Students rated as “proficient” demonstrate an entry-level expertis
of a proficient practitioner.
Digital Clinical Experience Score
100%
Subjective Data Collection Objective Data Collection
21 out of 21 6 out of 6
This score measures your performance on the Student Performance Index in relation to and
Education otherEmpathy
students in comparable academic programs. Yo
4 out of 4
Time
75 minutes total spent in assignment
Interaction with patient
75 minutes
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
Respiratory Results | Turned In
Nursing 562/562L Advanced Health Assessment - Spring 2021, N562
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Overview
Subjective Data Collection: 21 of 21 (100.0%)
Transcript
Subjective Data
Hover To Reveal... Indicates an item that
Collection Objective Data you found.
Hover over the Patient Data Indicates an item that
Collection Education & items below to reveal important is available to be found.
information, including Pro Tips
Empathy Documentation and Example Questions.
Category Scored Items Patient Data
Not Scored
Experts selected these topics as essential components
A combination of open and closed questions will
of a strong, thorough interview with this patient.
yiel better patient data. The following details are
facts of patient's case.
Chief Complaint
Established chief complaint Reports increased breathing problems and
shortness of breath
Reports decreased effectiveness of inhaler
History of Presenting Illness
Asked about onset of symptoms Reports symptoms began two days ago
Asked about frequency and duration of SOB Reports exacerbations lasting several minutes
episodes Reports exacerbated breathing about every 4
hours since original episode
Reports waking up twice a night with asthma
the past 2 nights
Asked about severity of symptoms Describes asthma severity as "not full attack,"
but worse than usual
Reports asthma has been interfering
with activities of daily life
Support
Asked about character of symptoms Reports recent wheezing
Cough has persisted since original asthma
exacerbation 2 days ago
Describes cough as "dry"
Describes cough as "small" and not severe
Reports cough slightly relieved by drinking
water Has not treated cough with medication or
home
remedies
Asked about aggravating factors Reports symptoms worse at night
Reports symptoms increase when lying flat on
back
Reports symptoms aggravated by movement
Medical History
Confirmed use of medications Confirms medications (no new medications
reported)
Followed up about inhaler use Uses an inhaler to treat asthma symptoms
Inhaler is Proventil
Reports most recent inhaler use was this morning
Reports using inhaler every 4 hours or so since
exacerbation
Prescribed usage is 2 puffs
Reports needing more than 2 puffs to
resolve asthma symptoms
Confirmed allergies Confirms allergies (no new allergies reported)
Followed up on exposure to allergy and asthma
Reports cat allergy triggered recent
triggers episodes Reports dust as a known trigger
Reports activity such as walking up stairs as a
known trigger
Denies seasonal pattern
Denies changes in weather as a trigger
Reports minimal exposure to asthma triggers at
work
Asked detailed questions about asthma history No current asthma doctor
Diagnosed with asthma in childhood
Age of diagnosis was 2 1/2 years old
Asked about hospitalizations for asthma Reports prior hospitalizations for asthma
Reports last hospitalization was age 16
Estimates 5 total hospitalizations for
asthma Reports she has never been
intubated
Followed up about non-medication forms
Denies record keeping of asthma exacerbation or
of asthma management shortness of breath episodes
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