4/17/2020 Focused Exam: Infection | Completed | Shadow Health
Focused Exam: Infection Results | Turned In
BNC NURS 324 - Nursing Care of Adults II - Gerontology Modules - Spring 2020, NURS 324
Return to Assignment (/assignments/284387/)
Your Results Lab Pass (/assignment_attempts/6224304/lab_pass.p
Overview
Subjective Data Collection: 40 of 53 (75.5%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
QSEN Competencies
Example Questions.
m
Documentation
er as
SBAR
Category Scored Items Patient Data
co
eH w
Reflections
Not Scored
o.
Experts selected these topics as essential components A combination of open and closed questions will yield
rs e of a strong, thorough interview with this patient. better patient data. The following details are facts of t
patient's case.
ou urc
Chief Complaint
o
Established chief complaint Reports pain
aC s
vi y re
Orientation
Established orientation Oriented to person
ed d
Disoriented to place
ar stu
Disoriented to time
Oriented somewhat to situation
Patient Status
sh is
Th
Asked about fluid intake and hydration Denies current thirst
Reports does not remember eating today
Reports does not remember drinking fluids today
History of Presenting Illness
Asked about onset, duration, and frequency of Reports pain began last night
symptoms Reports pain has been constant
Reports that pain increased this morning
Asked about location of pain Reports generalized abdominal pain
Reports back pain
Reports pain during urination
https://www.coursehero.com/file/59872326/infectionpdf/
https://app.shadowhealth.com/assignment_attempts/6224304 1/6
, 4/17/2020 Focused Exam: Infection | Completed | Shadow Health
Asked about characteristics of pain Reports pain during urination as "burning"
Reports back and abdominal pain as "aching"
Denies sharp or shooting pain
Denies cramping pain
Asked about aggravating factors of pain Reports no known aggravating factors
Asked about treatment and relieving factors of Denies treatment with medication at home
pain Denies use of heating pad
Asked about severity of pain Patient is unable to quantify
Past Medical History
Asked about existing health conditions Reports history of UTIs as an adult
Reports hypercholesterolemia
m
er as
Followed up on history of UTI Reports UTIs once or twice annually
co
Reports typical UTI treatment is to see a doctor for
eH w
antibiotics
o.
rs e Followed up on hypercholesterolemia Diagnosed age 58
ou urc
Asked about allergies Denies general allergies
Denies environmental allergies
o
Denies latex allergy
aC s
Denies food allergies
vi y re
Asked specifically about medication allergies Denies medication allergies
ed d
Home Medications
ar stu
Asked about home medications Reports taking 2 medications for
hypercholesterolemia
Denies taking vitamins
sh is
Denies taking herbal supplements
Th
Asked about medication regimen adherence Denies using a pillbox to organize medications
Reports that she occasionally misses doses "here
and there" if she forgets
Denies missing doses of medication because of
side effects
Denies difficulty obtaining medications because of
finances
Denies difficulty obtaining medications because of
transportation
Followed up on last dose of home medications Reports not being sure she took medications today
- "I don't think I did"
Reports last dose of medications was yesterday
https://www.coursehero.com/file/59872326/infectionpdf/
https://app.shadowhealth.com/assignment_attempts/6224304 2/6
Focused Exam: Infection Results | Turned In
BNC NURS 324 - Nursing Care of Adults II - Gerontology Modules - Spring 2020, NURS 324
Return to Assignment (/assignments/284387/)
Your Results Lab Pass (/assignment_attempts/6224304/lab_pass.p
Overview
Subjective Data Collection: 40 of 53 (75.5%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
QSEN Competencies
Example Questions.
m
Documentation
er as
SBAR
Category Scored Items Patient Data
co
eH w
Reflections
Not Scored
o.
Experts selected these topics as essential components A combination of open and closed questions will yield
rs e of a strong, thorough interview with this patient. better patient data. The following details are facts of t
patient's case.
ou urc
Chief Complaint
o
Established chief complaint Reports pain
aC s
vi y re
Orientation
Established orientation Oriented to person
ed d
Disoriented to place
ar stu
Disoriented to time
Oriented somewhat to situation
Patient Status
sh is
Th
Asked about fluid intake and hydration Denies current thirst
Reports does not remember eating today
Reports does not remember drinking fluids today
History of Presenting Illness
Asked about onset, duration, and frequency of Reports pain began last night
symptoms Reports pain has been constant
Reports that pain increased this morning
Asked about location of pain Reports generalized abdominal pain
Reports back pain
Reports pain during urination
https://www.coursehero.com/file/59872326/infectionpdf/
https://app.shadowhealth.com/assignment_attempts/6224304 1/6
, 4/17/2020 Focused Exam: Infection | Completed | Shadow Health
Asked about characteristics of pain Reports pain during urination as "burning"
Reports back and abdominal pain as "aching"
Denies sharp or shooting pain
Denies cramping pain
Asked about aggravating factors of pain Reports no known aggravating factors
Asked about treatment and relieving factors of Denies treatment with medication at home
pain Denies use of heating pad
Asked about severity of pain Patient is unable to quantify
Past Medical History
Asked about existing health conditions Reports history of UTIs as an adult
Reports hypercholesterolemia
m
er as
Followed up on history of UTI Reports UTIs once or twice annually
co
Reports typical UTI treatment is to see a doctor for
eH w
antibiotics
o.
rs e Followed up on hypercholesterolemia Diagnosed age 58
ou urc
Asked about allergies Denies general allergies
Denies environmental allergies
o
Denies latex allergy
aC s
Denies food allergies
vi y re
Asked specifically about medication allergies Denies medication allergies
ed d
Home Medications
ar stu
Asked about home medications Reports taking 2 medications for
hypercholesterolemia
Denies taking vitamins
sh is
Denies taking herbal supplements
Th
Asked about medication regimen adherence Denies using a pillbox to organize medications
Reports that she occasionally misses doses "here
and there" if she forgets
Denies missing doses of medication because of
side effects
Denies difficulty obtaining medications because of
finances
Denies difficulty obtaining medications because of
transportation
Followed up on last dose of home medications Reports not being sure she took medications today
- "I don't think I did"
Reports last dose of medications was yesterday
https://www.coursehero.com/file/59872326/infectionpdf/
https://app.shadowhealth.com/assignment_attempts/6224304 2/6
