Basic Patient Case Results John Larsen

Basic Patient Case Results
John Larsen ShadowHealth


Patient Assessment


Finding:
Asked for patient identification
(Found)
Pro Tip: Proper identification is critical for the protection of your patient. It is recommended to
check two identifiers before interacting with the patient.
Example Question:
Can you confirm your name?


Finding:
Checked vitals before giving medication
(Found)
Pro Tip: Assessing the patient's vitals may impact your care plan and the safe administration
of ordered medications.
Example Question:


Finding:
Asked current breathing status
(Available)
Pro Tip: Difficulty breathing is one of the adverse effects of enoxaparin, a medication the
patient received prior to this assessment.
Example Question:
How is your breathing?


Finding:
Asked about medication allergies
(Found)
Pro Tip: Patients may have allergies that are not included in their documentation, so asking
for verbal confirmation can prevent serious adverse events.
Example Question:

, Do you have any allergies to medications?


Finding:
Asked about current pain
(Found)
Pro Tip: This patient has been ordered pain medication. Assessing for pain is vital to
determining the efficacy of prior treatment and the need for further analgesic intervention.
Example Question:
Are you having pain right now?


Finding:
Ask about allergic reaction to codeine
(Available)
Pro Tip: Assessing the reaction type and severity of a stated allergy may help inform your
care plan and determine which medications are appropriate to administer.
Example Question:
What is your reaction to codeine?


Finding:
Asked about general experience with side effects
(Available)
Pro Tip: When administering routine medications, understanding the side effects that the
patient generally experiences can shape your care plan to ensure patient safety and comfort.
Example Question:
Have you experienced medication side effects before?


Finding:
Asked about thirst
(Available)
Pro Tip: Thirst can be an important indicator of the patient's general comfort and recent
intake. Excessive thirst may be an indicator of dehydration, which is a symptom of
rhabdomyolysis, a potentially life-threatening adverse effect associated with atorvastatin.
Example Question:
Are you thirsty?


Finding:
Checked intake and output before giving medication
(Found)