Focused Exam: Infection Results | Turned In
Medical Surgical Nursing: Promoting Wellness in the Older Adult (Los Angeles) - April 2019, NURS 201 shadow health
Focused Exam: Infection Results | Turned In
Medical Surgical Nursing: Promoting Wellness in the Older Adult (Los Angeles) - April 2019, NURS 201 shadow health
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Overview
Transcript
Subjective Data Collection Transcript
Started: May 14, 2019 | Patient Exam Time: 57 min
Objective Data Collection Education & Empathy QSEN Competencies Documentation
SBAR
ReflectionsHi Patricia my name is Addie and I will be your nurse today
Hello, dear.
how are you doing today?Greet
05/14/19 9:38 AM
PDT
Question
05/14/19 9:38 AM
PDT
I feel so bad. My back and abdomen ache so much. I've got this burning sensation when I use the bathroom.
i'm sorry you feel this wayEmpathize
05/14/19 9:42 AM
PDT
Goodness. Thank you.
can you tell me your nameQuestion
05/14/19 9:42 AM
PDT
Patricia Young.
thank youAll Lines (145)Interview Questions (57)Statements (42)Exam Actions (46) Empathize
05/14/19 9:42 AM
PDT
I appreciate the support.
what is your date of birthQuestion
05/14/19 9:42 AM
PDT
My birthday is December 29th . . . [Ms. Young reports correct birth year.]
do you know what the date is todayQuestion
05/14/19 9:43 AM
PDT
To be honest, I'm not sure . . . I lose track sometimes.
it's ok.Empathize
05/14/19 9:43 AM
PDT
Thanks. Its certainly hard.
today is may 14, 2019Educate
05/14/19 9:43 AM
PDT
I see. Thanks for filling me in.
do you know where youre atQuestion
05/14/19 9:44 AM
PDT
My daughter Mary has a knack for finances . . . I think my husband taught her. I trust her with managing our estate. I don't think she would ever take advantage of me.
on a scale of 0 to 10, what is yourpainQuestion
05/14/19 9:46 AM
PDT
A scale . . . I just don't know.
is the pain sharpQuestion
05/14/19 9:46 AM
PDT It's not a sharp or shooting kind of pain. It's not really like that. There's a deep ache in my back and stomach, and this burning pain when I urinate.
what starts the pain (Clarified to What do you think brought on the pain?.)Question
05/14/19 9:47 AM
PDT
I'm not sure what the cause is, I just know it's painful. (Clarified to what I think caused my pain.)
what are you doing to treat the pain?Question
05/14/19 9:47 AM
PDT
It's been constant . . . and I didn't try anything at home.
what makes the pain worseQuestion
05/14/19 9:47 AM
PDT
The pain was there all night, and felt worse this morning. I'm not sure I could say what makes it worse, I can only tell you how it feels. My abdomen and back hurt constantly, and the pain when I urinate is awful.
i'm sorry to hear thisEmpathize
05/14/19 9:49 AM
PDT
Youre sweet to say that.
how much fluids are you drinking a dayQuestion
05/14/19 9:50 AM
PDT
Fluids . . . um . . . I'm not sure . . .
remember drinking 8 to 12 glasses of water is what is expectedEducate
05/14/19 9:50 AM
PDT
Thanks for walking me through that.
do you have a history ofutiQuestion
05/14/19 9:50 AM
PDT
Yes, I've had UTIs before . . . maybe once a year . . . but this back pain . . . it just doesn't make sense.
back pain could also be the reason for the uti
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