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Abdominal Results | Turned In Health Assessment - Remediation/Refresher - January 2021, CCE 705 and 701 Return to Assignment (/assignments/432169/)

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Lab Pass (/assignment_attempts/9273095/lab_pass.pdf)

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Transcript Started: Mar 04, 2021 | Total Time: 29 min Subjective Data Collection All Lines (83)

Interview Questions (45)

Statements (4)

Exam Actions (34)

Objective Data Collection Documentation

Hello!

Question 03/04/21 1:13 AM EST

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.

What are my objectives in this assessment?

Question 03/04/21 1:15 AM EST

In your interview with Ms. Jones, you will ask about her inputs and outputs (I's and O's) and the overall health of her abdominal system so that you can identify any issues and document findings accurately. 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. You will also inquire into the health history of Ms. Jones' family with regards to the abdominal system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her abdominal system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones' abdominal system to gather objective data about the system's health and physiology. 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.

What is the situation?

Question 03/04/21 1:15 AM EST

It's 8 p.m. on Tina Jones' first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full abdominal exam on Ms. Jones. She's spent the whole day in bed, so you will want to determine whether she has full abdominal function and if bed rest has impacted her gastrointestinal health.

What else will this exam involve?

Question 03/04/21 1:17 AM EST

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. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.

How will I be evaluated?

Question 03/04/21 1:17 AM EST

In this assignment, you will be evaluated on your Subjective and Objective Data Collection. 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. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 35 and 50 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.

How does this assignment prepare me for the real world?

Question 03/04/21 1:17 AM EST

In this assessment, you will become familiarized with the structure and content of abdominal exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient's risk of disease, infection, injury, and complications º and obtain and assess objective data. In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What effects can bed rest have on the abdominal system?

Being on bedrest can cause constipation, gastric reflux. Inactivity and immobility can gradually slow down the metabolic rate.

Statement 03/04/21 1:19 AM EST

Time to begin.

Hello Tina, My name is Emily and i'll be your nurse today.

Greet 03/04/21 1:20 AM EST

Hey.

Can you tell me your name and date of birth?

Question 03/04/21 1:20 AM EST

My name's Tina Jones, and my birthday's February 17th.

Thank you. What brings you in today?

Question 03/04/21 1:20 AM EST

I feel like I've said this a bunch, but I scraped my foot last week and it got, like, infected. The pain was really killing me when I came here last night.

Oh no, i'm sorry to hear about your pain.

Empathize 03/04/21 1:21 AM EST

Thanks.

Are you currently having any issues with your stomach and bowels?

They're fine.

Question 03/04/21 1:21 AM EST

When was the last time you went to the restroom?

Question 03/04/21 1:22 AM EST

It was probably a few hours ago.

What are your typical bowel habits?

Question 03/04/21 1:22 AM EST

I don't go every day. I go every two days, maybe.

Do you have constipation?

Question 03/04/21 1:22 AM EST

No, I'm not having any problems with that.

Have you had any diarrhea?

Question 03/04/21 1:22 AM EST

No.

What are your stool characteristics?

Question 03/04/21 1:23 AM EST

It's normal, I think. Not hard, and not too, uh, soft or anything.

Do you ever get gassy?

Question 03/04/21 1:23 AM EST

Not usually.

Do you ever get nauseous?

Question 03/04/21 1:23 AM EST

No, almost never.

Vomiting?

Question 03/04/21 1:23 AM EST

No, I don't feel sick at all.

Have you had any appetite changes?

Question 03/04/21 1:24 AM EST

I've definitely been eating a lot more lately.

Have you recently gained or lost weight?

Question 03/04/21 1:24 AM EST

Well, I think I've lost some weight this month. [AUDIO COMING SOON]

What are your typical meals?

Question 03/04/21 1:24 AM EST

Oh, we try to make something easy. We eat a lot of frozen chicken breasts. We do hamburgers that we make at home every so often. We make sure we have a vegetable, and we eat a lot of potatoes. And we usually have rolls or something.

Its very important to get all the balanced nutrition for your body to function well.

Educate 03/04/21 1:25 AM EST

Thanks for telling me.

With your foot being hurt, have you been in bed a lot?

Question 03/04/21 1:25 AM EST

Yes! I'm in a lot of pain.

Being immobile can actually slow down your metabolic rate causing constipation and gastric reflux.

Educate 03/04/21 1:26 AM EST

Thanks for telling me.

How often are you drinking water? (Clarified to Do you drink water?.)

Question 03/04/21 1:27 AM EST

Yeah, I've had some water today; I'm not feeling thirsty now or anything. (Clarified to if I drink water.)

Whats your daily fluid intake?

Question 03/04/21 1:27 AM EST

I haven't really been keeping track, but I drink a lot of water lately. I've been thirstier than usual. Oh, and sometimes I'll drink Diet Coke too . . .

Okay, have you had any urinary issues?

Question 03/04/21 1:27 AM EST

No, I can pee fine.

How often do you pee?

Question 03/04/21 1:28 AM EST

I don't know. Every hour or two when I'm awake?

What does your urine look like?

Question 03/04/21 1:28 AM EST

Um, light yellow or almost clear? The regular color.

Do you ever get heartburn?

Question 03/04/21 1:28 AM EST

No.

Do you drink alcohol?

Very rarely.

Question 03/04/21 1:28 AM EST

How often do you drink alcohol?

Question 03/04/21 1:29 AM EST

Very rarely.

Do you use tobacco products?

Question 03/04/21 1:29 AM EST

No. I think it's gross.

Okay and do you use illicit drugs?

Question 03/04/21 1:29 AM EST

Yeah, in high school and a little after that I smoked pot sometimes. But I haven't done anything like that in a long time.

Have you noticed any changes in your weight?

Question 03/04/21 1:30 AM EST

Well, I think I've lost some weight this month. [AUDIO COMING SOON]

What weight changes have you noticed?

Question 03/04/21 1:30 AM EST

Well, in the past month I've lost some weight. . . I'd say about ten pounds, maybe.

Had you had any issues with your abdomen?

Question 03/04/21 1:30 AM EST

No, my stomach has felt fine.

Any GI changes? (Clarified to Do you have any gastrointestinal diseases?.)

Question 03/04/21 1:32 AM EST

I don't really have anything like that. [AUDIO COMING SOON] (Clarified to if I have gastrointestinal diseases.)

Any GI issues?

Question 03/04/21 1:32 AM EST

No, my stomach feels fine.

Any problems with the organs of your GI system?

Question 03/04/21 1:32 AM EST

No, my stomach feels fine.

What are your family history with gastrointestinal issues? (Clarified to Does your family have a history of gastrointestinal problems?.)

Question 03/04/21 1:33 AM EST

No, not that I know of. (Clarified to if my family has a history of gastrointestinal problems.)

What are your gastrointestinal issues?

I don't really have anything like that. [AUDIO COMING SOON]

Question 03/04/21 1:33 AM EST

Any family history of colon cancer?

Question 03/04/21 1:33 AM EST

Um, Grandpa Jones died of colon cancer.

Any history of gallstones?

Question 03/04/21 1:35 AM EST

No, as far as I know my gallbladder's never had any problems.

Any history of gall bladder problems?

Question 03/04/21 1:35 AM EST

No, as far as I know my gallbladder's never had any problems.

Kidney problems? (Clarified to Have you ever had any problems with your kidneys?.)

Question 03/04/21 1:35 AM EST

No. As far as I know, I've never had anything wrong with my kidneys. (Clarified to if I have had kidney problems.)

Okay may i do your abdominal exam now?

Question 03/04/21 1:35 AM EST

Okay.

Checked vitals

Whats your current pian level on a scale of 1-10?

Exam Action 03/04/21 1:36 AM EST

Question 03/04/21 1:37 AM EST

Uh, it's like a 6. Maybe more like a 7. It's better than before, that's for sure.

Okay i'm glad to hear that. Hopefully we can get you to feeling better!

Empathize 03/04/21 1:38 AM EST

Thanks.

Inspected left side of abdomen

Exam Action 03/04/21 1:38 AM EST

Inspected front of abdomen

Exam Action 03/04/21 1:38 AM EST

Inspected right side of abdomen

Auscultated right upper quadrant

Auscultated left upper quadrant

Auscultated left lower quadrant

Exam Action 03/04/21 1:38 AM EST

Exam Action 03/04/21 1:40 AM EST

Exam Action 03/04/21 1:40 AM EST

Exam Action 03/04/21 1:40 AM EST

Auscultated right lower quadrant

Auscultated aorta in abdomen

Auscultated right renal artery

Exam Action 03/04/21 1:40 AM EST

Exam Action 03/04/21 1:40 AM EST

Exam Action 03/04/21 1:40 AM EST

Auscultated left renal artery

Exam Action 03/04/21 1:40 AM EST

Auscultated left Iliac artery

Exam Action 03/04/21 1:40 AM EST

Auscultated right Iliac artery

Auscultated right femoral artery

Auscultated left femoral artery

Exam Action 03/04/21 1:40 AM EST

Exam Action 03/04/21 1:40 AM EST

Exam Action 03/04/21 1:40 AM EST

Percussed right upper quadrant

Exam Action 03/04/21 1:41 AM EST

Percussed left upper quadrant

Exam Action 03/04/21 1:41 AM EST

Percussed right lower quadrant

Percussed left lower quadrant

Percussed left flank for CVA tenderness

Percussed right flank for CVA tenderness

Percussed for liver span: 7 cm in the mid-clavicular line

Exam Action 03/04/21 1:41 AM EST

Exam Action 03/04/21 1:41 AM EST

Exam Action 03/04/21 1:41 AM EST

Exam Action 03/04/21 1:41 AM EST

Exam Action 03/04/21 1:41 AM EST

Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

03/04/21 1:41 AM EST

Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

Exam Action 03/04/21 1:41 AM EST

Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

Exam Action 03/04/21 1:42 AM EST

Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

03/04/21 1:42 AM EST

Palpated right upper quadrant with deep pressure: No masses

Exam Action

Exam Action

Exam Action 03/04/21 1:42 AM EST

Palpated left upper quadrant with deep pressure: No masses

Palpated right lower quadrant: with deep pressure: No masses

Palpated left lower quadrant with deep pressure: No masses

Exam Action 03/04/21 1:42 AM EST

Exam Action 03/04/21 1:42 AM EST

Exam Action 03/04/21 1:42 AM EST

Palpated liver: Palpable 1 cm below right costal margin

Exam Action 03/04/21 1:42 AM EST

Palpated for spleen: Not palpable

Exam Action 03/04/21 1:42 AM EST

Palpated for right kidney: Not palpable

Palpated for left kidney: Not palpable

Exam Action 03/04/21 1:42 AM EST

Exam Action 03/04/21 1:43 AM EST

Comments If your instructor provides individual feedback on this assignment, it will appear here.

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