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Patient Assessment and Health Literacy - NUR 325
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Transcript
Started: Feb 12, 2019 | Patient Exam Time: 464 min
Subjective Data Collection
All Lines (628) Interview Questions (253) Statements (12) Exam Actions (363)
Objective Data Collection
Question
Documentation
Hello! 02/12/19 12:39 PM
EST
Plan My Exam
Self-Reflection Hi. Im 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.
Question
What is the situation? 02/12/19 12:39 PM
EST
Six months have passed since Tina Jones was admitted to Shadow
General Hospital, and her foot wound has healed. Your role in this
simulation is that of a healthcare provider who will perform a
comprehensive assessment on Ms. Jones to demonstrate your
clinical competency.
Question
What are my objectives in this assessment? 02/12/19 12:39 PM
EST
,Updated Solutions
At the beginning of this assignment, you will be asked to identify
and organize the steps of your comprehensive exam. Having a
clear plan is essential to maximizing efficiency and obtaining a full
picture of the patients current health. Then you will collect subjective
data from Ms. Jones: inquire into her current health status, body
systems, mental health, and psychosocial history. Regardless of
whether you have assessed Tina previously, ask all questions that
are medically relevant to understanding her current health status. In
addition to collecting subjective data, you will perform a physical
exam on Ms. Jones systems to gather objective data about her
overall health. Ms. Jones has no new abnormal findings, so after you
complete an exam task, you do not need to make selections in the
Electronic Health Record, though you may document your findings if
you like. 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.
Question
What else will this exam involve? 02/12/19 12:40 PM
EST
You will complete nursing tasks to protect the patients safety,
privacy, and health. While it is not required for this assignment, 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. Activities
other than Subjective and Objective Data Collection, such as
Documentation and Education and Empathy, provide valuable
practice for their real-world counterparts. However, they are not
automatically graded by the simulation.
Question
How will I be evaluated? 02/12/19 12:40 PM
EST
In this assignment, you will be evaluated on your Subjective and
Objective Data Collection. 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. The evaluation of your physical exam requires
you only to complete all exam actions. Documentation of the exam
is optional, though encouraged, as it can provide you valuable real-
world experience. This assignment takes on average between 140
and 170 minutes. You can pause and resume the assignment at
any time; your work is always saved automatically.
Question
How does this assignment prepare me for the real world? 02/12/19 12:41 PM
EST
,Updated Solutions
In this assessment, you will become familiarized with the structure
and content of comprehensive assessments so that with real-life
patients, you can: º develop a mental model for sequencing a
comprehensive exam º ask effective and comprehensive
questions º evaluate the patients risk of disease, infection, injury,
and complications º and document data with professional
terminology.
In 1 or 2 sentences, answer this question to help prepare for the
upcoming exam: How does interviewing a healthy patient differ from
interviewing a patient with a known health condition?
In 1 or 2 sentences, answer this question to help prepare for the
upcoming exam: How does interviewing a healthy patient differ from
interviewing a patient with a known health condition?
A health assessment is individualized to each patient based on any
known health conditions, current condition and acuity. Knowing a
patient has an existing condition enables the nurse to custom tailor
the assessment, adding additional depth to the interview and Statement
assessment customized to the given disease state to seek additional 02/13/19 11:41 AM
information about effective management, symptoms, medication EST
compliance and patient perceptions of disease state while further
enabling the identification of knowledge gaps and facilitating the
provision of additional education.
Time to begin.
Question
Hello, I'm Kathleen. I'm your nurse today. 02/13/19 12:39 PM
EST
Hi.
Question
Can you please confirm your name and date of birth? 02/13/19 12:39 PM
EST
My name's Tina Jones, and my birthday's February 17th.
Question
Hi Tina. How old are you? (Clarified to How old are you?.) 02/13/19 12:40 PM
EST
I'm 28. (Clarified to what is my age.)
Question
What brought you into the clinic today? 02/13/19 12:40 PM
EST
, Updated Solutions
I came in because I'm required to have a recent physical exam for
the health insurance at my new job.
Empathize
Congrats on the new job. 02/13/19 12:40 PM
EST
Thanks.
Question
What is your new job? 02/13/19 12:41 PM
EST
Well, I'm starting my new job in two weeks, and I'm really excited
about that. I'm going to be an Accounting Clerk at this really nice
accounting firm.
Question
Are you excited or nervous about your new job? 02/13/19 12:41 PM
EST
I'm so excited about my new job. I think it's going to be a great
experience, and I can't wait to learn how to do a bunch of new
things.
Empathize
Are you having any health problems right now? 02/13/19 12:58 PM
EST
Thanks.
Question
Are you having any health issues currently? 02/13/19 12:58 PM
EST
I don't have any new problems--still just the old asthma and
diabetes.
Question
Can you list all of your current medications? 02/13/19 12:58 PM
EST
I'm taking metformin now, that's every day. And I take Yaz, the birth
control pill. And then my inhaler is the same, but that's not every day.
Question
What is your dose and frequency of metformin? 02/13/19 12:59 PM
EST
It's 850 mg. And I take one pill, twice a day.