Focused Exam: End of Life Results | Turned In
Medical Surgical Nursing: Promoting Wellness in the Older Adult (Los Angeles) - April 2019, NURS 201
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Your Results Lab Pass
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
SBAR
Reflections
Indicates an item that you found.
Indicates an item that is available to be
found.
Category Scored Items
Experts selected these topics as essential
components of a strong, thorough interview
with this patient.
Patient Data
Not Scored
A combination of open and closed questions
will yield better patient data. The following
details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports pain
Orientation
Established orientation Oriented to person
Oriented to place
Oriented to time
Oriented to situation
Patient Comfort and Status
Asked about fluid intake and hydration Denies current thirst
Reports very little water intake in the past
week
Subjective Data Collection: 52 of 52 (100.0%)
Hover To Reveal...
Hover over the Patient Data items
below to reveal important information,
including Pro Tips and Example
Questions.
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END OF LIFE SUBJECTIVE DATA
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Reports a few sips of ginger ale today
Asked about urinary comfort Reports last urination was around 10 AM
Denies pain or burning with urination
Asked about most recent meal Denies current hunger
Reports no food intake today
Last meal was a few bites of yogurt last
night
Asked about preferences for hospice
care
Reports wanting to be in hospice care
Asked about advanced directives Reports having an advanced directive
History of Present Illness
Asked about onset and duration of pain Pain became unbearable 2 days ago
Reports pain increasing over the past 2
days
Reports experiencing some pain most of
the time
Asked about location of pain Reports bone pain
Reports pain in legs
Reports pain in ribs
Asked about characteristics of pain Describes pain as sharp
Asked about aggravating factors of pain Reports that pain is constant - no periods
of relief or worsening
Asked about treatment and relieving
factors of pain
Reports that nothing relieves her current
pain
Reports prescription pain pill
Asked about severity of pain Reports current pain is a 4/10
Reports pain before medication was a 9/10
Past Medical History
Asked about existing health conditions Reports stage IV breast cancer with liver
metastasis
Reports hypertension diagnosis
This study source was downloaded by 100000831963712 from qwivy.com on 11-01-2021 07:09:13 GMT -05:00
https://www.qwivy.com/file/41419828/End-of-Life-Subjective-Datapdf/
This study resource was
shared via qwivy.com Powered by qwivy(www.qwivy.org)
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Version | 2021 |
Category | Exam (elaborations) |
Included files | |
Pages | 7 |
Language | English |
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