats (Available)Pro Tip: Asking about additional symptoms, such as night sweats, is one possible component of a review of systems interview. Finding: Denies loss of coordination (Available)Pro Tip: Asking if the patient has experienced loss of coordination is one possible component of a review of systems interview. Finding: Reports being up to date on shots (Found)Pro Tip: Discovering your patient's immunization history is important to her safety and reveals any susceptibilities she may have to infectious disease. Finding: Denies breast rashes (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as a rash, is one way of assessing overall breast health. A health history questionnaire consists of a set of survey questions that help either medical research, doctors or medical professional, hospitals or small clinics to understand the population they provide medical services to. Student: What type of drugs did you use? Gestational age, gravidity and parity would also usually be included at the beginni… I can give you some Advil at this time, and in a few hours, you can have more tramadol. but I don't do that anymore. Planning - Relevant: Educate - Diet: Educate the patient on balanced nutritional intake. The medication history is the part of the patient interview that provides the pharmacist the opportunity to utilize his or her expertise by precisely collecting each component of the medication history (however, a medication history may also be collected independent of a comprehensive patient interview). Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Finding: Denies chest pain or discomfort (Available)Pro Tip: Asking about chest pain is one possible component of a review of systems interview. 2. Finding: Reports inhaler is albuterol (Proventil) (Found)Pro Tip: Finding out the specific medication type or brand is essential in understanding whether it's a maintenance or rescue medication. Tina Jones: He died last year, so I was 27. Example Question: At what age were you diagnosed with asthma? Lumps have a range of severity, as they could be the result of breast injury or cancerous growths, but any abnormalities should be handled with the highest level of concern. Provide an appropriate intervention (pharmaceutical or otherwise) and educate the patient. Student: Do you currently take medicine for your diabetes? Tina Jones: I feel really stressed out right now! Example Question: Have you noticed any hair loss? I feel a lot better now that I'm just eating healthier than I did when I was taking the pills." And high cholesterol like everyone else in my family. Example Question: Has your heartbeat been irregular? Model Statement: "Thank you for sharing that information. Finding: Denies history of breast cancer (Available)Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. 0000011428 00000 n
Finding: Denies past pregnancies (Available)Pro Tip: A patient's history of pregnancy can shed light on other health conditions, body systems, or risk factors. Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient's most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient's condition and effectiveness of any treatments. Edema is caused by the presence of excess fluid in the tissues, and it can indicate an infection, weak heart or veins, or other organ problems. 0000008448 00000 n
Example Question: When was your last alcoholic drink? Finding: Denies depression (Available)Pro Tip: Asking about the patient's history with depression is one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. Asking Tina if her father had high blood pressure can reveal generational patterns. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]. Finding: Reports confusion about what the numbers mean (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. Intervene - Hypoglycemia: Administer insulin and/or oral hypoglycemics, per physician orders. 0000008295 00000 n
As a currently presenting symptom, it could indicate a change in patient status. Example Question: How many times a day do you take pain medication? 0000001607 00000 n
Finding: Asked about prescription medications. Finding: Reports ibuprofen helped a little (Found)Pro Tip: The efficacy of pain medication varies from patient to patient. This is the first time I've been in the hospital since I was probably sixteen, though. Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions. The presence of a physical injury supports her susceptibility to acute pain. Example Question: Do you have any lumps in your breasts? Example Question: Have you had a runny nose? But it is important to keeping your diabetes under control. https://arthritis.arizona.edu/history-taking-and-musculoskeletal-examination Asking Tina if her maternal grandmother had high blood pressure can reveal generational patterns. She seems happy. Finding: Denies current headache (Available)Pro Tip: Asking Tina is she currently has a headache is important because it might be contributing to her current discomfort and should be treated promptly. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. Student: How many puffs do you take when using your asthma inhaler? Example Question: Do you have muscle weakness? Finding: Reports pain prevented her from being able to walk to class (Available)Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don't fall behind. I'm not a huge health nut or anything. 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. As a currently presenting symptom, flank pain could result in a change to the patient's care plan. 0000014525 00000 n
The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as unspecified allergies. Finding: Denies history of STIs (Available)Pro Tip: Asking about a patient's history of STIs is one possible component of a review of systems interview. Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. Example Question: Does it hurt when you breathe? As a currently presenting symptom, nocturia could result in a change to the patient's care plan. Example Question: Have you had dry mouth? Finding: Reports periods of blurry vision (Found)Pro Tip: Asking about changes in vision is one possible component of a review of systems interview. Example Question: Have you ever been pregnant? Gaps in health literacy around asthma control Not Followed Up, Description: Tina describes increased inhaler use and decreased effectiveness, indicating that her asthma is uncontrolled. Student: How effective was the Neosporin? Tina Jones: He's a healthy guy. Student: Have you had any reproductive problems? Finding: Denies muscle pain (Found)Pro Tip: Asking about muscle pain is one possible component of a review of systems interview. You can document your findings, including vital signs, in the Electronic Health Record. ", 3.Gaps in health literacy around diabetic diet Not Encountered, Description: Tina describes controlling her diabetes by avoiding "sweets." Existing conditions can also inform your treatment and understanding of the patient's current health issues. .not always. Example Question: When was your last hospitalization? Example Question: Do you ever get tingling? Finding: Reports excessive facial or body hair (Available)Pro Tip: Increases in body hair can suggest changes in hormone levels. I know I need sleep, too. Finding: Denies lightheadedness (Available)Pro Tip: Asking about light-headedness is one possible component of a review of systems interview. Example Question: How often do you check your blood sugar? Finding: Reports acne (Found)Pro Tip: Adult acne can suggest stress or changes in hormone levels. Student: What else will this exam involve? The Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. Student: Has your foot been draining any liquids? 0000001826 00000 n
Palpitations. These essential vitamins provide energy, strengthens bone health, and repair cellular damage. Discovering a patient's individual response to pain medication is an important factor in your overall treatment plan. I think she had high blood pressure and cholesterol, too. . Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound. Example Question: How many nights a week do you drink alcohol? Evidence - Relevant: Evidence Pro Tip: As Tina discusses symptoms of her wound, including symptoms such as discharge, redness, warmth, and swelling, she reports strong evidence of impaired skin integrity. Finding: Denies joint pain (Available)Pro Tip: Asking about joint pain is one possible component of a review of systems interview. Finding: Reports paternal grandfather diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as oral infection or recent trauma. As a currently presenting symptom, it could indicate a change in patient status. Finding: Reports weight loss occurred over the past month (Available)Pro Tip:Finding out the timeline for weight loss can indicate if it's sudden or gradual. Finding: Reports cause of death was a car accident (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as allergic reactions, infection, or physical trauma. Mental health history information is gathered to create a succinct description of the client’s mental health. Finding: Reports asthma triggered by cats (Found)Pro Tip: Discovering occasional environmental triggers, such as animal allergies, gives you insight into exacerbating factors of your patient's condition. Evidence Pro Tip: Tina directly reports ineffective diabetes management when discussing her lack of treatment. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as vision loss. The updated Social history section on the patient Summary includes improvements to smoking status, which has been renamed “Tobacco Use”, and additional data elements to support recording alcohol use, financial resources, education, physical activity, stress, social isolation and connection, and exposure to violence.You can also find free text fields for Nutrition and Social history … Example Question: How long does the pain medication last? Contributing factors are a past history of hospitalization and asthma attacks, as well as sedentary lifestyle and obesity. They're crazy, but nobody's diagnosed with anything. I don't want to miss work or school but now it looks like I'll have to. Example Question: Do you urinate frequently? Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Priority - High Priority Pro Tip: Poorly managed diabetes and uncontrolled blood glucose complicate wound healing. Student: What happened with your father's car accident? Finding: Reports normal vaginal discharge (Available)Pro Tip: Asking about vaginal discharge is one possible component of a review of systems interview. Example Question: Do you use condoms when you are sexually active? ", 2.Impact of injury on daily life Followed Up, Description: Tina brings up her pain and frustration at how being unable to bear weight on her foot impacts her life. Example Question: What pain medication have you been taking? It's got all that going on." Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health. Or like, he'd make us rake the yard or wash his car or something. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as vision loss. Finding: Reports wheezing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as wheezing. Student: Have you had any prior hospitalizations? Example Question: How are you coping now? Consult / Refer: Consult with physical therapist to develop a plan to improve the patient's mobility. Example Question: Did the metformin cause any side effects? Finding: Reports 1 uncle has alcoholism (Found)Pro Tip: Asking about trends in substance abuse can help you understand your patient's risk for inherited diseases linked to addiction. Swollen lymph nodes may appear in the neck when an infection is present. Example Question: Do you have a family history of thyroid problems? Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot! Priority: High Priority Pro Tip: This is a high priority. Finding: Denies dental problems (Found)Pro Tip: Asking about symptoms, such as dental problems, is one possible component of a review of systems interview. 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. Student: How long ago was your dad's car accident? 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. Student: Have you had any change in appetite? A health worker uses a combination of suction and sterile medical instruments to empty the womb.