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1. Student: What is the situation?: Diana Shadow: Your patient is Tina Jones:, a 28-year-old African
American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this
simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission
process.
2. Student: What are my objectives in this assessment?: Diana Shadow: A health history
requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her
pre-existing conditions. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history.
These assessments together will give you a comprehensive picture of Ms. Jones' overall health. If you discover any
disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad
array of the symptoms' characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones
when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed
Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should
communicate with patients using accessible, everyday language, it is standard practice to use professional medical
terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam
activities in any order and move between them as needed. After obtaining Ms. Jones' health history, you will complete
an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified
diagnoses.
3. Student: How does this assignment prepare me for the real world?: Diana Shadow:
In this assessment, you will become familiarized with the structure and content of a health history exam so that with
real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the
patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and
identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses.
4. Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for
the upcoming exam: Why is it important to obtain a patient's complete health
history?: Student: So that you understand if there are any problems related to their chief complaint. Also, to help
treat their current condition.
5. Patient Exam - Vital Signs:: Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238,
Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%
6. Patient Exam - Interview::
7. Student: Hello, my name is Catlain, I am your nurse today.: Tina Jones: Hey.
8. Student: Can you confirm your name?: Tina Jones: Tina Jones:.
, Shadow Health - Tina Jones, Health History
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9. Student: Why did you come in today?: Tina Jones: I got this scrape on my foot a while ago, and it
got really infected. It's killing me.
10. Student: What additional symptoms have you experienced?: Tina Jones: 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.
11. Student: Can you rate your current pain level on a scale of 0 to 10?: Tina Jones:
...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit.
12. Student: Please describe the pain.: Tina Jones: It's throbbing and like, sharp if I try to put weight
on it.
13. Student: How did you hurt your foot?: Tina Jones: I was changing a light bulb, and I had to use
our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the
edge was!
14. Student: Has your foot been draining any liquids?: Tina Jones: Yeah, there's definitely pus.
15. Student: What color was the pus?: Tina Jones: It's... white or maybe off-white.
16. Student: How have you treated the wound?: Tina Jones: I've been taking Advil for my foot for
a few days.
17. Student: What did you do to treat your foot after your accident?: Tina Jones: I made
sure to clean it and keep it bandaged. And I put Neosporin on it.
18. Student: How effective was the Neosporin?: Tina Jones: Well, I'm here, so I guess it didn't do
its job.
19. 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.
20. 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!
21. 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.
22. Student: When were you diagnosed with diabetes?: Tina Jones: I was diagnosed when I
was 24.
23. Student: What do you do to manage your asthma?: Tina Jones: I try to avoid things that
give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
24. Student: What medications did you take for your diabetes?: Tina Jones: It was
metformin.
, Shadow Health - Tina Jones, Health History
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25. Student: Do you currently take medicine for your diabetes?: Tina Jones: No, I don't
take anything for my diabetes anymore.
26. 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.
27. 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.
28. Student: How frequently do you urinate?: Tina Jones: I don't know. Every hour or two when I'm
awake?
29. Student: What is your current diet?: Tina Jones: It's pretty good, I think. I'm not a huge health nut
or anything.
30. Student: Have you had any change in appetite?: Tina Jones: Yeah, lately I've definitely been
much hungrier than usual.
31. Student: Has your weight changed?: Tina Jones: Yeah, I've lost some weight recently.
32. Student: Do you know why you lost weight?: Tina Jones: I don't know what caused it, I just
lost weight.
33. Student: How often do you have asthma exacerbations?: Tina Jones: I haven't had a
full attack in years. But my breathing definitely acts up. . .not always. Max twice a week.
34. Student: What asthma symptoms have you experienced?: Tina Jones: My chest and
throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs.
35. 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: albutero
90mcg/spray MDI]
36. 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.
37. Student: What allergies do you have?: Tina Jones: I'm allergic to cats.
38. Student: When did you realize you were allergic to cats?: Tina Jones: For as long as I've
been around.
39. Student: How effective was your pain medication at home?: Tina Jones: Whatever
pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil
wasn't doing much for me -- it would only last a couple of hours.
40. Student: What medication allergies do you have?: Tina Jones: I'm allergic to penicillin.
, Shadow Health - Tina Jones, Health History
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41. Student: What food allergies do you have?: Tina Jones: I don't have any food allergies that I
know of.
42. Student: Are you allergic to dust, mold, or pollen?: Tina Jones: Well. . . I don't know if it's
allergies, but sometimes my asthma acts up around dust.
43. Student: What immunizations have you received?: Tina Jones: I got a tetanus booster for
work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college...I'm sure I
have a record somewhere at home.
44. Student: Have you received a flu vaccine?: Tina Jones: No.
45. Student: Have you had any prior hospitalizations?: Tina Jones: Well, before this I went a
bunch of times when I was little, for asthma attacks. This is the first time I've been in the hospital since I was probably
sixteen, though.
46. Student: Have you had any gastrointestinal problems?: Tina Jones: No. I've never really
had stomach or bowel problems.
47. Student: Do you have a family history of psychiatric illness?: Tina Jones: No. They're
crazy, but nobody's diagnosed with anything.
48. Student: Do you have any neck, throat or gland problems?: Tina Jones: No, not that I
noticed.
49. Student: Do you have any problems with your head?: Tina Jones: I don't think I have any
problems. I get headaches sometimes, but that's all.
50. Student: Any problems with your ears?: Tina Jones: No.
51. Student: Any problems with your eyes and vision?: Tina Jones: I've actually been noticing
problems lately. When I'm reading or studying I'll notice that things start to get kind of blurry.
52. Student: Any problems with your nose?: Tina Jones: My nose is fine right now. Sometimes it
runs, but not very often.
53. Student: Do you have problems with your mouth?: Tina Jones: No.
54. Student: Do you have a history of cardiovascular problems?: Tina Jones: My heart's
fine, thank God!
55. Student: Any problems with your heart?: Tina Jones: No, my heart's always been fine.
56. Student: Have you had any problems with your breasts?: Tina Jones: I haven't noticed
any pain there.
57. Student: Have you had any reproductive problems?: Tina Jones: I don't think I have
problems in that area. I just get really bad periods, that's all.