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Focused Exam: End of Life Results | Turned In
Medical Surgical Nursing: Promoting Wellness in the Older Adult (Los Angeles) - April 2019, NURS 201
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Your Results Lab Pass
Overview
Transcript
Transcript
Started: Apr 10, 2019 | Patient Exam Time: 117 min
Subjective Data
Collection
All Lines (97) Interview Questions (60) Statements (7) Exam Actions (30)
Objective Data
Collection Education Greet
Hi Mrs. Walker my name is Addie and I will be your 04/10/19 2:39 PM
& Empathy QSEN nurse today. PDT
Competencies
Documentation Hi.
SBAR Question
04/10/19 2:40 PM
Reflections what brings you in today PDT
I was having trouble with the pain from my cancer... I just
couldn't take it anymore at home.
Empathize
I'm sorry to hear that 04/10/19 2:41 PM
PDT
Yes, thanks very much.
Question
Could you please state your name 04/10/19 2:42 PM
for me? PDT
Regina Walker.
thank you
, Empathize
04/10/19 2:46 PM
PDT
Thank you for saying that. Really.
Question
Are you taking any home 04/10/19 2:49 PM
medications? PDT
I take two types of morphine at home every day and I also
manage my hypertension with Hyzaar.
Question
do you have any pain right 04/10/19 2:56 PM
now? PDT
Yes, even now I know the pain's there. It's been dulled, but
it's certainly not gone.
Question
on a scale of 0 to 10 what is your 04/10/19 2:56 PM
pain? PDT
Right now, I'm about a 4 of 10.
Question
where is your pain 04/10/19 2:57 PM
located? PDT
Well, everywhere really . . . These past days I've felt it
mostly in my ribs and legs but even my bones hurt.
Question
how does the pain 04/10/19 2:57 PM
feel? PDT
I can feel it all over my body . . . It's a sharp pain in my
bones, my legs, and my ribs. It's been getting much worse
over the past two days.
Question
do you know what aggravates the 04/10/19 2:58 PM
pain? PDT
Nothing makes the pain worse, nothing makes it better. It's
just constant and relentless.
Empathize
i'm sorry you are feeling this 04/10/19 3:00 PM
way PDT
I appreciate the sympathy.