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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
Greet
Education & Empathy
Hi Mrs. Walker my name is Addie and I will be your nurse today. 04/10/19 2:39 PM
PDT
QSEN Competencies
Documentation
Hi.
SBAR
Question
Reflections
what brings you in today 04/10/19 2:40 PM
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 for me? 04/10/19 2:42 PM
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 medications? 04/10/19 2:49 PM
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 now? 04/10/19 2:56 PM
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 pain? 04/10/19 2:56 PM
PDT
Right now, I'm about a 4 of 10.
Question
where is your pain located? 04/10/19 2:57 PM
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 feel? 04/10/19 2:57 PM
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 pain? 04/10/19 2:58 PM
PDT
Nothing makes the pain worse, nothing makes it better. It's just
constant and relentless.
Empathize
i'm sorry you are feeling this way 04/10/19 3:00 PM
PDT
I appreciate the sympathy.