Shadow Health Focused Exam, COPD- Subjective Data Collection Verified and Correct!
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Course
Nursing course
Institution
Nursing Course
Focused Exam: Abdominal Pain Results | Completed
ICHS - Capstone Spring 2021 - June 2021, nur2811ug
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7/14/2021 Focused Exam: Abdominal Pain | Completed | Shadow Health
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Focused Exam: Abdominal Pain Results | Completed
ICHS - Capstone Spring 2021 - June 2021, nur2811ug
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Reopen (/assignment_attempts/10179355/reope
m
Lab Pass (/assignment_attempts/10179355/lab_pass.
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Overview
Subjective Data Collection: 40 of 41 (97.6%)
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Transcript
Subjective Data Collection rs e
ou urc
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.
o
information, including Pro Tips and
Documentation
Example Questions.
aC s
Care Plan
vi y re
Self-Reflection
Category Scored Items Patient Data
Not Scored
ed d
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
ar stu
patient's case.
Chief Complaint
is
Established chief complaint Reports abdominal pain
Th
Reports difficulty with bowel movements
Orientation
sh
Asked about orientation Oriented to own person
Oriented to place
Oriented to situation
Oriented to time
History of Presenting Illness
Asked about onset of the pain Support
Reports discomfort for the past five days
This study source was downloaded by 100000817113117 from CourseHero.com on 09-14-2021 07:10:40 GMT -05:00
, 7/14/2021 Focused Exam: Abdominal Pain | Completed | Shadow Health
Reports pain worsened intensely 2-3 days ago
Asked about location of the pain Reports pain in lower abdomen
Reports pain is not localized
Denies flank pain
Asked about pain rating on a scale Reports current pain rating of 2/10
Reports pain at its lowest is 2/10
Reports pain at its worst is 8/10
Asked about characteristics of the pain Describes pain as dull
Describes pain as cramping
Describes pain as constant
Describes pain as fluctuating in severity
Asked about non-pharmacological relieving Reports that resting helps relieve pain
factors Reports drinking warm water to relieve pain was
ineffective
m
er as
Asked about pharmacological relieving factors Denies taking pain medication
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Denies taking laxatives
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o.
Asked about aggravating factors Reports pain is aggravated by eating
rs e Reports pain is aggravated by physical activity
ou urc
Asked about impact of pain on daily life Reports recent difficulty participating in usual
activities
o
Reports low energy
aC s
vi y re
Followed up on constipation Reports current constipation
Reports constipation all of last 5 days
Asked about diarrhea Reports recent diarrhea
ed d
ar stu
Followed up on diarrhea Reports diarrhea about six months ago
Reports diarrhea had a sudden onset
Reports diarrhea lasted one day
is
Th
Asked about substances in stool Denies mucus in stool
Denies blood in stool
sh
Asked about urination Reports slight decrease in frequency of urination
Reports darker urine recently
Denies blood in urine
Asked about fluid intake Reports decreased thirst
Reports decreased fluid intake for the last few
days
Typical fluid intake is 1-2 glasses of water a day
Denies drinking caffeinated drinks such as coffee
or soda
This study source was downloaded by 100000817113117 from CourseHero.com on 09-14-2021 07:10:40 GMT -05:00
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