NURS 3400 Tina HEENT assessment
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this
patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details
are facts of the patient's case.
Relevant Medical History
Finding:Asked about head problems
Finding:Reports occasional headaches(Found)Pro Tip: Headaches can be caused a variety of
ways, such as when sinus problems result in increased pressure buildup. Asking Tina if she gets
headaches is soliciting information about possible symptoms that she experiences.Example
Question:Do you get headaches?
Finding:Denies current headache(Available)Pro Tip: Assessing how a patient feels in the current
moment can allow you to juxtapose their chief complaint alongside symptoms they experience.
Asking Tina if she currently has a headache solicits information about how she is feeling
now.Example Question:Do you currently have a headache?
Finding:Denies head problems other than headaches(Available)Pro Tip: Broad, open questions
will allow Tina to describe, in her own words, any specific head conditions and symptoms that
she is experiencing.Example Question:Other than headaches, are you experiencing head
problems?
Finding:Asked about frequency of headaches
Finding:Reports headaches occur once a week(Available)Pro Tip: Establishing a timeline for how
often Tina gets headaches will illustrate how long she has been suffering these particular
symptoms and might indicate possible triggers.Example Question:How frequently do your
headaches occur?
Finding:Asked about duration of headaches
Finding:Reports headaches last a few hours(Found)Pro Tip: Establishing a timeline for how long
Tina's headaches last will illustrate how long she has been suffering these particular symptoms
and might indicate possible triggers.Example Question:How long do your headaches last?
Finding:Asked about character and location of headaches
Finding:Reports headaches as tight and throbbing(Available)Pro Tip: Specifying what the pain
feels like can narrow and define the type of headache Tina is experiencing. Soliciting this
information allows you to more accurately treat her symptoms.Example Question:What do your
headaches feel like?
Finding:Reports headache located behind her eyes(Found)Pro Tip: Specifying the location of
Tina's pain can narrow and define where Tina's pain is occurring. Soliciting this information
This study source was downloaded by 100000846188722 from CourseHero.com on 04-26-2022 10:30:23 GMT -05:00
, allows you to more accurately treat her symptoms.Example Question:Where do you feel your
headaches?
Finding:Asked to rate headache pain on a scale
Finding:Reports headaches as a 2/10 or 3/10(Available)Pro Tip: Pain severity might change for
a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a
quantified and relative measurement of her condition.Example Question:On a scale of 1 to 10,
how bad are your headaches?
Finding:Asked about headache treatment
Finding:Reports treating headaches with acetaminophen (Tylenol)(Found)Pro Tip: Tina's
response to a question about managing her headaches will reveal the severity of her
symptoms, her health literacy, and the way she's complied with previous treatment
plans.Example Question:Do you take anything to treat your headaches?
Finding:Reports resting to treat headache(Found)Pro Tip: Tina's response to a question about
managing her headaches will reveal the severity of her symptoms, her health literacy, and the
way she's complied with previous treatment plans.Example Question:Do you do anything to
treat your headaches?
Finding:Reports acetaminophen (Tylenol) and rest usually resolve symptoms(Found)Pro Tip:
Tina's response to a question about managing her headaches will reveal the severity of her
symptoms, her health literacy, and the way she's complied with previous treatment
plans.Example Question:What helps with your headaches?
Finding:Asked about headache triggers
Finding:Reports headaches only happen when reading or studying(Found)Pro Tip: Soliciting
information about possible headache triggers will allow Tina to consider what, if any,
activities, weather patterns, movements, or sensory input is correlated with her
headaches.Example Question:When do you get headaches?
Finding:Reports that blurry vision and headaches often coincide(Available)Pro Tip: Soliciting
information about whether Tina's headaches coincide with her blurry vision will allow you
to consider whether the two are related and how then to customize treatment.Example
Question:Do your headaches coincide with your blurry vision?
Finding:Asked about vision
Finding:Reports occasional blurry vision(Found)Pro Tip: Broad, open questions will allow Tina
to describe, in her own words, any specific vision conditions and symptoms that she is
experiencing.Example Question:Have you been having problems with your vision?
Finding:Asked about onset and frequency of blurry vision
Finding:Reports worsening vision began within the past year(Available)Pro Tip: Establishing a
timeline of when Tina's blurry vision has been worsening will illustrate how long she has
been suffering these particular symptoms and might indicate possible triggers.Example
Question:When did your vision begin worsening?
Finding:Reports blurry vision only occurs when reading for long periods(Available)Pro Tip:
Establishing a timeline of Tina's blurry vision will illustrate how long she has been suffering
these particular symptoms and might indicate possible triggers.Example Question:When
does your blurry vision occur?
Finding:Reports noticing blurry vision increasing in the past few months(Available)Pro
Tip: Establishing a timeline of Tina's blurry vision will illustrate how long she has been
suffering
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this
patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details
are facts of the patient's case.
Relevant Medical History
Finding:Asked about head problems
Finding:Reports occasional headaches(Found)Pro Tip: Headaches can be caused a variety of
ways, such as when sinus problems result in increased pressure buildup. Asking Tina if she gets
headaches is soliciting information about possible symptoms that she experiences.Example
Question:Do you get headaches?
Finding:Denies current headache(Available)Pro Tip: Assessing how a patient feels in the current
moment can allow you to juxtapose their chief complaint alongside symptoms they experience.
Asking Tina if she currently has a headache solicits information about how she is feeling
now.Example Question:Do you currently have a headache?
Finding:Denies head problems other than headaches(Available)Pro Tip: Broad, open questions
will allow Tina to describe, in her own words, any specific head conditions and symptoms that
she is experiencing.Example Question:Other than headaches, are you experiencing head
problems?
Finding:Asked about frequency of headaches
Finding:Reports headaches occur once a week(Available)Pro Tip: Establishing a timeline for how
often Tina gets headaches will illustrate how long she has been suffering these particular
symptoms and might indicate possible triggers.Example Question:How frequently do your
headaches occur?
Finding:Asked about duration of headaches
Finding:Reports headaches last a few hours(Found)Pro Tip: Establishing a timeline for how long
Tina's headaches last will illustrate how long she has been suffering these particular symptoms
and might indicate possible triggers.Example Question:How long do your headaches last?
Finding:Asked about character and location of headaches
Finding:Reports headaches as tight and throbbing(Available)Pro Tip: Specifying what the pain
feels like can narrow and define the type of headache Tina is experiencing. Soliciting this
information allows you to more accurately treat her symptoms.Example Question:What do your
headaches feel like?
Finding:Reports headache located behind her eyes(Found)Pro Tip: Specifying the location of
Tina's pain can narrow and define where Tina's pain is occurring. Soliciting this information
This study source was downloaded by 100000846188722 from CourseHero.com on 04-26-2022 10:30:23 GMT -05:00
, allows you to more accurately treat her symptoms.Example Question:Where do you feel your
headaches?
Finding:Asked to rate headache pain on a scale
Finding:Reports headaches as a 2/10 or 3/10(Available)Pro Tip: Pain severity might change for
a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a
quantified and relative measurement of her condition.Example Question:On a scale of 1 to 10,
how bad are your headaches?
Finding:Asked about headache treatment
Finding:Reports treating headaches with acetaminophen (Tylenol)(Found)Pro Tip: Tina's
response to a question about managing her headaches will reveal the severity of her
symptoms, her health literacy, and the way she's complied with previous treatment
plans.Example Question:Do you take anything to treat your headaches?
Finding:Reports resting to treat headache(Found)Pro Tip: Tina's response to a question about
managing her headaches will reveal the severity of her symptoms, her health literacy, and the
way she's complied with previous treatment plans.Example Question:Do you do anything to
treat your headaches?
Finding:Reports acetaminophen (Tylenol) and rest usually resolve symptoms(Found)Pro Tip:
Tina's response to a question about managing her headaches will reveal the severity of her
symptoms, her health literacy, and the way she's complied with previous treatment
plans.Example Question:What helps with your headaches?
Finding:Asked about headache triggers
Finding:Reports headaches only happen when reading or studying(Found)Pro Tip: Soliciting
information about possible headache triggers will allow Tina to consider what, if any,
activities, weather patterns, movements, or sensory input is correlated with her
headaches.Example Question:When do you get headaches?
Finding:Reports that blurry vision and headaches often coincide(Available)Pro Tip: Soliciting
information about whether Tina's headaches coincide with her blurry vision will allow you
to consider whether the two are related and how then to customize treatment.Example
Question:Do your headaches coincide with your blurry vision?
Finding:Asked about vision
Finding:Reports occasional blurry vision(Found)Pro Tip: Broad, open questions will allow Tina
to describe, in her own words, any specific vision conditions and symptoms that she is
experiencing.Example Question:Have you been having problems with your vision?
Finding:Asked about onset and frequency of blurry vision
Finding:Reports worsening vision began within the past year(Available)Pro Tip: Establishing a
timeline of when Tina's blurry vision has been worsening will illustrate how long she has
been suffering these particular symptoms and might indicate possible triggers.Example
Question:When did your vision begin worsening?
Finding:Reports blurry vision only occurs when reading for long periods(Available)Pro Tip:
Establishing a timeline of Tina's blurry vision will illustrate how long she has been suffering
these particular symptoms and might indicate possible triggers.Example Question:When
does your blurry vision occur?
Finding:Reports noticing blurry vision increasing in the past few months(Available)Pro
Tip: Establishing a timeline of Tina's blurry vision will illustrate how long she has been
suffering
