NURS MISC Focused Exam: Type 1 Diabetes (Patient: Chelsea Warren)

Focused Exam: Type 1 Diabetes Patient: Chelsea Warren Digital Clinical Experience Score Subjective Data Collection: 25 of 25 (100.0% Category Finding: Assessed patient status Finding: Reports feeling "way better" (Found) Pro Tip: Assessing a pediatric patient's status involves asking about their current comfort, needs, and chief complaint. It's important to check in with a patient's status, because it may reveal insight into their current condition. Example Question: How do you feel? Finding: Reports eagerness to go home (Found) Pro Tip: Assessing a pediatric patient's status involves asking about their current comfort, needs, and chief complaint. It's important to check in with a patient's status, because it may reveal insight into their current condition. Example Question: How do you feel? Finding: Asked about patient's comfort Finding: Reports feeling comfortable (Found) Pro Tip: Assessing a pediatric patient's status involves asking about their current comfort, needs, and chief complaint. It's important to check in with a patient's status, because it may reveal insight into their current condition. Example Question: Are you having pain right now? Finding: Asked about patient's needs Finding: Denies needing anything (Found) Pro Tip: Assessing a pediatric patient's status involves asking about their current comfort, needs, and chief complaint. It's important to check in with a patient's status, because it may reveal insight into their current condition. Example Question: Do you need anything? Finding: Asked patient about symptoms of DKA Finding: Denies remembering incident very well (Found) Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Why were you admitted? Finding: Reports feeling nauseated at a horseback riding lesson (Found) Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Why were you admitted? Finding: Reports vomiting (Found) Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Why were you admitted? Finding: Asked about patient's other symptoms prior to DKA Finding: Reports frequent urination prior to DKA (Found) Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Have you been urinating more often than usual? Finding: Reports excessive thirst prior to DKA (Found) Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Have you been feeling more thirsty lately? Finding: Reports fatigue prior to DKA (Found) Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you always fatigued? Finding: Reports lack of appetite prior to DKA (Available) Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How is your appetite? Finding: Asked about onset of prior symptoms Finding: Reports other symptoms began around 10 days prior (Found) Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: When did you start feeling sick? Finding: Assessed patient's knowledge of type 1 diabetes Finding: Reports knowledge of type 1 diabetes (Found) Pro Tip: Assessing a pediatric patient's knowledge of their preexisting conditions helps you determine how to educate both guardian and patient. Example Question: What type of diabetes do you have? Finding: Asked about diet at mother's house Finding: Reports mother is a "health nut" (Found) Pro Tip: Assessing a pediatric patient's diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their chief complaint. Details of their current diet will help you to educate the patient on a diet that will help in the treatment and management of their condition. Example Question: What is your diet like? Finding: Reports typical breakfast at mother's home is yogurt and fruit (Available) Pro Tip: Assessing a pediatric patient's diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their chief complaint. Details of their current diet will help you to educate the patient on a diet that will help in the treatment and management of their condition. Example Question: What's your usual breakfast? Finding: Reports typical lunch is a salad with chicken (Available) Pro Tip: Assessing a pediatric patient's diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their chief complaint. Details of their current diet will help you to educate the patient on a diet that will help in the treatment and management of their condition. Example Question: What do you usually eat for lunch? Finding: Reports typical dinner is grilled meat and vegetables (Available) Pro Tip: Assessing a pediatric patient's diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their chief complaint. Details of their current diet will help you to educate the patient on a diet that will help in the treatment and management of their condition. Example Question: What's a typical dinner? Finding: Asked about social activities Finding: Reports riding horses 2-3 times a week after school (Found) Pro Tip: A pediatric patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness. Asking about a pediatric patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: How often do you ride horses? Finding: Asked about substance use Finding: Denies tobacco use (Available) Pro Tip: A pediatric patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness. Asking about a pediatric patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Have you ever experimented with smoking? Finding: Denies vaping (Available) Pro Tip: A pediatric patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness. Asking about a pediatric patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Have you ever vaped or used an ecigarette? Finding: Denies alcohol use (Available) Pro Tip: A pediatric patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness. Asking about a pediatric patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you drink alcohol? Finding: Asked about general symptoms Finding: Denies current excessive thirst (Found) Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you been feeling more thirsty lately? Finding: Asked about gastrointestinal symptoms Finding: Denies current nausea (Found) Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Did your nausea improve? Finding: Denies current vomiting (Found) Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Are you going to be sick? Finding: Reports normal bowel movements (Available) Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Are you feeling constipated? Finding: Asked about urinary symptoms Finding: Denies current frequent urination (Found) Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: How long have you been urinating more frequently? Finding: Denies high volume of urine (Found) Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you urinate a lot? Finding: Asked about neurological system Finding: Denies neurological symptoms (Found) Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you feel tingling anywhere? Finding: Confirmed guardian's relationship to patient Finding: Reports he is patient's father (Found) Pro Tip: Determining the guardian's relationship to a pediatric patient confirms the appropriate family members are present. Knowing who is with the pediatric patient will help you to develop the best approach to gathering information on the patient's condition. Example Question: what is your relationship to the patient Finding: Asked about patient's diagnosi Finding: Reports patient is diagnosed with type 1 diabetes (Found) Pro Tip: Asking a pediatric patient's guardian about the duration and onset of the patient's current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What is your daughter's diagnosis Finding: Followed up on history of present illness leading to diagnosis Finding: Reports patient was admitted to hospital two days prior (Found) Pro Tip: Asking a pediatric patient's guardian about the duration and onset of the patient's current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: When was your daughter hospitalized Finding: Reports patient had diabetic ketoacidosis when admitted (Found) Pro Tip: Asking a pediatric patient's guardian about the duration and onset of the patient's current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Did your daughter have complications with her diabetes? Finding: Asked guardian about symptoms of DKA