11/30/2017 Health History | Completed | Shadow Health
Health History Results | Turned In
Nurs 347 Health Assessment - Fall '17, NURS 347
Return to Assignment
Your Results Lab Pass
Overview
Subjective Data Collection: 74 of 88 (84.1%)
Transcript
Subjective Data Collection Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
Objective Data Collection
below to reveal important found.
information, including Pro Tips and
Education & Empathy
Example Questions.
Documentation
Information Processing
Catego Scored Items Patient Data
Not Scored
Health History Tips and Tricks
ry
Experts selected these topics as essential A combination of open and closed questions
Hallway
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Self-Reflection
History of Presenting Illness: Foot Wound
Established chief complaint Reports pain
Reports open foot wound
Asked to rate pain on a scale Rates present pain at a 7 out of 10
Asked for details about the pain Describes the pain as throbbing
Describes the pain as sharp when she
attempts to stand
Initial injury occurred 1 week ago
Pain has increased in the past 2 days
Reports feeling pain radiating into ankle
Pain prevents bearing weight on foot
Clarified location of wound Confirmed that right foot is injured
Confirmed that wound is on the plantar
surface of her foot
Determined details of the injury Scraped foot on bottom rung of a step
stool
Reports no other injuries besides foot
wound
Was not drinking at the time of the injury
Was not wearing shoes at the time of
injury
Has not seen a healthcare provider for
the injury
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, 11/30/2017 Health History | Completed | Shadow Health
Asked about drainage from the foot Reports that the wound bled a little after
wound sustaining the injury
Reports seeing pus draining from wound
Began noticing pus 2 days ago
Followed up about character of Describes pus as white or yellow in color
drainage from the foot wound Reports no odor from the wound
Asked about home treatment of foot Describes wound care regimen of
wound cleaning and bandaging
Cleaned wound twice a day
Cleaned wound with hydrogen peroxide
Changed bandage twice a day
Applied neosporin
Asked about other foot wound Reports swelling around foot wound
symptoms Noticed swelling getting worse in the
past 2 days
Reports redness around the wound
Reports that the wound feels warm
Explored impact of patient's foot injury Pain affects ability to walk
on activities of daily living Pain affects job performance
Pain prevented her from attending class
Asked about recent fever Reports recent feverish episode
Past Medical History: Diabetes
Asked details about diabetes diagnosis Diagnosed as an adult
Specific age of diagnosis is 24 years old
Reports that her diabetes is Type 2
Asked about diabetes management Reports that she tries to manage
through diet diabetes with diet
Reports "staying away from sweets"
Reports drinking diet coke instead of
regular
Asked about current diabetes Does not currently take medication for
medication use diabetes
Asked about past diabetes medication Used to take diabetes medication
use Previous medication was prescription
metformin
Last use of medication was 3 years ago
Explored the reasons the patient Reports that she "got sick of dealing with
stopped her diabetes regimen it"
This study source was downloaded by 100000840862941 from CourseHero.com on 02-17-2022 11:24:28 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/2518858 2/9
https://www.coursehero.com/file/36256732/Health-History-Completed-Shadow-Healthpdf/
Health History Results | Turned In
Nurs 347 Health Assessment - Fall '17, NURS 347
Return to Assignment
Your Results Lab Pass
Overview
Subjective Data Collection: 74 of 88 (84.1%)
Transcript
Subjective Data Collection Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
Objective Data Collection
below to reveal important found.
information, including Pro Tips and
Education & Empathy
Example Questions.
Documentation
Information Processing
Catego Scored Items Patient Data
Not Scored
Health History Tips and Tricks
ry
Experts selected these topics as essential A combination of open and closed questions
Hallway
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Self-Reflection
History of Presenting Illness: Foot Wound
Established chief complaint Reports pain
Reports open foot wound
Asked to rate pain on a scale Rates present pain at a 7 out of 10
Asked for details about the pain Describes the pain as throbbing
Describes the pain as sharp when she
attempts to stand
Initial injury occurred 1 week ago
Pain has increased in the past 2 days
Reports feeling pain radiating into ankle
Pain prevents bearing weight on foot
Clarified location of wound Confirmed that right foot is injured
Confirmed that wound is on the plantar
surface of her foot
Determined details of the injury Scraped foot on bottom rung of a step
stool
Reports no other injuries besides foot
wound
Was not drinking at the time of the injury
Was not wearing shoes at the time of
injury
Has not seen a healthcare provider for
the injury
This study source was downloaded by 100000840862941 from CourseHero.com on 02-17-2022 11:24:28 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/2518858 1/9
https://www.coursehero.com/file/36256732/Health-History-Completed-Shadow-Healthpdf/
, 11/30/2017 Health History | Completed | Shadow Health
Asked about drainage from the foot Reports that the wound bled a little after
wound sustaining the injury
Reports seeing pus draining from wound
Began noticing pus 2 days ago
Followed up about character of Describes pus as white or yellow in color
drainage from the foot wound Reports no odor from the wound
Asked about home treatment of foot Describes wound care regimen of
wound cleaning and bandaging
Cleaned wound twice a day
Cleaned wound with hydrogen peroxide
Changed bandage twice a day
Applied neosporin
Asked about other foot wound Reports swelling around foot wound
symptoms Noticed swelling getting worse in the
past 2 days
Reports redness around the wound
Reports that the wound feels warm
Explored impact of patient's foot injury Pain affects ability to walk
on activities of daily living Pain affects job performance
Pain prevented her from attending class
Asked about recent fever Reports recent feverish episode
Past Medical History: Diabetes
Asked details about diabetes diagnosis Diagnosed as an adult
Specific age of diagnosis is 24 years old
Reports that her diabetes is Type 2
Asked about diabetes management Reports that she tries to manage
through diet diabetes with diet
Reports "staying away from sweets"
Reports drinking diet coke instead of
regular
Asked about current diabetes Does not currently take medication for
medication use diabetes
Asked about past diabetes medication Used to take diabetes medication
use Previous medication was prescription
metformin
Last use of medication was 3 years ago
Explored the reasons the patient Reports that she "got sick of dealing with
stopped her diabetes regimen it"
This study source was downloaded by 100000840862941 from CourseHero.com on 02-17-2022 11:24:28 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/2518858 2/9
https://www.coursehero.com/file/36256732/Health-History-Completed-Shadow-Healthpdf/
