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Infection Shadow Health...

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Focused Exam: Infection | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/8354

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Focused Exam: Infection Results | Turned In Community & Population Health Nursing - Fall 2020, NUR 460 Return to Assignment (/assignments/406689/)

Your Results

Reopen (/assignment_attempts/8354140/reopen) Lab Pass (/assignment_attempts/8354140/lab_pass.pdf)

Overview

Transcript

Transcript Started: Nov 02, 2020 | Total Time: 42 min Subjective Data Collection All Lines (122)

Interview Questions (86)

Statements (2)

Exam Actions (34)

Objective Data Collection Education & Empathy

Assessed IV bag

Exam Action 11/02/20 7:39 PM EST

Assessed IV pump

Exam Action 11/02/20 7:39 PM EST

Assessed IV site

Exam Action 11/02/20 7:39 PM EST

Assessed vitals

Exam Action 11/02/20 7:39 PM EST

Assessed urine quality: cloudy, pink or amber, and a foul odor

Exam Action 11/02/20 7:40 PM EST

QSEN Competencies Documentation Care Plan Program Competency Progress Reflections

Checked Patient Wristbands: All information is correct

do you feel safe at home

Exam Action 11/02/20 7:41 PM EST

Question 11/02/20 7:41 PM EST

I feel very safe at home.

are you being abused

Question 11/02/20 7:41 PM EST

No, not at all . . . I am very safe at home.

financial abuse?

Question 11/02/20 7:41 PM EST

My daughter Mary has a knack for finances . . . I think my husband taught her. I trust her with managing our estate. I don't think she would ever take advantage of me.

what brings you in today

Gracious . . . this pain is just . . . oh, it's just terrible. Last night, it was there, but not as much . . . not as much as this morning. It hasn't let up a bit . . .

Question 11/02/20 7:43 PM EST

Suppor t

Focused Exam: Infection | Completed | Shadow Health

rate your pain

https://app.shadowhealth.com/assignment_attempts/8354

Question 11/02/20 7:43 PM EST

A scale . . . I just don't know.

how would you rate your pain

Question 11/02/20 7:43 PM EST

A scale . . . I just don't know.

where are you

Question 11/02/20 7:44 PM EST

I'm in the clinic in Dr. Turner's office . . . Is he coming in soon?

what is your name

Question 11/02/20 7:44 PM EST

Patricia Young.

how old are you

Question 11/02/20 7:44 PM EST

Um, well . . . you get old enough and it gets a little hard to keep track . . .

when is your birthday

Question 11/02/20 7:44 PM EST

My birthday is December 29th . . . [Ms. Young reports correct birth year.]

how did you hurt yourself (Clarified to Have you ever thought about hurting yourself?.)

Question 11/02/20 7:44 PM EST

No, no . . . I'd never. I don't recall ever feeling that way, even when I was at my lowest point in life. I had children to live for . . . that kept me going . . . (Clarified to if I have ever thought about hurting myself.)

Inspected eyes

allergies

Exam Action 11/02/20 7:45 PM EST

Question 11/02/20 7:45 PM EST

No allergies here.

med allergies (No matching questions found.)

Question 11/02/20 7:45 PM EST

what helps your pain

Question 11/02/20 7:45 PM EST

I also didn't try treating at home. I wasn't sure what to do . . . I asked Mary to bring me here . . . so I could get some help.

what makes your pain better

Question 11/02/20 7:45 PM EST

I also didn't try treating at home. I wasn't sure what to do . . . I asked Mary to bring me here . . . so I could get some help.

what your medical history

Question 11/02/20 7:45 PM EST

Focused Exam: Infection | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/8354

I have some high cholesterol, and I've had a few UTIs before.

past surgeries?

Question 11/02/20 7:46 PM EST

I had surgery years ago. I suppose I was 48 years old. They took my gallbladder out, so I was in the hospital for a bit.

what medications do you take

Question 11/02/20 7:46 PM EST

I'm taking two medications for my high cholesterol. I think they're called, um, Lip-something . . . and Pravicole? Privacon?

family health issues (Clarified to What health problems run in your family?.)

Question 11/02/20 7:46 PM EST

Our family health problems . . . a lot of us have high cholesterol. My brothers do, and they also have heart disease. My dad died of a heart attack, and my mother died of a stroke, years ago. (Clarified to what health problems run in my family.)

do you have friends

Question 11/02/20 7:47 PM EST

Friends . . . oh . . . I think of my family as my friends.

do you drink

Question 11/02/20 7:47 PM EST

Well, I drink a little wine on special occasions.

do you smoke

Question 11/02/20 7:47 PM EST

No, I've never had a cigarette or any other kind of tobacco. I stayed away from those coffin nails, even in the 1950s when people thought they were good for you.

how eyes

Question 11/02/20 7:47 PM EST

I haven't had any vision problems, or any issues with my eyes.

how ears (No matching questions found.)

how lungs

Question 11/02/20 7:48 PM EST

Question 11/02/20 7:48 PM EST

I haven't had any problems with my lungs. I don't normally feel out of breath.

how stomach

Question 11/02/20 7:48 PM EST

Well, my back and my abdomen started hurting last night. They ache so much. The pain got worse this morning. It also hurts when I use the bathroom. It's this terrible burning sensation.

how bones. (No matching questions found.)

Question 11/02/20 7:48 PM EST

how bones (No matching questions found.)

Question 11/02/20 7:49 PM EST

Focused Exam: Infection | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/8354

how muscles (No matching questions found.)

Question 11/02/20 7:49 PM EST

how muscles and bones (No matching questions found.)

Question 11/02/20 7:49 PM EST

how musculoskeletal (No matching questions found.)

Question 11/02/20 7:49 PM EST

how is your musculoskeletal system

Question 11/02/20 7:49 PM EST

I have occasional aches and pains, but it's nothing out of the ordinary for a lady my age.

Inspected mouth

Exam Action 11/02/20 7:50 PM EST

we will inspect perineal

Question 11/02/20 7:50 PM EST

Thanks for walking me through that.

Inspected perineal area: some redness present

Exam Action 11/02/20 7:50 PM EST

Inspected abdomen

Exam Action 11/02/20 7:51 PM EST

Inspected front of left hand

Exam Action 11/02/20 7:51 PM EST

Inspected front of right hand

Exam Action 11/02/20 7:51 PM EST

Inspected front of legs

Exam Action 11/02/20 7:51 PM EST

Inspected feet

Exam Action 11/02/20 7:51 PM EST

Inspected right palm

Exam Action 11/02/20 7:51 PM EST

Inspected back of legs

Exam Action 11/02/20 7:51 PM EST

Inspected back of feet

Exam Action 11/02/20 7:51 PM EST

Inspected upper back and neck

Exam Action 11/02/20 7:51 PM EST

Auscultated carotids

Exam Action 11/02/20 7:51 PM EST

Auscultated breath sounds

Exam Action 11/02/20 7:52 PM EST

Auscultated heart sounds

Exam Action 11/02/20 7:52 PM EST

Palpated abdomen with light pressure

Exam Action 11/02/20 7:52 PM EST

Focused Exam: Infection | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/8354

Palpated abdomen with deep pressure

Exam Action 11/02/20 7:52 PM EST

Palpated abdomen with light pressure

Exam Action 11/02/20 7:52 PM EST

Palpated abdomen with deep pressure

Exam Action 11/02/20 7:52 PM EST

Palpated posterior tibial pulse

Exam Action 11/02/20 7:52 PM EST

Palpated dorsalis pedis pulse

Exam Action 11/02/20 7:52 PM EST

Percussed Right CVA: Tenderness reported

Exam Action 11/02/20 7:52 PM EST

Oww...

Percussed Left CVA: Tenderness reported

Exam Action 11/02/20 7:52 PM EST

Hmmm...

remember apple, penny and table

Question 11/02/20 7:53 PM EST

Apple, penny, and table.

repeat the three words

Question 11/02/20 7:53 PM EST

Apple, penny, and... uh, I'm not sure of the last one?

Tested fine motor skills

Exam Action 11/02/20 7:53 PM EST

Tested grip

Exam Action 11/02/20 7:53 PM EST

Tested skin turgor

Exam Action 11/02/20 7:53 PM EST

Tested capillary refill

Exam Action 11/02/20 7:54 PM EST

Tested gait: hesitancy, right and left step length equal, some path deviation, discontinuity between steps, heels set apart, and greater than 12 seconds to complete.

Exam Action 11/02/20 7:54 PM EST

how fluid intake (Clarified to What is your normal daily fluid intake?.)

Question 11/02/20 7:55 PM EST

Well, I love my coffee. My daughter makes a big pot in the morning, so I drink about three cups a day. (Clarified to what my typical daily fluid intake is.)

what triggers your pain

Question 11/02/20 7:56 PM EST

I'm not sure what the cause is, I just know it's painful.

what aggravates your pain

Question 11/02/20 7:56 PM EST

Focused Exam: Infection | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/8354

The pain was there all night, and felt worse this morning. I'm not sure I could say what makes it worse, I can only tell you how it feels. My abdomen and back hurt constantly, and the pain when I urinate is awful.

UTI history

Question 11/02/20 7:57 PM EST

Yes, I've had UTIs before . . . maybe once a year . . . but this back pain . . . it just doesn't make sense.

hypercholesterolemia history (Clarified to Tell me about your hypercholesterolemia..)

Question 11/02/20 7:58 PM EST

You do mean my high cholesterol, right? Well, I have it . . . I've been on medication for it . . . since my late 50s. (Clarified to to tell you about my hypercholesterolemia.)

medication allergies? (Clarified to Do you have medication allergies?.)

Question 11/02/20 7:58 PM EST

No, I don't have any allergies. (Clarified to if I have medication allergies.)

med regimen (No matching questions found.)

Question 11/02/20 8:02 PM EST

medication regimen (Clarified to How well do you adhere to your medication regimen?.)

Question 11/02/20 8:02 PM EST

Well . . . I occasionally miss a dose here or there if I forget, but I think I remember most doses. (Clarified to how well I adhere to my medication regimen.)

last dose of home medication (No matching questions found.)

Question 11/02/20 8:06 PM EST

last dose medication (Clarified to When was the last time you took any medications?.)

Question 11/02/20 8:06 PM EST

Oh . . . hm. I don't remember if I took my medication today . . . but I'm fairly sure I took them yesterday. (Clarified to when I last took medication.)

tell me about both meds (Clarified to Can you tell me about your alcohol use?.)

Question 11/02/20 8:07 PM EST

Well, I drink a little wine on special occasions. (Clarified to to tell you about my alcohol use.)

tell me about your cholesterol meds

Question 11/02/20 8:07 PM EST

Well, my cholesterol is high.

tell me about medications (Clarified to What medications do you take?.)

Question 11/02/20 8:07 PM EST

I'm taking two medications for my high cholesterol. I think they're called, um, Lip-something . . . and Pravicole? Privacon? (Clarified to what medications I am taking.)

why do you take cholesterol meds (Clarified to What cholesterol medication do you take?.)

Question 11/02/20 8:07 PM EST

I'm taking two medications for my high cholesterol. I think they're called, um, Lip-something . . . and Pravicole? Privacon? (Clarified to what cholesterol medication I take.)

how sex activity

Question 11/02/20 8:08 PM EST

Focused Exam: Infection | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/8354

It's been a very long time . . . My husband William was my only partner, and he's passed away. I don't . . . I don't feel like pursuing a relationship like that again, if that answers your question.

what is your sexual activity

Question 11/02/20 8:08 PM EST

It's been a very long time . . . My husband William was my only partner, and he's passed away. I don't . . . I don't feel like pursuing a relationship like that again, if that answers your question.

do you exercise

Question 11/02/20 8:09 PM EST

I used to take more walks around my neighborhood . . . I just haven't had the energy . . . Most days I sit and watch TV. I like to crochet a little while I watch the History Channel.

sexual activity and STI

Question 11/02/20 8:13 PM EST

It's been a very long time . . . My husband William was my only partner, and he's passed away. I don't . . . I don't feel like pursuing a relationship like that again, if that answers your question.

history of STI

Question 11/02/20 8:15 PM EST

Well, I only ever had sexual relations with William, and he's been gone for . . . for years. Eleven? Eleven years.

how heart (Clarified to How long has your heart had problems?.)

Question 11/02/20 8:15 PM EST

Well, I was diagnosed with high cholesterol when I was 58, so I suppose I've had heart problems since then. (Clarified to how long my heart has had problems.)

how is your heart

Question 11/02/20 8:15 PM EST

My heart rate seems fine.

how stomach

Question 11/02/20 8:15 PM EST

Well, my back and my abdomen started hurting last night. They ache so much. The pain got worse this morning. It also hurts when I use the bathroom. It's this terrible burning sensation.

how is your gastrointestinal

Question 11/02/20 8:16 PM EST

My stomach has been just fine, really.

how is your brain

Question 11/02/20 8:16 PM EST

Well what kind of a question is that? My brain is . . . is fine. [AUDIO COMING SOON]

how is your neurological

I have felt a little weak lately. I don't have much energy to do many things . . . I'm fairly sedentary. I also feel somewhat disoriented. It's hard for me to keep track of things sometimes.

Question 11/02/20 8:16 PM EST

Focused Exam: Infection | Completed | Shadow Health

how is your genitourinary

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Question 11/02/20 8:16 PM EST

I have this terrible pain when I use the bathroom. It feel this awful burning when I urinate, and I am so irritated down there.

bathing (No matching questions found.)

Question 11/02/20 8:17 PM EST

how bathing

Question 11/02/20 8:17 PM EST

Oh, I take a shower . . . maybe once every other day or so. I'm lucky that I can still manage on my own.

how toilet

Question 11/02/20 8:17 PM EST

I don't need help in the bathroom.

how transfer

Question 11/02/20 8:17 PM EST

I'm afraid I'm not sure what you mean by "transfer" . . . could you run that by me again? Maybe ask me a different way.

how dress (No matching questions found.)

Question 11/02/20 8:18 PM EST

can dress (No matching questions found.)

Question 11/02/20 8:18 PM EST

can you dress (Clarified to Are you able to dress yourself?.)

Question 11/02/20 8:18 PM EST

I don't have any problems dressing myself. (Clarified to if I can dress myself without problems.)

are eat

Question 11/02/20 8:18 PM EST

Since yesterday, I haven't felt hungry at all. I just have no appetite. Normally, I don't feel full too quickly, but right now I just have no appetite at all.

can you eat

Question 11/02/20 8:18 PM EST

Since yesterday, I haven't felt hungry at all. I just have no appetite. Normally, I don't feel full too quickly, but right now I just have no appetite at all.

eat independently

Question 11/02/20 8:19 PM EST

I can feed myself just fine.

how sleep

Question 11/02/20 8:20 PM EST

I've always been a good sleeper. My husband William used to joke that I could sleep through anything.

how fall

Question 11/02/20 8:20 PM EST

Focused Exam: Infection | Completed | Shadow Health

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I've never had problems with falls.

how gait

Question 11/02/20 8:20 PM EST

My gait is a little unsteady these days, but I don't need any devices to help me get around.

how is your gait

Question 11/02/20 8:20 PM EST

My gait is a little unsteady these days, but I don't need any devices to help me get around.

any skin breakdown

Question 11/02/20 8:20 PM EST

Skin problems . . . I think my skin is fine.

any gait issues

Question 11/02/20 8:20 PM EST

My gait is a little unsteady sometimes . . . but I manage to do OK. Sometimes my aches and pains slow me down a bit.

ambulatory aids you have?

Question 11/02/20 8:20 PM EST

I don't use anything like that to get around. I'm a little unsteady on my feet, but I think I do well enough to not need a cane, walker, or anything like that.

any weight changes

Question 11/02/20 8:21 PM EST

I have gained some weight lately . . . about ten pounds. It happened when I moved in with my daughter a few months ago . . . She's an excellent cook ...