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Focused Exam: Infection Results | Completed
Gerontology - Fall 2021, RNSG 1261
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Overview
Transcript
Transcript
Started: Sep 10, 2021 | Total Time: 133 min
Subjective Data Collection
All Lines (193) Interview Questions (139) Statements (9) Exam Actions (45)
Objective Data Collection
Education & Empathy Gre
Good Day Ms. Young. I am Meghan and I will be your nurse today.
09/10/21 7:06 PM C
QSEN Competencies
Documentation Hello, dear.
Care Plan
Questio
Reflections What has brought you in today?
09/10/21 7:06 PM C
Gracious . . . this pain is just . . . oh, it's just terrible. Last night, it was there, but not as much .
. . not as much as this morning. It hasn't let up a bit . . .
I am sorry to hear about your pain. We are going to work together to help reduce your pain Empathi
level. 09/10/21 7:07 PM C
Thank you, my dear.
Questio
If you were to rate your pain on a scale of 0 - 10, where would you rate your current pain level.
09/10/21 7:08 PM C
A scale . . . I just don't know.
If 0 is no pain, and 10 is the worst pain you've ever had, what number would you give your Questio
pain? 09/10/21 7:08 PM C
A scale . . . I just don't know.
Questio
Could you tell me your full name?
09/10/21 7:09 PM C
My name is Patricia Young.
Questio
Would you verify your birthdate please?
09/10/21 7:09 PM C
My birthday is December 29th . . . [Ms. Young reports correct birth year.]
Support
, Questio
Do you know where you are?
09/10/21 7:09 PM C
I'm in the clinic in Dr. Turner's office . . . Is he coming in soon?
Questio
I will follow up with you regarding Dr. Turner, ok? (No matching questions found.)
09/10/21 7:09 PM C
Educa
I will follow up with you regarding Dr. Turner, ok?
09/10/21 7:10 PM C
I'm not sure I knew that. Thanks.
Questio
Do you know what day it is?
09/10/21 7:10 PM C
To be honest, I'm not sure . . . I lose track sometimes.
Questio
Can you tell me more about your pain? (Clarified to Can you describe your pain?.)
09/10/21 7:10 PM C
I couldn't really tell you what the pain is like at its worst . . . It's a constant pain, though. I have
this ache in my back and my abdomen, and it burns when I urinate. (Clarified to what the pain
is like.)
Questio
Is there anything that makes the pain better?
09/10/21 7:11 PM C
It's been constant . . . and I didn't try anything at home.
Questio
Are you taking any medication for your pain?
09/10/21 7:11 PM C
I didn't take anything at home for the pain. I just wasn't sure what to take. I was feeling a little
confused, and I was just in so much pain, that my daughter thought it would be better if I
came here first . . .
Questio
Do you take any vitamins or supplements?
09/10/21 7:11 PM C
I don't take any vitamins or supplements.
Questio
Are you on any medications?
09/10/21 7:11 PM C
Yes, I take two medications for my high cholesterol - Lip . . . Lipitor? Liptar? and . . . Prav-
something. I don't remember the exact name.
Questio
when do you take your lipitor?
09/10/21 7:12 PM C
Well, I take my high cholesterol medications every day. I take one before breakfast . . . but at
the moment I can't remember which one.
Questio
When was the last time you took your medications?
09/10/21 7:12 PM C
Oh . . . hm. I don't remember if I took my medication today . . . but I'm fairly sure I took them
yesterday.
, Questio
How are you feeling?
09/10/21 7:13 PM C
I'm not well. I'm in pain when I . . . urinate . . . my abdomen hurts and hurts.
Empathi
That must be challenging for you.
09/10/21 7:13 PM C
Thanks. Its certainly hard.
Questio
Have you ever been hospitalized before today?
09/10/21 7:14 PM C
Years ago I had my gallbladder out. I was . . . well, it's hard to remember . . . my late 40's,
maybe 50's . . . I haven't been back to the hospital since.
Questio
Do you have any family illness history I should know about?
09/10/21 7:14 PM C
I was diagnosed with, hmm . . . high cholesterol . . . I've also had a few UTIs as an adult.
Questio
When was your last UTI/
09/10/21 7:15 PM C
When . . . I don't know, honestly. It has been a little while. It might have been about six
months ago.
Questio
When were you diagnosed with high cholesterol?
09/10/21 7:15 PM C
I was diagnosed when I was . . . oh . . . late 50s, I suppose.
Questio
How long have you been taking lipitor?
09/10/21 7:15 PM C
I started the Lipitor about two months ago.
Questio
Were you taking any prescriptions prior to lipitor?
09/10/21 7:15 PM C
Yes, I take two medications for my high cholesterol - Lip . . . Lipitor? Liptar? and . . . Prav-
something. I don't remember the exact name.
Questio
Do you have any chronic illnesses?
09/10/21 7:15 PM C
I have high cholesterol . . . and I've had some urinary problems before.
Questio
Do you have any allergies to medications?
09/10/21 7:16 PM C
No, I don't have any allergies.
Questio
Do you have any food allergies?
09/10/21 7:16 PM C
I don't have any food allergies.
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