Health History Simulation: Tina Jones Case Study, Exams of Nursing

Download Health History Simulation: Tina Jones Case Study and more Exams Nursing in PDF only on Docsity!

Shadow Health - Tina Jones, Health

History

Health History Tips & Tricks: - TJ Health Interview

Student: Hello! - Diana Shadow: Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.

Student: What is the situation? - Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process.

Student: What are my objectives in this assessment? - Diana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre- existing conditions. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones' overall health. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. Jones' health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses.

Student: What else will this exam involve? - Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are

activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation.

Student: How will I be evaluated? - Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically.

Student: How does this assignment prepare me for the real world? - Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real- life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses.

Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient's complete health history? - Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition.

Diana Shadow: Time to begin. -

Patient Exam - Vital Signs: - Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%

Patient Exam - Interview: -

Student: Hello, my name is Catlain, I am your nurse today. - Tina Jones: Hey.

Student: How effective was the Neosporin? - Tina Jones: Well, I'm here, so I guess it didn't do its job.

Student: Can you walk with your foot being injured? - Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain.

Student: What preexisting medical conditions do you have? - Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot!

Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. - Tina Jones: Thanks.

Student: When were you diagnosed with diabetes? - Tina Jones: I was diagnosed when I was 24.

Student: What do you do to manage your asthma? - Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

Student: What medications did you take for your diabetes? - Tina Jones: It was metformin.

Student: Do you currently take medicine for your diabetes? - Tina Jones: No, I don't take anything for my diabetes anymore.

Student: What made you stop taking medication for your diabetes? - Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills.

Student: Do you monitor your blood glucose? - Tina Jones: I have a monitor at home, but to be honest I don't really use it that often.

Student: How frequently do you urinate? - Tina Jones: I don't know. Every hour or two when I'm awake?

Student: What is your current diet? - Tina Jones: It's pretty good, I think. I'm not a huge health nut or anything.

Student: Have you had any change in appetite? - Tina Jones: Yeah, lately I've definitely been much hungrier than usual.

Student: Has your weight changed? - Tina Jones: Yeah, I've lost some weight recently.

Student: Do you know why you lost weight? - Tina Jones: I don't know what caused it, I just lost weight.

Student: How often do you have asthma exacerbations? - Tina Jones: I haven't had a full attack in years. But my breathing definitely acts up.. .not always. Max twice a week.

Student: What asthma symptoms have you experienced? - Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs.

Student: How many puffs do you take when using your asthma inhaler? - Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]

Student: What are some things that trigger your asthma? - Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too.

Student: What allergies do you have? - Tina Jones: I'm allergic to cats.

Student: When did you realize you were allergic to cats? - Tina Jones: For as long as I've been around.

Student: Do you have any problems with your head? - Tina Jones: I don't think I have any problems. I get headaches sometimes, but that's all.

Student: Any problems with your ears? - Tina Jones: No.

Student: Any problems with your eyes and vision? - Tina Jones: I've actually been noticing problems lately. When I'm reading or studying I'll notice that things start to get kind of blurry.

Student: Any problems with your nose? - Tina Jones: My nose is fine right now. Sometimes it runs, but not very often.

Student: Do you have problems with your mouth? - Tina Jones: No.

Student: Do you have a history of cardiovascular problems? - Tina Jones: My heart's fine, thank God!

Student: Any problems with your heart? - Tina Jones: No, my heart's always been fine.

Student: Have you had any problems with your breasts? - Tina Jones: I haven't noticed any pain there.

Student: Have you had any reproductive problems? - Tina Jones: I don't think I have problems in that area. I just get really bad periods, that's all.

Student: Have you had any neurological problems? - Tina Jones: No, I haven't.

Student: Have you had any musculoskeletal problems? - Tina Jones: No.

Student: Do you have a history of skin disease? - Tina Jones: Um, I have acne, if that counts.

Student: Does your paternal grandfather have any health problems? - Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and...I'm pretty sure he had diabetes. And high cholesterol like everyone else in my family.

Student: Does your mother have any health problems? - Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

Student: Does your father have any health problems? - Tina Jones: Well, he passed away. But he had a couple things... Type 2 diabetes, like me, and high cholesterol and blood pressure.

Student: How did your father die? - Tina Jones: He died in a car accident.

Student: Where is your wound located? - Tina Jones: It's on the ball of my foot.

Student: Do you get thirsty often? - Tina Jones: You know, I did notice lately that I've been really thirsty.

Student: What happened with your father's car accident? - Tina Jones: It was last year... I guess a little over a year ago.

Student: How long ago was your dad's car accident? - Tina Jones: It was last year... I guess a little over a year ago.

Student: How did you cope with your fathers death? - Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kind of depressed. So, I guess at first I just focused on getting things done--groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months.

Student: Does your family have a history of headaches? - Tina Jones: No, not that I know of.

Student: How much alcohol do you drink? - Tina Jones: I only have a few drinks when I go out.

Student: What is your level of education? - Tina Jones: Well, I'm finishing up my bachelor's degree right now.

Student: What are stressors? - Tina Jones: I feel really stressed out right now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too.

Student: We are going to take care of everything as quickly as possible. - Tina Jones: Thanks.

Student: Where do you live? - Tina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. It's like a half hour from here.

Student: What is your belief system? - Tina Jones: I'm Baptist. My faith is a big part of my life--when things get hard like they've been this past year, I know I can trust that God's looking out for me. I've been going to the same church since I was a kid, too, so the people at church are practically part of my family.

Student: Have you experienced abuse? - Tina Jones: I've never had been in any kind of situation like that... It's scary to think about.

Student: Have you used illicit drugs? - Tina Jones: Well, I used to smoke pot... but I don't do that anymore.

Student: What type of drugs did you use? - Tina Jones: Um...I've smoked pot before. In high school, and after high school... I definitely don't anymore, though.

Student: Have you used drugs other than marijuana? - Tina Jones: No.

Student: When did you last use drugs? - Tina Jones: I haven't smoked pot since I was twenty or twenty- one.

Student: Have you ever smoked cigarettes? - Tina Jones: No. I think it's gross.

Student: Have you been around people that are smoking? - Tina Jones: Some of my friend's smoke when we go out drinking. But I don't smoke, and nobody at home smokes.

Student: How old were you when your father died? - Tina Jones: He died last year, so I was 27.

Student: Did your father die from any disease? - Tina Jones: He died in a car accident.

Student: Can you tell me about your father's health? - Tina Jones: He had high blood pressure and cholesterol. And diabetes -- we have diabetes in common.

Student: I can't even imagine how you feel about losing your father - Tina Jones: Thanks.

Student: Tell me about your father. - Tina Jones: Dad was a little stricter than Mom growing up... he would sometimes get kind of mad at us when we did something wrong. But he never hit us or anything. He would just get really calm and quiet and tell us to go to our rooms without supper, or that we were grounded when we were older. Or like, he'd make us rake the yard or wash his car or something. It's pretty sad to

Finding: Reports pain is sharp when she attempts to stand (Found)Pro Tip: Determining what physical activities and movements exacerbate the patient's pain can help you better understand the problems and assess treatment needs. This can also alert you if a patient's activities of daily living are hindered. - Example Question: What is the pain like when you stand on your foot?

Finding: Reports pain has increased in the past 2 days (Available)Pro Tip:Finding out how the patient's pain has changed will give you insight into the acceleration of infection. - Example Question: How has the pain changed over time?

Finding: Reports feeling pain radiating into ankle (Available)Pro Tip: Asking about where else the patient's pain radiates can help determine the progression of infection. - Example Question: Does the pain radiate anywhere else?

Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care. - Example Question: Can you bear weight on your foot?

Finding: Asked location of wound -

Finding: Reports right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patient's safety. - Example Question: Which foot is in pain?

Finding: Reports wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient's biggest complaint. - Example Question: Where is the wound?

Finding: Asked details of the injury -

Finding: Reports she scraped foot on bottom rung of a step stool (Found)Pro Tip: Discovering how an injury happened helps to assess your patient's risk factors for injury. - Example Question: How did your injury happen?

Finding: Reports injury occurred 1 week ago (Available)Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute. - Example Question: When did your injury occur?

Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. - Example Question: Did you injure anything besides your foot?

Finding: Reports being barefoot at the time of injury (Available)Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances. - Example Question: Were you wearing shoes when you fell?

Finding: Denies seeing a healthcare provider for the injury until now (Available)Pro Tip: It's crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound. - Example Question: Have you seen a healthcare provider for this injury?

Finding: Asked about drainage from the foot wound -

Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound. - Example Question: Did your foot bleed?

Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. - Example Question: Did you notice any discharge from the wound?

Finding: Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective (Found)Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Tina's diabetes diagnosis will have a large impact on her body's healing ability, which should be taken into consideration during your exam. - Example Question: Did the ointment help?

Finding: Asked about other foot wound symptoms -

Finding: Reports swelling around foot wound (Found)Pro Tip: Asking about the presence of swelling helps you gather information about your patient's complaint, as well as potential related illnesses. - Example Question: Is there swelling around the wound?

Finding: Reports swelling worsened in the past 2 days (Available)Pro Tip:Finding out how long swelling appeared will help you understand the timeline for the infection progression. - Example Question: How long have you noticed swelling around the wound?

Finding: Reports redness around the wound (Found)Pro Tip: Asking about redness will help you understand the timeline for the infection progression. - Example Question: Did you notice any redness around the wound?

Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression. - Example Question: Does the wound feel warm?

Finding: Explored impact of patient's foot injury on activities of daily living -

Finding: Reports pain affects ability to walk (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can walk or not, as a lack of mobility can compromise quality of life. - Example Question: Does your injury impact your ability to walk?

Finding: Reports pain affects ability to stand at work for long periods of time (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care.

With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance. - Example Question: Does your foot pain affect your work?

Finding: Reports pain prevented her from being able to walk to class (Available)Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don't fall behind. - Example Question: Has your injury prevented you from going to class?

Past Medical History -

Finding: Asked about preexisting medical conditions -

Finding: Reports diabetes (Found)Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. In Tina's case, it is important to identify her diabetes diagnosis because that condition has a direct relationship with her current foot infection. - Example Question: Do you have any existing conditions?

Finding: Reports asthma (Found)Pro Tip: It is important to identify any existing medical conditions, such as Tina's asthma, because that information is an integral part of her health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. - Example Question: Do you have any other conditions?

Finding: Followed up on diabetes diagnosis -

Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patient's illness is an essential element of the illnesses history. - Example Question: At what age were you diagnosed with diabetes?

ineffective in the past, which will allow you to make a more informed decision about current treatment.

• Example Question: Do you remember what you were prescribed for diabetes?

Finding: Reports last use of medication was 3 years ago (Available)Pro Tip: It important to discover when Tina stopped taking any medications and what caused her to stop. Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment. - Example Question: When was the last time you took your diabetes medication on a regular basis?

Finding: Followed up on stopping diabetes regimen -

Finding: Reports disliking diabetes medication side effects (Found)Pro Tip: Asking about side effects from medication can provide information about your patient's reaction to treatment. - Example Question: Did the metformin cause any side effects?

Finding: Reports that she didn't like checking sugar and taking daily pills (Found)Pro Tip: Asking reasons for noncompliance can reveal information about your patient's health literacy, side effects, financial situation, and more. - Example Question: What's preventing you from taking your diabetes medication?

Finding: Asked about blood glucose monitoring -

Finding: Reports infrequent blood glucose monitoring (Found)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. - Example Question: Tell me about your blood sugar monitoring.

Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. - Example Question: How often do you check your blood sugar?

Finding: Reports confusion about what the numbers mean (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. If you find gaps in

the patient's literacy, that is your opportunity to provide education. - Example Question: What are your usual blood sugar levels?

Finding: Asked about thirst -

Finding: Reports increased thirst (Found)Pro Tip: Your patient's thirst can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - Example Question: Have you been more thirsty lately?

Finding: Reports increased water intake (Available)Pro Tip: Your patient's fluid intake can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - Example Question: Are you drinking more water than normal?

Finding: Asked about frequency of urination -

Finding: Reports more frequent urination (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - Example Question: Have you been urinating more often than usual?

Finding: Reports urinating every hour or two during the day (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - Example Question: How often do you urinate during the day?

Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health. - Example Question: How often do you wake up at night to urinate?

Finding: Asked about diet -