End of Life Shadow Health Complete (Regina Walker)-Subjective Data

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.

This study source was downloaded by 100000831963712 from qwivy.com on 11-01-2021 07:09:13 GMT -05:00

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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
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