Shadow Health - Tina Jones, Health History
1. Acute pain - -Priority: High Priority Pro Tip: Managing acute pain is an
immediate high priority, because other health concerns cannot be
effectively addressed while a patient experiences severe pain. Evidence -
Relevant: "...Like a 7. It hurts a lot, but whatever pain med the ER gave
me is helping a little bit." "It's throbbing and like, sharp if I try to put
weight on it." Evidence Pro Tip: Tina expresses pain, which is the strongest
evidence for this problem. She reports intense pain on a numerical scale
and describes pain characteristics. The presence of a physical injury
supports her susceptibility to acute pain. Planning - Relevant: Assess -
Pain: Assess the patient's pain at regular intervals and with each
assessment of vital signs. Assess - Pain: Assess the patient's response to
pain medication. Educate - Medication: Educate the patient on
medications used for pain relief. Educate - Pain: Educate the patient on
non-pharmaceutical methods to reduce pain intensity. Intervene - Pain:
Administer non-pharmacologic interventions to reduce pain. Intervene -
Pain: Administer prescribed analgesics to provide optimal pain relief.
Planning Pro Tip: To reduce the patient's pain, assess her current rating.
Provide an appropriate intervention (pharmaceutical or otherwise) and
educate the patient. After an appropriate time interval, assess pain levels
again to see how the intervention affected the pain.
- 1.Expression of pain Followed Up - -Description: Tina expresses
frustration about her level of pain. Student: How effective was the
Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job.
Student: Can you walk with your foot being injured? Tina Jones: No, I can't.
I can't put any weight on it without like, shooting pain. Student: What
preexisting medical conditions do you have? Tina Jones: I mean, I have
asthma and diabetes, but right I now I just care about my foot! Student: I
understand your foot hurts, but I need to know this information to make
sure I take care of the problem correctly. Tina Jones: Thanks. Model
Statement: "I'm sorry to hear that your pain is returning. We want you to
be in as little pain as possible. I can give you some Advil at this time, and
in a few hours, you can have more tramadol. I can also walk through some
pain management exercises with you that don't involve medication, if you
are interested."
- 2. Impaired skin integrity - -Priority: High Priority Pro Tip: This is a high
priority. The infection is the most immediate threat to the patient's health,
and the wound is at risk for delayed healing because of the patient's
uncontrolled blood glucose. Evidence - Relevant: Evidence Pro Tip: As Tina
discusses symptoms of her wound, including symptoms such as discharge,
redness, warmth, and swelling, she reports strong evidence of impaired
skin integrity. Planning - Relevant: Planning Pro Tip: Because wound
infections impact the patient's overall health, it's important to assess
,perfusion, hydration, and swelling. Assess the status of the wound itself
and ensure proper cleaning and dressing per the physician's order.
Prevent worsening infection by educating the patient about wound care
and self-monitoring.
- 2.Impact of injury on daily life Followed Up - -Description: Tina brings
up her pain and frustration at how being unable to bear weight on her foot
impacts her life. Student: What are stressors? Tina Jones: I feel really
stressed out right now! Honestly, I didn't realize that I'd be admitted to
the hospital for my foot. I don't want to miss work or school but now it
looks like I'll have to. And I want my foot to stop hurting. I know I need
sleep, too. Student: We are going to take care of everything as quickly as
possible. Tina Jones: Thanks. Model Statement: "This sounds like a
challenging time for you. I understand your frustration at having your life
interrupted by foot pain. Please let me know if there is anything I can help
you with, such as contacting your employer or asking a family member to
bring your schoolwork. We'll do our best to get you feeling better and, on
your way, home as soon as possible."
- 3. Impaired walking - -Priority - High Priority Pro Tip: This is a high
priority. The patient is unable to bear weight on her affected leg, which
prevents walking. This impacts her daily life and increases her risk for falls
and deep-vein thrombosis. Evidence - Relevant: "I mean, it's all red and
swollen, and there's pus, it feels hot, it hurts like hell... It's got all that
going on." "I got this scrape on my foot a while ago, and it got really
infected. It's killing me." "No, I can't. I can't put any weight on it without
like, shooting pain." Evidence Pro Tip: The strongest evidence of impaired
walking is that Tina directly reports she can't bear weight or walk on her
affected foot. Other supporting data points are the presence of her foot
wound and her general reports of pain. Planning - Relevant: Assess -
Musculoskeletal: Assess the patient's ability to bear weight and gait.
Assess - Musculoskeletal: Assess the patient's mobility. Consult / Refer:
Consult with physical therapist to develop a plan to improve the patient's
mobility. Intervene - Mobility: Assist the patient as needed with mobility.
Intervene - Mobility: Provide assistive devices to facilitate mobility
(crutches, therapeutic boot to minimize pressure on plantar surface,
wheelchair). Planning Pro Tip: Assess how well the patient can bear weight
and walk. While the patient is in your care, work with other healthcare
professionals to keep the pain managed and improve the patient's
mobility. Provide assistance with activities such as toileting and ensure
that the patient can access and use assistive devices.
- 3.Gaps in health literacy around diabetic diet Not Encountered - -
Description: Tina describes controlling her diabetes by avoiding "sweets."
Model Statement: "Staying away from sugar is a great start. I can give you
some more information on what a balanced diet looks like for someone
with diabetes. For example, many starchy foods break down into glucose
in the body, like pasta, and so you can eat those in moderation, too. Most
,people with diabetes feel better when they limit all starches, eat protein,
and take regular medication."
- 4. Ineffective diabetes management - -Priority - High Priority Pro Tip:
Poorly managed diabetes and uncontrolled blood glucose complicate
wound healing. As the underlying cause for delayed healing and infection,
they must be addressed. Evidence - Relevant: "No, I don't take anything
for my diabetes anymore." "I guess I just got sick of feeling sick and gassy
all the time, and it was overwhelming, remembering to take pills and
check my sugar. I feel a lot better now that I'm just eating healthier than I
did when I was taking the pills." "I have a monitor at home, but to be
honest I don't really use it that often." Evidence Pro Tip: Tina directly
reports ineffective diabetes management when discussing her lack of
treatment. She expresses gaps in health literacy about the risk of ceasing
prescribed medication and blood glucose monitoring. Supporting evidence
comes from her inability to incorporate meaningful dietary changes or
increase her exercise. Planning - Relevant: Assess - Health Literacy and
Patterns: Assess the patient's knowledge related to diabetic disease
process, assess personal/social supports. Assess - Health Literacy and
Patterns: Assess the patient's perceived barriers to adherence to the
prescribed regimen (cost, adverse effects, lack of knowledge). Assess -
Health Literacy and Patterns: Assess the patient's readiness for
change/education. Educate - Disease Process: Educate the patient on
diabetes pathophysiology, risks of morbidity and mortality, importance of
self-care. Planning Pro Tip: To gain a deep understanding of your patient's
situation, determine her level of health literacy, her feelings and beliefs
about the disease, and the motivation behind her choices. Educate the
patient about what risks are, and what good diabetes care looks like. Most
importantly, ask about her goals and changes she may be willing to make.
- 4.Lack of treatment with diabetes medication Not Followed Up - -
Description: Tina reveals that she does not treat her diabetes with
medication. Student: Do you currently take medicine for your diabetes?
Tina Jones: No, I don't take anything for my diabetes anymore. Student:
What made you stop taking medication for your diabetes? Tina Jones: I
guess I just got sick of feeling sick and gassy all the time, and it was
overwhelming, remembering to take pills and check my sugar. I feel a lot
better now that I'm just eating healthier than I did when I was taking the
pills. Model Statement: "I understand that it can be challenging to keep up
with daily medication. But it's important to keep your blood sugar under
control to prevent long-term damage to your health, and medication can
really help. I'd like to talk with you more about getting back onto a
prescription. We could start you at a low dose, which reduces the side
effects."
- 5. Lack of blood glucose monitoring Not Followed Up - -Description:
Tina reveals that she does not check her blood sugar. Student: Do you
monitor your blood glucose? Tina Jones: I have a monitor at home, but to
be honest I don't really use it that often. Model Statement: "I understand
, how it can feel like a frustrating chore to check your sugar every day. But
it is important to keeping your diabetes under control. When you monitor
your sugar, it helps you understand what foods, activities, and times of
day contribute to you feeling your best. And keeping your sugar down will
help your foot wound heal quickly, too. If you would like, I can help you
find a monitor that is as painless as possible. I can also teach you more
about what the numbers mean."
- 5. Risk for falls - -Priority - High Priority Pro Tip: The patient's foot
wound impairs her walking, which in turn increases her risk for falls while
she is an admitted patient. Her past history of injury also adds to this risk.
Evidence - Relevant: Evidence Pro Tip: The strongest evidence of Tina's fall
risk is reports of being unable to bear weight or walk on her foot. Other
supporting evidence is her recent injury caused by falling. Planning -
Relevant: Planning Pro Tip: Protect your patient by taking all fall
precautions, and educate your patient about how to be safe as she goes
through her daily activities at the hospital. Make sure that the patient
feels comfortable asking for your assistance.
- 6. Gaps in health literacy around asthma control Not Followed Up - -
Description: Tina describes increased inhaler use and decreased
effectiveness, indicating that her asthma is uncontrolled. Student: How
many puffs do you take when using your asthma inhaler? Tina Jones: I
usually use two puffs from my inhaler, but sometimes I need three. [Nurse
confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are
some things that trigger your asthma? Tina Jones: Being around cats is the
worst, but dust and running up stairs can make my breathing bad, too.
Student: What allergies do you have? Tina Jones: I'm allergic to cats.
Model Statement: "It sounds like your asthma is giving you some
problems, and you're not getting full relief from your inhaler. I would like
to talk with you about changing your medication and your regimen, to
reduce your frequent breathing problems, so that you feel better day-to-
day. Most patients find that using a daily inhaler is an easy way to reduce
your asthma symptoms even more."
- 6. Risk for unstable blood glucose level - -Priority - High Priority Pro
Tip: Uncontrolled blood glucose levels delay or prevent wound healing,
and must be addressed to resolve the infection. Unstable blood glucose
levels could increase the patient's risk for falls. Evidence - Relevant:
"Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent
blood glucose monitoring and a general lack of diabetes management,
which increases her risk for fluctuating blood glucose levels. Infection can
contribute to poorer glycemic control, and so Tina is likely to experience
blood glucose levels that are significantly higher than her baseline.
Planning - Relevant: Assess - Vitals: Assess the patient's blood glucose
levels according to orders. Educate - Disease Process: Educate the patient
on the signs and symptoms of hyper- and hypoglycemia. Intervene - Diet:
Provide the patient a diet without concentrated sweets. Intervene -
Hypoglycemia: Administer insulin and/or oral hypoglycemics, per
1. Acute pain - -Priority: High Priority Pro Tip: Managing acute pain is an
immediate high priority, because other health concerns cannot be
effectively addressed while a patient experiences severe pain. Evidence -
Relevant: "...Like a 7. It hurts a lot, but whatever pain med the ER gave
me is helping a little bit." "It's throbbing and like, sharp if I try to put
weight on it." Evidence Pro Tip: Tina expresses pain, which is the strongest
evidence for this problem. She reports intense pain on a numerical scale
and describes pain characteristics. The presence of a physical injury
supports her susceptibility to acute pain. Planning - Relevant: Assess -
Pain: Assess the patient's pain at regular intervals and with each
assessment of vital signs. Assess - Pain: Assess the patient's response to
pain medication. Educate - Medication: Educate the patient on
medications used for pain relief. Educate - Pain: Educate the patient on
non-pharmaceutical methods to reduce pain intensity. Intervene - Pain:
Administer non-pharmacologic interventions to reduce pain. Intervene -
Pain: Administer prescribed analgesics to provide optimal pain relief.
Planning Pro Tip: To reduce the patient's pain, assess her current rating.
Provide an appropriate intervention (pharmaceutical or otherwise) and
educate the patient. After an appropriate time interval, assess pain levels
again to see how the intervention affected the pain.
- 1.Expression of pain Followed Up - -Description: Tina expresses
frustration about her level of pain. Student: How effective was the
Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job.
Student: Can you walk with your foot being injured? Tina Jones: No, I can't.
I can't put any weight on it without like, shooting pain. Student: What
preexisting medical conditions do you have? Tina Jones: I mean, I have
asthma and diabetes, but right I now I just care about my foot! Student: I
understand your foot hurts, but I need to know this information to make
sure I take care of the problem correctly. Tina Jones: Thanks. Model
Statement: "I'm sorry to hear that your pain is returning. We want you to
be in as little pain as possible. I can give you some Advil at this time, and
in a few hours, you can have more tramadol. I can also walk through some
pain management exercises with you that don't involve medication, if you
are interested."
- 2. Impaired skin integrity - -Priority: High Priority Pro Tip: This is a high
priority. The infection is the most immediate threat to the patient's health,
and the wound is at risk for delayed healing because of the patient's
uncontrolled blood glucose. Evidence - Relevant: Evidence Pro Tip: As Tina
discusses symptoms of her wound, including symptoms such as discharge,
redness, warmth, and swelling, she reports strong evidence of impaired
skin integrity. Planning - Relevant: Planning Pro Tip: Because wound
infections impact the patient's overall health, it's important to assess
,perfusion, hydration, and swelling. Assess the status of the wound itself
and ensure proper cleaning and dressing per the physician's order.
Prevent worsening infection by educating the patient about wound care
and self-monitoring.
- 2.Impact of injury on daily life Followed Up - -Description: Tina brings
up her pain and frustration at how being unable to bear weight on her foot
impacts her life. Student: What are stressors? Tina Jones: I feel really
stressed out right now! Honestly, I didn't realize that I'd be admitted to
the hospital for my foot. I don't want to miss work or school but now it
looks like I'll have to. And I want my foot to stop hurting. I know I need
sleep, too. Student: We are going to take care of everything as quickly as
possible. Tina Jones: Thanks. Model Statement: "This sounds like a
challenging time for you. I understand your frustration at having your life
interrupted by foot pain. Please let me know if there is anything I can help
you with, such as contacting your employer or asking a family member to
bring your schoolwork. We'll do our best to get you feeling better and, on
your way, home as soon as possible."
- 3. Impaired walking - -Priority - High Priority Pro Tip: This is a high
priority. The patient is unable to bear weight on her affected leg, which
prevents walking. This impacts her daily life and increases her risk for falls
and deep-vein thrombosis. Evidence - Relevant: "I mean, it's all red and
swollen, and there's pus, it feels hot, it hurts like hell... It's got all that
going on." "I got this scrape on my foot a while ago, and it got really
infected. It's killing me." "No, I can't. I can't put any weight on it without
like, shooting pain." Evidence Pro Tip: The strongest evidence of impaired
walking is that Tina directly reports she can't bear weight or walk on her
affected foot. Other supporting data points are the presence of her foot
wound and her general reports of pain. Planning - Relevant: Assess -
Musculoskeletal: Assess the patient's ability to bear weight and gait.
Assess - Musculoskeletal: Assess the patient's mobility. Consult / Refer:
Consult with physical therapist to develop a plan to improve the patient's
mobility. Intervene - Mobility: Assist the patient as needed with mobility.
Intervene - Mobility: Provide assistive devices to facilitate mobility
(crutches, therapeutic boot to minimize pressure on plantar surface,
wheelchair). Planning Pro Tip: Assess how well the patient can bear weight
and walk. While the patient is in your care, work with other healthcare
professionals to keep the pain managed and improve the patient's
mobility. Provide assistance with activities such as toileting and ensure
that the patient can access and use assistive devices.
- 3.Gaps in health literacy around diabetic diet Not Encountered - -
Description: Tina describes controlling her diabetes by avoiding "sweets."
Model Statement: "Staying away from sugar is a great start. I can give you
some more information on what a balanced diet looks like for someone
with diabetes. For example, many starchy foods break down into glucose
in the body, like pasta, and so you can eat those in moderation, too. Most
,people with diabetes feel better when they limit all starches, eat protein,
and take regular medication."
- 4. Ineffective diabetes management - -Priority - High Priority Pro Tip:
Poorly managed diabetes and uncontrolled blood glucose complicate
wound healing. As the underlying cause for delayed healing and infection,
they must be addressed. Evidence - Relevant: "No, I don't take anything
for my diabetes anymore." "I guess I just got sick of feeling sick and gassy
all the time, and it was overwhelming, remembering to take pills and
check my sugar. I feel a lot better now that I'm just eating healthier than I
did when I was taking the pills." "I have a monitor at home, but to be
honest I don't really use it that often." Evidence Pro Tip: Tina directly
reports ineffective diabetes management when discussing her lack of
treatment. She expresses gaps in health literacy about the risk of ceasing
prescribed medication and blood glucose monitoring. Supporting evidence
comes from her inability to incorporate meaningful dietary changes or
increase her exercise. Planning - Relevant: Assess - Health Literacy and
Patterns: Assess the patient's knowledge related to diabetic disease
process, assess personal/social supports. Assess - Health Literacy and
Patterns: Assess the patient's perceived barriers to adherence to the
prescribed regimen (cost, adverse effects, lack of knowledge). Assess -
Health Literacy and Patterns: Assess the patient's readiness for
change/education. Educate - Disease Process: Educate the patient on
diabetes pathophysiology, risks of morbidity and mortality, importance of
self-care. Planning Pro Tip: To gain a deep understanding of your patient's
situation, determine her level of health literacy, her feelings and beliefs
about the disease, and the motivation behind her choices. Educate the
patient about what risks are, and what good diabetes care looks like. Most
importantly, ask about her goals and changes she may be willing to make.
- 4.Lack of treatment with diabetes medication Not Followed Up - -
Description: Tina reveals that she does not treat her diabetes with
medication. Student: Do you currently take medicine for your diabetes?
Tina Jones: No, I don't take anything for my diabetes anymore. Student:
What made you stop taking medication for your diabetes? Tina Jones: I
guess I just got sick of feeling sick and gassy all the time, and it was
overwhelming, remembering to take pills and check my sugar. I feel a lot
better now that I'm just eating healthier than I did when I was taking the
pills. Model Statement: "I understand that it can be challenging to keep up
with daily medication. But it's important to keep your blood sugar under
control to prevent long-term damage to your health, and medication can
really help. I'd like to talk with you more about getting back onto a
prescription. We could start you at a low dose, which reduces the side
effects."
- 5. Lack of blood glucose monitoring Not Followed Up - -Description:
Tina reveals that she does not check her blood sugar. Student: Do you
monitor your blood glucose? Tina Jones: I have a monitor at home, but to
be honest I don't really use it that often. Model Statement: "I understand
, how it can feel like a frustrating chore to check your sugar every day. But
it is important to keeping your diabetes under control. When you monitor
your sugar, it helps you understand what foods, activities, and times of
day contribute to you feeling your best. And keeping your sugar down will
help your foot wound heal quickly, too. If you would like, I can help you
find a monitor that is as painless as possible. I can also teach you more
about what the numbers mean."
- 5. Risk for falls - -Priority - High Priority Pro Tip: The patient's foot
wound impairs her walking, which in turn increases her risk for falls while
she is an admitted patient. Her past history of injury also adds to this risk.
Evidence - Relevant: Evidence Pro Tip: The strongest evidence of Tina's fall
risk is reports of being unable to bear weight or walk on her foot. Other
supporting evidence is her recent injury caused by falling. Planning -
Relevant: Planning Pro Tip: Protect your patient by taking all fall
precautions, and educate your patient about how to be safe as she goes
through her daily activities at the hospital. Make sure that the patient
feels comfortable asking for your assistance.
- 6. Gaps in health literacy around asthma control Not Followed Up - -
Description: Tina describes increased inhaler use and decreased
effectiveness, indicating that her asthma is uncontrolled. Student: How
many puffs do you take when using your asthma inhaler? Tina Jones: I
usually use two puffs from my inhaler, but sometimes I need three. [Nurse
confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are
some things that trigger your asthma? Tina Jones: Being around cats is the
worst, but dust and running up stairs can make my breathing bad, too.
Student: What allergies do you have? Tina Jones: I'm allergic to cats.
Model Statement: "It sounds like your asthma is giving you some
problems, and you're not getting full relief from your inhaler. I would like
to talk with you about changing your medication and your regimen, to
reduce your frequent breathing problems, so that you feel better day-to-
day. Most patients find that using a daily inhaler is an easy way to reduce
your asthma symptoms even more."
- 6. Risk for unstable blood glucose level - -Priority - High Priority Pro
Tip: Uncontrolled blood glucose levels delay or prevent wound healing,
and must be addressed to resolve the infection. Unstable blood glucose
levels could increase the patient's risk for falls. Evidence - Relevant:
"Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent
blood glucose monitoring and a general lack of diabetes management,
which increases her risk for fluctuating blood glucose levels. Infection can
contribute to poorer glycemic control, and so Tina is likely to experience
blood glucose levels that are significantly higher than her baseline.
Planning - Relevant: Assess - Vitals: Assess the patient's blood glucose
levels according to orders. Educate - Disease Process: Educate the patient
on the signs and symptoms of hyper- and hypoglycemia. Intervene - Diet:
Provide the patient a diet without concentrated sweets. Intervene -
Hypoglycemia: Administer insulin and/or oral hypoglycemics, per
