TINA JONES HEALTH HISTORY SHADOW
HEALTH
NURSING 111:
Health
Assessment
Laboratory
,Your Results La b Pa s s
Category Scored Items
Experts selected these topics
Patient Data
as essential components of a
strong, thorough interview Not Scored
with this patient. A combination of open and
closed questions will yield
better patient data. The
following details are facts of the
patient's case.
Chief Complaint
Established chief complaint Reports pain
Reports foot
wound
History of Presenting Illness
Asked to rate current Reports current pain is 7/10
pain level on a scale
Asked for details about the pain Reports pain is throbbing
Reports pain is sharp when
she attempts to stand
Reports pain has increased
in the past 2 days
Reports feeling pain radiating
into ankle
, Reports pain prevents
bearing weight on foot
Asked location of wound Reports right foot is injured
Reports wound is on the
plantar surface of her foot
Asked details of the injury Reports she scraped
foot on bottom rung of a
step stool
Reports injury occurred 1
week ago Denies other
injuries besides foot
wound Reports being
barefoot at the time of
injury
Denies seeing a
healthcare provider for the
injury until now
Asked about drainage Reports that the wound
from the foot wound bled a little after sustaining
the injury
Reports seeing pus draining
from wound Reports noticing
pus 2 days ago
Followed up on drainage Reports pus as
white or yellow
Denies odor from
the wound
Asked about home Reports wound care
treatment of foot wound regimen of bandaging
HEALTH
NURSING 111:
Health
Assessment
Laboratory
,Your Results La b Pa s s
Category Scored Items
Experts selected these topics
Patient Data
as essential components of a
strong, thorough interview Not Scored
with this patient. A combination of open and
closed questions will yield
better patient data. The
following details are facts of the
patient's case.
Chief Complaint
Established chief complaint Reports pain
Reports foot
wound
History of Presenting Illness
Asked to rate current Reports current pain is 7/10
pain level on a scale
Asked for details about the pain Reports pain is throbbing
Reports pain is sharp when
she attempts to stand
Reports pain has increased
in the past 2 days
Reports feeling pain radiating
into ankle
, Reports pain prevents
bearing weight on foot
Asked location of wound Reports right foot is injured
Reports wound is on the
plantar surface of her foot
Asked details of the injury Reports she scraped
foot on bottom rung of a
step stool
Reports injury occurred 1
week ago Denies other
injuries besides foot
wound Reports being
barefoot at the time of
injury
Denies seeing a
healthcare provider for the
injury until now
Asked about drainage Reports that the wound
from the foot wound bled a little after sustaining
the injury
Reports seeing pus draining
from wound Reports noticing
pus 2 days ago
Followed up on drainage Reports pus as
white or yellow
Denies odor from
the wound
Asked about home Reports wound care
treatment of foot wound regimen of bandaging
