NR 509 Week 1 Shadow Health Comprehensive Health History Assignment

	Height: 170 cm
	Weight: 90 kg
	BMI: 31
	Random blood glucose: 238
	Temperature: 101.1 F
	Blood pressure: 142/82
	Respiratory rate: 19
	O2 sat: 99%
	Heart rate: 86
	Hallo M. Tina, my name is pam and i will taking care of you today
	Hey.
	how are you doing today?
	Not so great… My foot really hurts right now.
	im sorry to hear that can you tell me more about it
	I appreciate you telling me that.
	what brings you to the clinic today?
	I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me! shadow health Comprehensive Health History Assignment – NR 509 Week 1
	tell me about your more about the pain
	It’s throbbing and like, sharp if I try to put weight on it.
	how long have you been experiencing the pain?
	Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
	did you see any doctor?
	To be honest, I haven’t been to a doctor for just a check-up in. . . at least two years. But I did see a doctor at the ER about my foot.
	were you given any medication? (Clarified to Did the ER prescribe anything?.)
	Yes, they wrote me a prescription for some pain pills. (Clarified to if the ER prescribed me any medications.) shadow health Comprehensive Health History Assignment – NR 509 Week 1
	what type of pain pills
	It’s called tramadol.
	how many mg
	I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]
	how often do you take it
	I don’t take anything now, but I used to be on the pill.
	how many pills of tramadol do you take
	I take two at a time.
	how often do you take it
	I don’t take anything now, but I used to be on the pill.
	on a scale of 1-10 how much is your pain (Clarified to On a scale of 0-10 how would you rate the pain in your right foot?.)
	I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. (Clarified to how I would rate my foot pain on a scale.) WE GUARANTEE A DCE SCORE OF ABOVE 95% AND HANDLE THE SOAP NOTE
	have you noticed any drainage
	Yeah, there’s definitely pus.
	is the pus has any color
	Yeah, there’s definitely pus.
	are you allergic to any medication
	Yeah, I’m allergic to penicillin.
	do you have food allergies
	Nope, no food allergies that I know of.
	do you have any environmental allergies
	No, unless cats count.
	tell me about the cat allergy
	Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up. shadow health Comprehensive Health History Assignment – NR 509 Week 1
	do you take anything for the allergies
	I don’t take anything, unless my inhaler counts.
	do you have any other medical conditions
	Um, the only things I know I’m diagnosed with are diabetes. And asthma.
	do you take anything for diabetes
	I don’t take anything for my diabetes anymore.
	how do you control your diabetes
	I just watch what I eat and try to stay away from sweets.
	do you take any asthma medication
	I just use my inhaler.
	what is the name of your inhaler
	It’s just a regular Proventil inhaler.
	how many mg
	I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]
	how many cg is your inhaler (Clarified to How many times did you use your inhaler?.)	Question 03/08/20 3:59 PM PDT
	At my cousin’s? I did two puffs, and then I had to do another one a little later. . . that’s been happening sometimes lately. (Clarified to how many times I used my inhaler.)
	do you have any medical history shadow health Comprehensive Health History Assignment – NR 509 Week 1
	Yeah. . . I have asthma and diabetes.
	does your family have any medical history
	My mom has some issues, and I think some of my grandparents did, too.
	what kind of issues does you mother have
	Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
	any other medical history in the family (Clarified to What health problems run in your family?.)
	My mom has some issues, and I think some of my grandparents did, too. (Clarified to what health problems run in my family.)
	does you father have any medical issues
	Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure.
	do you smoke?
	No. I think it’s gross.
	do you drink alcohol
	I do sometimes, yeah, when I go out with my friends.
	how many drinks do you have when you drink
	Just a few. I’m not a big drinker.
	do you take any illegal drugs
	Well, I used to smoke pot. . . but I don’t do that anymore.
	do your friends smoke pot
	Yeah, a couple of my friends smoke when we go out. I don’t like being around smokers, though.
	what do you plan to stop smoking with your friends
	I’m pretty optimistic about the future actually. In a couple of months I’ll have my degree, and I’ll probably get my own place again. I’m planning on trying for one of the accounting jobs in our regional office, too. If that works out, I would like to start dating again… maybe I’ll find someone I want to marry, start a family with?
	do you have shortness of breath
	No, my breathing is fine right now.
	are you in pain
	Yeah, my foot’s really bothering me.
	what makes it worse
	I’d say the pain is at its worst when I have to put any weight on my foot. . . otherwise, it’s when the pain pills wear off.
	can i take a look on your foot (Clarified to May I take a look at your foot now?.)
	Ok. (Clarified to permission to examine my foot.)
	tell me if you fill the pork (No matching questions found.)
	tell me if you fill the prick (No matching questions found.)
	how often do you take the pain medication
	I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
	how old are you
	I’m 28.
	let me listen to you lungs (No matching questions found.)	Question 03/08/xx 4:11 PM PDT
	do you have any problem with your eyes	Question 03/08/xx 4:12 PM PDT
	I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry.
	have you seen an eye doctor	Question 03/08/xx 4:12 PM PDT
	I have a couple times as a kid, by the school nurse. Not recently though.
	do you wear glasses	Question 03/08/xx 4:12 PM PDT
	I don’t wear glasses–or contacts.
	do you have any chest pain	Question 03/08/xx 4:13 PM PDT
	No, my chest feels tight when I have breathing problems, but it doesn’t hurt.
	have you seen a heart doctor	Question 03/08/xx 4:13 PM PDT
	No, my heart’s always been fine.
	how is your abdomen	Question 03/08xx 4:14 PM PDT
	My stomach feels fine.
	have you heard any problems with elimination (Clarified to Do you have difficulty moving your bowels?.)	Question 03/08/xx 4:14 PM PDT
	No. No problems like that. (Clarified to if I have trouble moving my bowels.)
	any pain on urination	Question 03/08/xx 4:14 PM PDT
	It doesn’t hurt or feel different when I pee.
	do you check blood sugar (Clarified to Do you check your sugars often?.)	Question 03/08/xx 4:15 PM PDT
	I don’t check it very often, honestly. . . I think the last time was about a month ago. (Clarified to if I check my blood sugar often.)
	i see bs is 238 (No matching questions found.)	Question 03/08/xx 4:15 PM PDT
	your blood sugar is elevated	Question 03/08/xx 4:15 PM PDT
	They checked it last week at the ER, and they said it was high, but I don’t remember what the number was. I wasn’t thinking about my blood glucose; I was worried about my foot!
	Measured wound: 2 cm x 1.5 cm, 2.5 mm deep	Exam Action 03/08/xx 4:16 PM PDT
	let me take look of your foot (Clarified to Can I look at your foot?.)	Question 03/08/xx 4:16 PM PDT
	Sure. (Clarified to if I can show you my foot.)
	i see it is open , let me know if you feel pain (No matching questions found.)	Question 03/08/xx 4:17 PM PDT
	Swabbed wound and sent to lab for C & S	Exam Action 03/08/xx 4:17 PM PDT
	Cleansed and irrigated wound with normal saline and applied dry sterile dressing.	Exam Action 03/08/xx 4:17 PM PDT
	i will take a look of your pupils is that okay (No matching questions found.)	Question 03/08xxx 4:18 PM PDT
	you need to keep your foot off the ground	Educate 03/08/xx 4:19 PM PDT
	Sure, I think I understand what you mean.
	how long does the pain last	Question 03/08/xx 4:20 PM PDT
	For the last couple of days, the pain is pretty much constant.
	do you have any cough	Question 03/08/xx 4:26 PM PDT
	I don’t have a cough, no.
	any chills	Question 03/08/xx 4:26 PM PDT
	I got some chills last night, before my fever really kicked in.
	ear ache	Question 03/08/xx 4:27 PM PDT
	No.
	when was your last menstrual period	Question 03/08/xx 4:28 PM PDT
	I don’t keep track very well because it’s kind of all over the map, but my last one was probably three weeks ago.
	is it heavy bleeding or normal (No matching questions found.)	Question 03/08/xx 4:29 PM PDT
	describe the bleeding to me (No matching questions found.)	Question 03/08/xx 4:29 PM PDT
	are they regular (No matching questions found.)	Question 03/08/xx 4:30 PM PDT
	do you have regular period	Question 03/08/xx 4:30 PM PDT
	It’s not regular. Sometimes it’s every month, but sometimes it’s more like every two months. I don’t write it down or anything. I probably get…six periods a year.
	do you have any other concerns	Question 03/08/xx 4:32 PM PDT
	Um, the only things I know I’m diagnosed with are diabetes. And asthma.
	have you been taking any OTC medication (Clarified to Do you take over the counter medications a lot?.)	Question 03/08/xx 4:35 PM PDT
	No, I only take Advil when my cramps get bad, and sometimes Tylenol for headaches. Lately I’ve been taking Advil for my foot, too. (Clarified to if I take over the counter medication a lot.)
	how many mg of tylenol	Question 03/08/xx 4:35 PM PDT
	I take the extra-strength acetaminophen, the gel kind, 500 mg. It’s what we usually have around the house. [AUDIO COMING SOON]
	how often do you take tylenol	Question 03/08/xx 4:36 PM PDT
	I maybe take it once a week. Or less.
	you mentioned you take advil how many mg? (Clarified to Can you tell me the dosage of the ibuprofen?.)	Question 03/08/xx 4:36 PM PDT
	I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON] (Clarified to how many milligrams of ibuprofen I take.)
	have you notice any weight gain in last month	Question 03/08/xx 4:37 PM PDT
	Usually my weight’s pretty stable, but I’ve actually lost a little weight recently.
	it is important to check your blood sugar often and record it	Educate 03/08/xx 4:44 PM PDT
	OK, I understand.
	try to not weight on your right foot while walking	Question 03/08/xx 4:45 PM PDT
	No, I can’t. I can’t put any weight on it without like, shooting pain.
	make sure you clean the wound with normal saline and cover it with clean dressing	Question 03/08/xx 4:46 PM PDT
	Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
	you want to keep it as clean as possible (No matching questions found.)	Question 03/08/xx 4:46 PM PDT
	report any drainage or any foul smell	Question 03/08/xx 4:47 PM PDT
	Um, no, not that I know of… That sounds gross.
	notify the clinic if you have a any chills	Question 03/08/xx 4:47 PM PDT
	I got some chills last night, before my fever really kicked in.
	always wear shoes when you are walking (Clarified to Are you able to wear shoes normally?.)	Question 03/08/xx 4:48 PM PDT
	My sneakers are too tight, so I’ve been wearing flip-flops at home, or slip-ons. (Clarified to if I can wear shoes.)
	inspect you feet daily since you are diabetic (No matching questions found.)	Question 03/08/xx 4:48 PM PDT
	protect your feet from cold	Question 03/08/ 4:49 PM PDT
	Not really.
	you need to also wear comfortable shoes (No matching questions found.)	Question 03/08/20 4:50 PM PDT
	do you have problem sleeping
	I usually sleep pretty well, but the last couple nights the pain has made it hard to get good sleep.
	Measured wound: 2 cm x 1.5 cm, 2.5 mm deep
	Swabbed wound and sent to lab for C & S
	Cleansed and irrigated wound with normal saline and applied dry sterile dressing.

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

1 Expression of pain

Followed Up

	Description: Tina expresses frustration about her level of pain.
	how are you doing today?	Question 03:45 PM PDT
	Not so great… My foot really hurts right now.
	im sorry to hear that can you tell me more about it	Empathize 03:46 PM PDT
	I appreciate you telling me that.
	Model Statement: “I’m sorry to hear that your pain is returning. We want you to be in as little pain as possible. Together we can figure out the best way to reduce your pain quickly.”

2 Impact of injury on daily life

Not Encountered

3 Gaps in health literacy around diabetic diet

Not Followed Up

4 Lack of treatment with diabetes medication

Not Followed Up

5 Lack of blood glucose monitoring

Followed Up shadow health Comprehensive Health History Assignment – NR 509 Week 1

	Description: Tina reveals that she does not check her blood sugar.
	do you check blood sugar (Clarified to: Do you check your sugars often?)	Question 04:15 PM PDT
	I don’t check it very often, honestly. . . I think the last time was about a month ago. (Clarified to: if I check my blood sugar often)
	your blood sugar is elevated	Question 04:15 PM PDT
	They checked it last week at the ER, and they said it was high, but I don’t remember what the number was. I wasn’t thinking about my blood glucose; I was worried about my foot!
	let me take look of your foot (Clarified to: Can I look at your foot?)	Question 04:16 PM PDT
	Sure. (Clarified to: if I can show you my foot)
	you need to keep your foot off the ground	Educate 04:19 PM PDT
	Sure, I think I understand what you mean.
	Model Statement: “I understand how it can feel like a frustrating chore to check your sugar every day. But it is important to keeping your diabetes under control. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. And keeping your sugar down will help your foot wound heal quickly, too. If you would like, I can help you find a monitor that is as painless as possible. I can also teach you more about what the numbers mean.

DON’T STRESS YOURSELF, JUST CHAT WITH US IN THE RIGHT CORNER BELOW

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Identifying Data & Reliability Tina is a 28 year old female with chief complaint of right foot wound shadow health Comprehensive Health History Assignment – NR 509 Week 1	Return to Canvas to complete your SOAP note for this assignment shadow health Comprehensive Health History Assignment – NR 509 Week 1
General Survey patient has wound to the bottom of the foot, complains of pain when she bears weight	Return to Canvas to complete your SOAP note for this assignment
Chief Complaint right foot pain	Return to Canvas to complete your SOAP note for this assignment

Student Documentation

Model Documentation

Identifying Data & Reliability

Tina is a 28 year old female with chief complaint of right foot wound

shadow health Comprehensive Health History Assignment – NR 509 Week 1

Return to Canvas to complete your SOAP note for this assignment shadow health Comprehensive Health History Assignment – NR 509 Week 1

General Survey

patient has wound to the bottom of the foot, complains of pain when she bears weight

Return to Canvas to complete your SOAP note for this assignment

Chief Complaint

right foot pain

Return to Canvas to complete your SOAP note for this assignment

Each relevant diagnosis is scored on a four-point scale:

Priority (1 point): the correct priority of the diagnosis was chosen
Evidence (up to 2 points): the strength of the patient cue(s) selected as evidence for the identified diagnosis
- Required Evidence: selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points
- Supporting Evidence: selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 point
Planning (1 point): the plan proposed to address the diagnosis includes at least one correct component

1. Acute pain of the foot

2 of 4 points

Priority 1 / 1
Student Response: High Correct Priority: High	Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain.
Evidence 0 / 2
Relevant (None provided) Irrelevant “Measured wound: 2 cm x 1.5 cm, 2.5 mm deep”	Evidence Pro Tip: Tina reports intense pain and rates her pain on a numerical scale. She also reports characteristics of the pain, including its duration of one week; this timespan defines her pain as acute.
Planning 1 / 1
Relevant Educate – Medication: Educate the patient on medications used for pain relief. Educate – Medication: Educate the patient on non-pharmaceutical methods to reduce pain intensity. Irrelevant Assess – Integumentary: Assess wound parameters (size, depth). Intervene – Labs: Obtain a wound culture. Intervene – Labs: Obtain blood for culture x2 (blood from two sites). Intervene – Labs: Order a complete blood count test (CBC). Intervene – Prescribe: Prescribe antibiotics.	Planning Pro Tip: Intervene to reduce the pain by prescribing an appropriate analgesic and educating the patient on its effective use and potential side effects. Provide the patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation). shadow health Comprehensive Health History Assignment – NR 509 Week 1

2. Local infection of skin and subcutaneous tissue of the foot

2 of 4 points

Priority 1 / 1
Student Response: High Correct Priority: High	Priority Pro Tip: Treating this infection is a high priority, as failure to treat the infection may lead to it spreading to surrounding tissues or systemically. Treating the infection can prevent adverse events such as osteomyelitis and bacteremia.
Evidence 0 / 2
Relevant (None provided) Irrelevant “Measured wound: 2 cm x 1.5 cm, 2.5 mm deep”	Evidence Pro Tip: Tina presents with an open wound on the plantar surface of the foot. The wound is red, swollen, warm, and produces purulent discharge. Tina reports that the appearance and level of discomfort have worsened with time- all of these factors support a diagnosis of acute infection.
Planning 1 / 1
Relevant Intervene – Other: Clean wound and cover with sterile dressing. Educate – Health Maintenance: Educate the patient on wound care procedure. Irrelevant (None provided)	Planning Pro Tip: Assess the wound directly and obtain a culture so that the infectious organism may be identified, then clean and re-dress the wound. Regional lymph nodes may be swollen. Because the infection is the root cause of Tina’s other acute issues, prescribing an anti-infective will begin to resolve the issues; after receiving culture results, the specific anti-infective given may be changed. Ensure that Tina understands how to treat the wound, use the anti-infective effectively, and to report symptoms of a worsening infection. Foot care is especially important for diabetics, so you should help Tina better understand diabetes’ impact on wound healing and the need to proactively monitor her foot health.

3. Uncontrolled type 2 diabetes mellitus

2 of 4 points

Priority 1 / 1
Student Response: High Correct Priority: High	Priority Pro Tip: Tina’s uncontrolled diabetes will delay her wound healing and places her at risk for end organ damage. The need to provide better glucose control for Tina makes this a high priority.
Evidence 0 / 2
Relevant (None provided) Irrelevant “Measured wound: 2 cm x 1.5 cm, 2.5 mm deep”	Evidence Pro Tip: Tina’s current blood glucose level supports a diagnosis of uncontrolled type 2 DM. Tina reports symptoms consistent with poor control such as polyuria, polydipsia, and nocturia.
Planning 1 / 1
Relevant Educate – Health Maintenance: Educate the patient on self-monitoring of blood glucose level procedure and its role in treating diabetes. shadow health Comprehensive Health History Assignment – NR 509 Week 1 Educate – Health Maintenance: Educate the patient on the impact of diet, exercise, and weight loss on glycemic control. Irrelevant Educate – Health Maintenance: Educate the patient on the role of lifestyle changes, including diet and exercise, in improving health outcomes.	Planning Pro Tip: Assess for impacts of Tina’s uncontrolled diabetes including diminished peripheral pulses, peripheral and sensory neuropathy, and retinopathy, and order labs to check for renal function and abnormal lipid levels. Establish a baseline fasting glucose level and educate Tina on the need to monitor her blood glucose and be aware of symptoms of hyperglycemia. Provide better control by prescribing a first-line drug for glucose control. As Tina’s diabetes is uncontrolled, educate her on appropriate diet, monitoring, and treatment regimens.

DON’T STRESS YOURSELF, JUST CHAT WITH US IN THE RIGHT CORNER BELOW

4. Asthma

2 of 4 points

Priority 1 / 1
Student Response: Low Correct Priority: Low	Priority Pro Tip: Although Tina requires education to better manage her asthma, she does not report active respiratory complaints, making this a lower priority diagnosis. shadow health Comprehensive Health History Assignment – NR 509 Week 1
Evidence 0 / 2
Relevant (None provided) Irrelevant “Measured wound: 2 cm x 1.5 cm, 2.5 mm deep”	Evidence Pro Tip: Tina reports a personal history of asthma, including past hospitalizations for asthma attacks, as well as her use of an albuterol inhaler. Her sibling’s asthma is of interest, given the strong genetic and environmental factors in the development of asthma.
Planning 1 / 1
Relevant Assess – Respiratory: Assess lung sounds with auscultation. Assess – Respiratory: Assess pulmonary function using spirometry. shadow health Comprehensive Health History Assignment – NR 509 Week 1 Assess – Respiratory: Assess respirations (rate, rhythm, depth, quality). Educate – Health Maintenance: Educate the patient on avoiding triggers of asthma. Educate – Health Maintenance: Educate the patient on enacting her asthma action plan including proper use of rescue inhaler. Irrelevant Assess – Respiratory: Assess for reduced forced expiratory volume using spirometry.	Planning Pro Tip: Because Tina does not report treatment for maintenance of her asthma, instead relying on a rescue inhaler for sporadic attacks, educate her on developing and enacting a proactive plan to manage the disease. Though Tina does not report an active respiratory complaint, it is valuable to assess for abnormal findings that she may not report. shadow health Comprehensive Health History Assignment – NR 509 Week 1

NR 509 Week 1 Shadow Health Comprehensive Health History Assignment