Shadow Health - Tina Jones: Health History Questions and Answers, Exams of Nursing

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Shadow Health - Tina Jones, Health

History questions and answers

Student: What is the situation? - correct answer 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? - correct answer 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: How does this assignment prepare me for the real world? - correct answer 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? - correct answer Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition.

Patient Exam - Vital Signs: - correct answer 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: - correct answer Student: Hello, my name is Catlain, I am your nurse today. - correct answer Tina Jones: Hey. Student: Can you confirm your name? - correct answer Tina Jones: Tina Jones:. Student: Why did you come in today? - correct answer Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me. Student: What additional symptoms have you experienced? - correct answer Tina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on. Student: Can you rate your current pain level on a scale of 0 to 10? - correct answer Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. Student: Please describe the pain. - correct answer Tina Jones: It's throbbing and like, sharp if I try to put weight on it. Student: How did you hurt your foot? - correct answer Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was! Student: Has your foot been draining any liquids? - correct answer Tina Jones: Yeah, there's definitely pus.

Student: Do you currently take medicine for your diabetes? - correct answer Tina Jones: No, I don't take anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? - correct answer 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? - correct answer 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? - correct answer Tina Jones: I don't know. Every hour or two when I'm awake? Student: What is your current diet? - correct answer 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? - correct answer Tina Jones: Yeah, lately I've definitely been much hungrier than usual. Student: Has your weight changed? - correct answer Tina Jones: Yeah, I've lost some weight recently. Student: Do you know why you lost weight? - correct answer Tina Jones: I don't know what caused it, I just lost weight. Student: How often do you have asthma exacerbations? - correct answer 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? - correct answer 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? - correct answer 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? - correct answer 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? - correct answer Tina Jones: I'm allergic to cats. Student: When did you realize you were allergic to cats? - correct answer Tina Jones: For as long as I've been around. Student: How effective was your pain medication at home? - correct answer Tina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn't doing much for me -- it would only last a couple of hours. Student: What medication allergies do you have? - correct answer Tina Jones: I'm allergic to penicillin. Student: What food allergies do you have? - correct answer Tina Jones: I don't have any food allergies that I know of. Student: Are you allergic to dust, mold, or pollen? - correct answer Tina Jones: Well... I don't know if it's allergies, but sometimes my asthma acts up around dust.

Student: Do you have problems with your mouth? - correct answer Tina Jones: No. Student: Do you have a history of cardiovascular problems? - correct answer Tina Jones: My heart's fine, thank God! Student: Any problems with your heart? - correct answer Tina Jones: No, my heart's always been fine. Student: Have you had any problems with your breasts? - correct answer Tina Jones: I haven't noticed any pain there. Student: Have you had any reproductive problems? - correct answer 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? - correct answer Tina Jones: No, I haven't. Student: Have you had any musculoskeletal problems? - correct answer Tina Jones: No. Student: Do you have a history of skin disease? - correct answer Tina Jones: Um, I have acne, if that counts. Student: Does your paternal grandfather have any health problems? - correct answer 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? - correct answer 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? - correct answer 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? - correct answer Tina Jones: He died in a car accident. Student: Where is your wound located? - correct answer Tina Jones: It's on the ball of my foot. Student: Do you get thirsty often? - correct answer Tina Jones: You know, I did notice lately that I've been really thirsty. Student: What happened with your father's car accident? - correct answer Tina Jones: It was last year... I guess a little over a year ago. Student: How long ago was your dad's car accident? - correct answer Tina Jones: It was last year... I guess a little over a year ago. Student: How did you cope with your fathers death? - correct answer 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: What caused your dads accident? - correct answer Tina Jones: He was driving to work, and it was raining...and his car hydroplaned. And hit a tree. So, it was really sudden. Student: How is your paternal grandmother's health? - correct answer Tina Jones: Granny's doing good. She's still living on her own. She's slowing down, but we help her out. She lives

Student: How much alcohol do you drink? - correct answer Tina Jones: I only have a few drinks when I go out. Student: What is your level of education? - correct answer Tina Jones: Well, I'm finishing up my bachelor's degree right now. Student: What are stressors? - correct answer 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. - correct answer Tina Jones: Thanks. Student: Where do you live? - correct answer 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? - correct answer 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? - correct answer 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? - correct answer Tina Jones: Well, I used to smoke pot... but I don't do that anymore. Student: What type of drugs did you use? - correct answer 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? - correct answer Tina Jones: No. Student: When did you last use drugs? - correct answer Tina Jones: I haven't smoked pot since I was twenty or twenty-one. Student: Have you ever smoked cigarettes? - correct answer Tina Jones: No. I think it's gross. Student: Have you been around people that are smoking? - correct answer 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? - correct answer Tina Jones: He died last year, so I was 27. Student: Did your father die from any disease? - correct answer Tina Jones: He died in a car accident. Student: Can you tell me about your father's health? - correct answer 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 - correct answer Tina Jones: Thanks. Student: Tell me about your father. - correct answer 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 Student: How old was your father when he died? - correct answer Tina Jones: Last year when Dad passed, he was only 58.

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. - correct answer 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. - correct answer 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. - correct answer 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. - correct answer Example Question: Can you bear weight on your foot? Finding: Asked location of wound - correct answer 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. - correct answer 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. - correct answer Example Question: Where is the wound? Finding: Asked details of the injury - correct answer

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. - correct answer 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. - correct answer 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.

• correct answer 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. - correct answer 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. - correct answer Example Question: Have you seen a healthcare provider for this injury? Finding: Asked about drainage from the foot wound - correct answer 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. - correct answer 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. - correct answer 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. - correct answer Example Question: Did the ointment help? Finding: Asked about other foot wound symptoms - correct answer 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. - correct answer 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. - correct answer 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. - correct answer 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. - correct answer Example Question: Does the wound feel warm? Finding: Explored impact of patient's foot injury on activities of daily living - correct answer 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. - correct answer 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. - correct answer 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. - correct answer Example Question: Has your injury prevented you from going to class? Past Medical History - correct answer Finding: Asked about preexisting medical conditions - correct answer 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. - correct answer 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. - correct answer Example Question: Do you have any other conditions? Finding: Followed up on diabetes diagnosis - correct answer 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. - correct answer Example Question: At what age were you diagnosed with diabetes?

metformin, will provide a timeline of her asthma treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. - correct answer 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. - correct answer Example Question: When was the last time you took your diabetes medication on a regular basis? Finding: Followed up on stopping diabetes regimen - correct answer 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. - correct answer 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. - correct answer Example Question: What's preventing you from taking your diabetes medication? Finding: Asked about blood glucose monitoring - correct answer 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. - correct answer 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.

• correct answer 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. - correct answer Example Question: What are your usual blood sugar levels? Finding: Asked about thirst - correct answer 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. - correct answer 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. - correct answer Example Question: Are you drinking more water than normal? Finding: Asked about frequency of urination - correct answer 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. - correct answer 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. - correct answer 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. - correct answer Example Question: How often do you wake up at night to urinate?