Focused Exam Pain Completed Shadow Health PDF

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4/28/2021

Focused Exam: Pain | Completed | Shadow Health

Focused Exam: Pain Results | Turned In Nursing Care of Older Adults - Spring 2021, NUR 260 Return to Assignment (/assignments/459203/)

Notice: The detailed results of your assignment attempt are now available because the Due Date has passed. Your assignment score(s) has not changed.

Your Results

Overview

Lab Pass (/assignment_attempts/9122494/lab_pass.p

Subjective Data Collection: 54 of 58 (93.1%)

Transcript Subjective Data Collection Hover To Reveal...

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Objective Data Collection Education & Empathy QSEN Competencies Documentation SBAR

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Patient Data Not Scored

Experts selected these topics as essential components of a strong, thorough interview with this patient.

A combination of open and closed questions will yiel better patient data. The following details are facts of patient's case.

Orientation

Established orientation

Oriented to person Oriented to place Oriented to time Oriented to situation

Chief Complaint

Established chief complaint

Reports pain Reports recent fall Reports worry about worsening symptoms

History of Present Illness

Asked about onset and duration of symptoms

Reports recent episode of severe pain started this morning Reports pain has been getting progressively worse in the last few weeks

Asked about location of pain

Reports hip pain Reports knee pain

Asked about characteristics of pain

Describes pain as aching Describes pain as "deep"

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Focused Exam: Pain | Completed | Shadow Health Denies shooting or sharp pain Reports occasional "grating" sensation in joints Denies burning pain Denies stinging pain

Asked about severity of pain

Reports current pain is a 1 Reports pain before medication was a 9

Asked about non-medication relieving factors of pain

Reports that rest typically relieves the pain Reports not using any non-medication treatments to treat this morning's pain Reports occasional use of moist heat as treatment on hips Reports using range of motion exercises for knees Reports wearing elastic supports on knees bilaterally Denies use of ice as treatment

Asked about aggravating factors of pain

Reports that exercise exacerbates pain and stiffness Reports that weight bearing exacerbates pain and stiffness Reports that pain and stiffness are worse in the morning Reports that changes in weather exacerbate pain and stiffness

Followed up on details of the fall

Reports falling getting out of bed Reports hitting his back on bed frame Denies dizziness, syncope, or vertigo at time of fall Denies substance use that could have related to the fall

Past Medical History

Asked about existing health conditions

Reports osteoarthritis diagnosis Reports hypertension diagnosis Reports chronic kidney disease diagnosis Reports atrial fibrillation diagnosis

Followed up about osteoarthritis diagnosis

Followed up about osteoarthritis symptoms and ADLs

Followed up about hypertension diagnosis

Diagnosed age 66

Reports increasing problems with gait Reports increasing problems with exercise

Diagnosed at age 55 Reports belief that blood pressure is wellcontrolled Reports typical blood pressure as 130/85 Reports eating a low sodium diet

Followed up about atrial fibrillation diagnosis

Diagnosed at age 61 Denies recent episodes of palpitations or problems Denies pacemaker or surgical intervention

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Focused Exam: Pain | Completed | Shadow Health

Followed up about chronic kidney disease diagnosis

Asked about allergies

Diagnosed at age 62 Reports disease is stage 2

Denies general allergies Denies environmental allergies Denies latex allergy

Asked specifically about medication allergies

Denies medication allergies

Home Medications

Asked about home medications

Reports medication for osteoarthritis Reports medications for atrial fibrillation Reports medication for hypertension Denies medication for chronic kidney disease Denies pain medication at home Denies taking vitamins Denies taking herbal supplements

Asked about medication regimen adherence

Reports using a pillbox to organize medications Denies missing doses of medication Denies missing doses of medication because of side effects Denies difficulty obtaining medications because of finances Denies difficulty obtaining medications because of transportation

Followed up on last dose of home medications

Reports taking naproxen at 5 am this morning to try to relieve pain Denies taking other medications today

Followed up on anticoagulant medication for atrial fibrillation

Reports taking apixaban Reports apixaban dosage: 2.5 mg Reports apixaban frequency: 1x daily Denies apixaban side effects

Followed up on calcium channel blocker medication for atrial fibrillation

Reports taking verapamil Reports verapamil dosage: 80 mg Reports verapamil frequency: 3x daily Denies verapamil side effects

Followed up on combination ARB / diuretic for hypertension

Reports taking Hyzaar (losartan and hydrochlorothiazide combination) Reports Hyzaar dosage: 100 losartan /25 mg hydrochlorothiazide Reports Hyzaar frequency: 1x daily Denies Hyzaar side effects

Followed up on oral medication for osteoarthritis

Reports taking naproxen Reports naproxen dosage: 220 mg Reports naproxen frequency: 2x daily Denies naproxen side effects

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Focused Exam: Pain | Completed | Shadow Health Reports that naproxen is typically effective at reducing pain Reports that naproxen is OTC

Followed up on injections for osteoarthritis

Reports injections are kenalog (triamcinolone) Reports kenalog dosage: 10 mg/mL Reports kenalog frequency: 4 times per year Reports kenalog location: Injected into each hip and knee joint Denies side effects Reports that injections are effective in reducing pain Reports that last injection was "at least" 3 months ago

Patient Status

Asked about medication administered in ER

Reports receiving morphine Reports morphine has been effective

Asked about patient comfort and needs

Denies needing to use the bathroom

Social History

Asked about substance use

Denies recent alcohol use Denies illicit drug use Denies use of tobacco and nicotine products

Family History

Asked about relevant family history

Denies family history of osteoarthritis Denies family history of kidney stones Denies family history of chronic kidney disease Denies family history of atrial fibrillation Reports father and mother had hypertension

Review of Systems

Asked about general symptoms

Denies fever Denies chills Denies night sweats

Asked about review of systems for HEENT

Denies impaired hearing Denies vision problems

Asked about review of systems for respiratory

Denies cough Denies shortness of breath Denies dyspnea on exertion Denies wheezing

Asked about review of systems for cardiovascular

Denies chest pain Denies palpitations Denies edema Denies claudication

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Focused Exam: Pain | Completed | Shadow Health

Asked about review of systems for gastrointestinal

Denies abdominal pain Denies difficulty swallowing Denies nausea Denies vomiting Denies constipation Denies diarrhea Denies changes in stool or bowel patterns

Asked about review of systems for neurological

Reports weakness in lower extremities Reports sore lower back Denies frequent headaches Denies numbness or tingling Denies changes in coordination Denies changes in memory

Asked about review of systems for musculoskeletal

Denies predisposing traumatic injuries Reports limited range of motion in joints Denies muscle spasms

Asked about review of systems for psychological

Denies mood change Denies suicidal thoughts

Functional Status & Geriatric Syndromes

Asked about living environment

Reports living at home Reports living with wife Reports appropriate levels of privacy Reports enjoying his home life Denies loneliness

Asked about feeling safe at home

Reports feeling safe at home

Asked about depression

Asked about bathing

Reports being able to bathe independently Reports being able to reach all parts of his body Reports being able to get out of shower safely by being "extra careful"

Asked about dressing

Reports being able to retrieve clothing Reports being able to put on clothes Denies difficulty with buttons and zippers Denies difficulty tying shoes

Asked about toileting

Reports being able to get up from the toilet with support (uses bathroom sink for support) Reports being able to arrange clothing during toileting Reports being able to clean genital area without help

Asked about transferring

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Reports difficulty getting out of bed in the morning

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4/28/2021

Focused Exam: Pain | Completed | Shadow Health Reports some difficulty getting out of chairs Reports occasional use of cane to transfer

Asked about continence

Reports full control over bowels Reports full control over bladder

Asked about feeding and eating

Reports being fully able to eat and feed himself Reports being fully able to get food from plate to mouth Reports being able to prepare food

Asked about sleeping habits

Reports that sleep is good Denies insomnia Denies frequent waking Denies oversleeping

Asked about confusion

Asked about evidence of falls

Denies confusion

Denies previous falls Denies dizziness, syncope, or vertigo

Asked about gait and ambulatory aids

Reports some problems with gait Denies bedrest Denies use of wheelchair Reports occasional use of cane to walk Reports occasional use of furniture as support while walking Reports occasional problems with balance because of arthritis pain

Asked about skin breakdown

Reports that his skin seems thin Denies open wounds Denies rashes or lesions Denies bruising (may have bruising on back from fall, but it hasn't appeared yet) Denies pruritus

Asked about weight changes

Asked about oral or dental problems

Denies weight changes

Denies tooth problems and dental pain Denies issues with mouth, jaw, or gums Reports no issues with being able to chew food

Asked about appetite changes

Denies changes in appetite Denies feeling full quickly

Asked about effects of health on social activity

Reports that social activity has remained the same, although he has to sit through some events Reports feeling worried about reduced mobility and independence

Asked about patient's perception of health

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Describes health as fair

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Focused Exam: Pain | Completed | Shadow Health Asked about tiredness, energy levels, and fatigue

Reports increased fatigue and low energy Describes fatigue as "having hardly any energy" and "needing to rest much more than usual" Reports fatigue occurs in the afternoons Reports fatigue for the last 3 months

Asked about recent ER visits or hospitalizations

Denies ER visits or hospitalization in the last 3 months Reports last hospitalization was 3 years ago Reports last hospitalization was for kidney stones

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

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