RNSG 1261 Patricia Young - Infection Pain - Subjective Data

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Focused Exam: Infection Results | Completed
Gerontology - Fall 2021, RNSG 1261
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Overview
Subjective Data Collection: 52 of 53 (98.1%)
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.
Documentation

Care Plan
Category Scored Items Patient Data
Reflections
Not Scored

Experts selected these topics as essential components A combination of open and closed questions will yie
of a strong, thorough interview with this patient. better patient data. The following details are facts o
patient's case.



Chief Complaint


Established chief complaint Reports pain




Orientation


Established orientation Oriented to person
Disoriented to place
Disoriented to time
Oriented somewhat to situation




Patient Status


Asked about fluid intake and hydration Denies current thirst
Reports does not remember eating today
Reports does not remember drinking fluids today

Support
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, 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



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



Followed up on history of UTI Reports UTIs once or twice annually
Reports typical UTI treatment is to see a doctor
for antibiotics



Followed up on hypercholesterolemia Diagnosed age 58



Asked about allergies Denies general allergies
Denies environmental allergies
Denies latex allergy
Denies food allergies



Asked specifically about medication allergies Denies medication allergies




Home Medications


Asked about home medications Reports taking 2 medications for
hypercholesterolemia
Denies taking vitamins
Denies taking herbal supplements



Asked about medication regimen adherence Denies using a pillbox to organize medications
Reports that she occasionally misses doses "her
and there" if she forgets
This study source was downloaded by 100000847426977 from CourseHero.com on 07-06-2022 05:23:15 GMT -05:00


https://www.coursehero.com/file/105720416/21-09-10-Patricia-Young-Infection-Pain-Subjective-Datapdf/