Shadow Health - Tina Jones, Health History With Complete Solution

Shadow Health - Tina Jones, Health

History

Health History Tips & Tricks: Ans- TJ Health Interview

Student: Hello! Ans- Diana Shadow: Hi. I'm Preceptor Diana. I will explain the details of

this assignment and your objectives, just as a preceptor would in real life. Pay close

attention to this information as it will help guide your exam. At the end of this prebrief,

you will answer a short question about the upcoming assignment. During the simulation,

you may return to these instructions at any time by scrolling to the top of your transcript.

Student: What is the situation? Ans- 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.

Student: What are my objectives in this assessment? Ans- 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.

Student: What else will this exam involve? Ans- Diana Shadow: You will complete

nursing tasks to protect the patients safety, privacy, and health. You can document your

findings, including vital signs, in the Electronic Health Record. This record provides

necessary information for healthcare professionals who will continue patient care.

Besides Subjective Data Collection, and Education and Empathy, there are activities

within the simulation that provide valuable practice for their real-world counterparts, but

they are not automatically graded by the simulation.

Student: How will I be evaluated? Ans- Diana Shadow: In this assignment, you will be

evaluated on your Subjective Data Collection, as well as your Education and Empathy.

Your success in Education and Empathy is based on whether you promptly respond

after identifying a moment worthy of therapeutic communication. The evaluation of your

interview is dependent on how you word your questions therapeutically and precisely

and explore all relevant topics with comprehensive breadth and depth. You will also be

evaluated on your ability to collect data and form nursing diagnoses in the information

processing activity. This assignment takes on average between 90 and 110 minutes.

This exam may take longer than in real life, because in this safe simulation, students of

all experience levels can take time to hone and review their skills. You can pause and

resume the assignment at any time; your work is always saved automatically.

Student: How does this assignment prepare me for the real world? Ans- 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.

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? AnsStudent: So that you understand if there are any problems related to their chief

complaint. Also, to help treat their current condition.

Diana Shadow: Time to begin. AnsPatient Exam - Vital Signs: Ans- 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%

Patient Exam - Interview: AnsStudent: Hello, my name is Catlain, I am your nurse today. Ans- Tina Jones: Hey.

Student: Can you confirm your name? Ans- Tina Jones: Tina Jones:.

Student: Why did you come in today? Ans- Tina Jones: I got this scrape on my foot a

while ago, and it got really infected. It's killing me.

Student: What additional symptoms have you experienced? Ans- 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.

Student: Can you rate your current pain level on a scale of 0 to 10? Ans- Tina

Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little

bit.

Student: Please describe the pain. Ans- Tina Jones: It's throbbing and like, sharp if I try

to put weight on it.

Student: How did you hurt your foot? Ans- 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!

Student: Has your foot been draining any liquids? Ans- Tina Jones: Yeah, there's

definitely pus.

Student: What color was the pus? Ans- Tina Jones: It's... white or maybe off-white.

Student: How have you treated the wound? Ans- Tina Jones: I've been taking Advil for

my foot for a few days.

Student: What did you do to treat your foot after your accident? Ans- Tina Jones: I made

sure to clean it and keep it bandaged. And I put Neosporin on it.

Student: How effective was the Neosporin? Ans- Tina Jones: Well, I'm here, so I guess

it didn't do its job.

Student: Can you walk with your foot being injured? Ans- Tina Jones: No, I can't. I can't

put any weight on it without like, shooting pain.

Student: What preexisting medical conditions do you have? Ans- Tina Jones: I mean, I

have asthma and diabetes, but right I now I just care about my foot!

Student: I understand your foot hurts, but I need to know this information to make sure I

take care of the problem correctly. Ans- Tina Jones: Thanks.

Student: When were you diagnosed with diabetes? Ans- Tina Jones: I was diagnosed

when I was 24.

Student: What do you do to manage your asthma? Ans- 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.

Student: What medications did you take for your diabetes? Ans- Tina Jones: It was

metformin.

Student: Do you currently take medicine for your diabetes? Ans- Tina Jones: No, I don't

take anything for my diabetes anymore.

Student: What made you stop taking medication for your diabetes? Ans- 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.

Student: Do you monitor your blood glucose? Ans- Tina Jones: I have a monitor at

home, but to be honest I don't really use it that often.

Student: How frequently do you urinate? Ans- Tina Jones: I don't know. Every hour or

two when I'm awake?

Student: What is your current diet? Ans- Tina Jones: It's pretty good, I think. I'm not a

huge health nut or anything.

Student: Have you had any change in appetite? Ans- Tina Jones: Yeah, lately I've

definitely been much hungrier than usual.

Student: Has your weight changed? Ans- Tina Jones: Yeah, I've lost some weight

recently.

Student: Do you know why you lost weight? Ans- Tina Jones: I don't know what caused

it, I just lost weight.

Student: How often do you have asthma exacerbations? Ans- Tina Jones: I haven't had

a full attack in years. But my breathing definitely acts up. . .not always. Max twice a

week.

Student: What asthma symptoms have you experienced? Ans- 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.

Student: How many puffs do you take when using your asthma inhaler? Ans- Tina

Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse

confirmed with Pharmacy: albuterol 90mcg/spray MDI]

Student: What are some things that trigger your asthma? Ans- Tina Jones: Being

around cats is the worst, but dust and running up stairs can make my breathing bad,

too.

Student: What allergies do you have? Ans- Tina Jones: I'm allergic to cats.

Student: When did you realize you were allergic to cats? Ans- Tina Jones: For as long

as I've been around.

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