Shadow Health: Nursing Assessment Revision Bundle

Asked about reproductive system - Reports last menstrual period was 2 weeks ago Reports menstrual cycle is normal Reports rare cramping Asked about breast health - Reports doing occasional breast exams Denies having a mammogram Denies changes to breasts Denies history of breast cancer Asked a...

Asked about foot wound - reports swelling has improved reports wound warmth has improved reports wound discharge has improved reports wound is still a little red Asked about history of slow healing wounds - denies history of slow healing wound Asked current wound healing time - reports wound ha...

Reason for Visit - Asked about reason for visit Finding: Reports seeking a new primary care provider Culture -Asked about language use Finding: Reports using English Pro Tip: Asking about the client's language use will let you know if you may need to connect them with an interpreter in orde...

Established chief complaint - -reports leg pain -reports leg swelling Established orientation - -oriented to person -oriented to place -oriented to time -oriented to situation Asked about onset and duration of symptoms - -reports fall was 9 am this morning -reports lower leg pain started 2 d...

Relevant Medical History Asked about heart problems - Denies heart problems Asked about heartbeat - Reports normal heartbeat Reports normal heart rate Denies palpitations Denies arrhythmia Asked about high blood pressure - Denies high blood pressure Reports last blood pressure check 140 over ...

Asked about head problems - 1- do you get HAs 2- do you currently have a HA 3- other than headaches, are you experiencing any other health problems? Asked about frequency of headaches - how frequently does your headaches occur Asked about duration of headaches - how long do your headaches last ...

Established chief complaint - -Reports pain: Do you have any? -Reports foot wound Asked to rate current pain level on a scale - Can you rate your pain? Asked for details about the pain - -Can you describe your pain? -What is the pain like when you stand on your foot? -how has the pain changed o...

Hello Mrs. Jones, my name is Shailee, and I will be taking care of you today. - Can you confirm your name and DOB - On a scale of 0-10 how is your pain? 0 being the no pain. 10 being the most painful. - I am sorry you are going through this pain. Do you know your height? - Do you know your ...

Chief Complaint - Scrape on foot. It is infected and causing pain(7 out of 10). - Right foot pain, fever, nausea - History of Present Illness - A week ago the scrape startedand the pain got a lot worse in last few days. - Ms. Jones is a pleasant 28-year-old African American woman who presented ...