NR 509 History Assignment Subjective Shadow

Overview Transcript

Subjective Data Collection

Objective Data Collection Education & Empathy Documentation Information Processing

Health History Tips and Tricks

Self-Reflection

Subjective Data Collection: 94 of 104 (90.4%)

Indicates an item that you found.

Indicates an item that is available to be found.

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Category Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

Established chief complaint Reports pain

Reports open foot wound

NR 509 History Assignment Subjective Shadow

History of Present Illness

Asked for details about the pain Describes the pain as throbbing

Describes the pain as sharp when she attempts to stand

Initial injury occurred 1 week ago Pain has increased in the past 2 days

Reports feeling pain radiating into ankle Pain prevents bearing weight on foot

Asked to rate pain on a scale Rates present pain at a 7 out of 10

Clarified location of wound Confirmed that right foot is injured

Confirmed that wound is on the plantar surface of her foot

Determined details of the injury Scraped foot on a cement step Reports mild ankle injury

Was not drinking at the time of the injury Was not wearing shoes at the time of injury

Asked about the assessment of the injury at the ER Went to the ER after sustaining the injury

Decided to go because she suspected an ankle sprain Received an x-ray

X-ray showed no broken bones Received a prescription for pain pills

Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the

injury

Reports seeing pus draining from wound Began noticing pus 2 days ago

Followed up about character of drainage from the foot wound

Describes pus as white or yellow in color Reports no odor from the wound

Asked about home treatment of foot wound Describes wound care regimen of cleaning and

bandaging

Cleaned wound twice a day

Cleaned wound with hydrogen peroxide Changed bandage twice a day

Applied neosporin

NR 509 History Assignment Subjective Shadow

Asked about other foot wound symptoms Reports swelling around foot wound

Noticed swelling getting worse in the past 2 days Reports redness around the wound

Reports that the wound feels warm

Explored impact of patient’s foot injury on activities of daily living

Pain affects ability to walk Pain affects job performance

Pain prevented her from attending class

Asked about recent fever Reports a fever last night

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NR 509 -Tina Jones Health History Narrative

Ms. Tina Jones is a pleasant 28- year- old African American woman who presented to the clinic with complaints of recent sleep disturbance which has lasted a month. She has been having disturbed sleep 4- 5 nights a week. She states that her sleep is “shallow and not restful”. She complains of di?culty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep without di?culty. On average she sleeps 4 or 5 hours per night and awakens at 8:00am daily. She does not take any prescription or over the counter sleep aids. Poor sleep behavior occurring over a limited time period induces changes in mood as well as diminishes alertness and cognitive performance. However, the effects of poor sleep behavior are cumulative. More specifically, chronic poor sleep and chronic insomnia have been linked to elevated risks of negative physiological and mental health outcomes (Bassett et al., 2015).

General Evaluation

She is the primary source of the history. Her speech is clear and coherent. She maintains good contact throughout the interview. Ms. Jones is alert and oriented. She is well nourished. She is well groomed, dressed appropriately, has good hygiene, and interacts appropriately.

Chief Complaint

Ms. Jones’s chief complaint is being unable to sleep due to anxiety.

Medications

Allergies

Ms. Jones is allergic to cats, dust, and penicillin. Cats trigger her asthma and causes wheezing, sneezing, and itching. Her Penicillin allergy causes rash.

Immunizations

She reports a tetanus booster a couple of years ago. She denied influenza and Pneumonia vaccines.

Family History

Ms. Jones’ mom has …

Social History

Ms. Jones is very active in church and with family. She previously lived alone, but moved back in with her mom and younger sister to help with finances and to help care for her sister after the death of her father. She is working on her bachelor’s degree in accounting. She does not use tobacco products. She does not use drugs, but tried pot when younger. She drinks socially only two to three times per month when out with friends. She is currently single with no children. She is currently not on contraceptives, but used birth control while sexually active with previous partner. She is experiencing some sleep disturbance which is caused by anxiety about coming exam and job search.

HEENT

There is no family history of headaches. She denies any head trauma. Patient states that her vision gets blurry when reading or studying. She states that her eyes do not hurt when her vision gets blurry. Her eyes get red and itchy when she is around cats. She also sneezes and experiences rhinitis and congestion around cats. She denies changes in weight, fatigue, weakness, fever, chills, and night sweats. She denies history of trauma. She denies current headache. She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. She denies increased tearing or itching prior to this past week. She denies hearing loss, tinnitus, vertigo, discharge, or earache. She denies rhinorrhea prior to this episode or stu?ness, sneezing, itching, previous allergy, epistaxis, or sinus pressure.

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Neurologic/Psychiatric

She denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. She endorses changes in concentration and sleep. She denies changes or di?culties in coordination. She states that her mood has been “o?” and she does not feel like herself. She does complain of increased anxiety related to upcoming exams and job search. She has no history of depression, but does state that she feels helpless and notes that her performance at work and school is beginning to decline. She denies tension or memory loss. There is no past suicide attempts. She denies suicidal or homicidal ideation.

The sleep disturbance which is due to worries is signi?cantly associated with poor quality of sleep, higher levels of psychological distress and reduced well-being. The present study suggests that trait characteristics of pre-sleep cognitive arousal, predisposition to arousal and tendency to worry may play an important role in the disruption of sleep due to worries (Marques, Gomes, Ferreira, & Azevedo, 2016).

Subjective Data

Reports di?culty sleeping, with worry “racing thoughts” before bed
Falling asleep takes 1+ hours, and she wakes up 2 to 3 times each night
Sleeps an average of 4 or 5 hours a night
Describes upcoming college graduation and need to secure employment
Reports feeling nervous and worrying about the future
Associated e?ects on mood: slight irritability, di?culty concentrating, and fatigue
Associated e?ects on GI: decreased appetite, feeling “a little queasy” from lack of sleep, high cholesterol and hypertension

Objective Data

Pulse Oximetry 98%

Blood Pressure (BP) 146/92

Blood Glucose 190

Heart rate 96

References

Bassett, S. M., Lupis, S. B., Gianferante, D., Rohleder, N., & Wolf, J. M. (2015). Sleep quality but not sleep quantity effects on cortisol responses to acute psychosocial stress. Stress: The International Journal on the Biology of Stress, 18(6), 638-644. doi:10.3109/10253890.2015.1087503

Marques, D., Gomes, A., Ferreira, M., & Azevedo, M. (2016). Don’t worry, sleep well: predictors of sleep loss over worry. Sleep & Biological Rhythms, 14(3), 309-318. doi:10.1007/s41105-016-0060-z

NR 509 Week 7 Completion of Immersion Program/Exam

___________, my name is ____________, I will be doing your exam today. I’ll begin with inspecting your face. I’ll note that I don’t see any discolorations or lesions & the head is midline & symmetrical.
LYMPH NODES: Next, I’ll palpate the lymph nodes. I’ll begin with the preauricular lymph nodes & postauricular lymph nodes. Next the occipital lymph nodes. I’ll move forward to palpate the tonsillar lymph nodes, submandibular & submental. I’m palpating the anterior cervical lymph nodes & posterior cervical lymph nodes & lastly the supraclavicular lymph nodes. I don’t feel any enlargement & they’re equal bilaterally.
FACE : I’m testing trigeminal nerve, which is cranial nerve # 5. Palpating over the masseter muscle as the pt clenches the jaw. I don’t feel any distortions & my pt has great strength. Now, I’m testing the sensory portion of the trigeminal nerve. I’ll ask my pt to close your eyes & let me know where you feel my touch. (>> Forehead, right cheek, left cheek, chin, nose)……….Next, I’ll test the facial nerve, which is cranial nerve # 7. I’m going to ask you to do some facial expressions. I’m going to have you smile, next, frown for me. Now raise your eyebrows & puff up your cheeks, pucker your lips. I notice all expressions have bilateral symmetry.

EARS
EYES
NOSE
MOUTH
NECK & THROAT
HEART/CHEST ((pt sitting))
UPPER EXTREMITIES
ABDOMEN ((have pt lie down))
LOWER EXTREMITIES

NR 509 Week 2 Alternate Writing Assignment, Respiratory

Purpose

As a family nurse practitioner, you must possess excellent physical assessment skills. This alternative writing assignment mirrors the discussion content of the debriefing session and will allow the student to expand their knowledge of physical health assessment principles specific to the advanced practice role.

Course Outcomes

This assignment is guided by the following Course Outcomes (COs):

Apply advanced practice nursing knowledge to collecting health history information and physical examination findings for various patient populations. (PO 1, 2)
Differentiate normal and abnormal health history and physical examination findings. (PO 1, 2)
Adapt health history and physical examination skills to the developmental, gender-related, age-specific, and special population needs of the individual patient. (PO 1, 2)

The purposes of this assignment are to: (a) identify and articulate advanced assessment health history and physical examination techniques which are relevant to a focused body system (CO 1), (b) differentiate normal and abnormal findings with regard to a disease or condition that impacts the body system (CO 2), and (c) adapt advanced assessment skills if necessary to suit the needs of specific patient populations (CO 4).

NOTE: You are to complete this alternative writing assignment ONLY if you had not participated or do not plan to participate in a debriefing session for the given week.

Due Date: This alternative written assignment is due no later than the Sunday of the week in which you did not attend the weekly debriefing session. The standard MSN Participation Late Assignment policy applies to this assignment.

Preparing the Paper:

Select a focused body system from the weekly lesson which corresponds with the week of the written assignment.
Carefully read and review the selected body system in your course textbooks.
Incorporate at least one scholarly peer-reviewed journal article that relates to the body system. It may be useful to identify an article that relates to a disease that impacts the body system.
The paper must clearly articulate the relevance of advanced physical assessment skills, techniques, application of advanced practice knowledge, and assessment modification (when necessary) to accommodate for specific patient populations.
Provide concluding statements that should summarize key points of the overall assignment content.
In-text citations and reference page(s) must be written using proper APA format (6th edition).

NR 509 History Assignment Subjective Shadow