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Tina Jones: Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Self- Reflection$9.09
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Tina Jones: Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Self- Reflection
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Tina Jones: Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Self- Reflection
tina jones transcript subjective data collection objective data collection education amp empathy documentation information processing health history tips and tricks self reflection
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Shadow Health: Patient Tina Jones:
Transcript Subjective Data Collection
Objective Data Collection Education &
Empathy Documentation Information
Processing Health History Tips and
Tricks Self-
Reflection
Shadow Health – Tina Jones, Health History
Health History Tips …
& Tricks:
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 Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been
situation? 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 pr ocess.
,Student: What are my Diana Shadow: A health history requires you to ask questions related to Ms. Jones’ past and present
objectives in this health, from her current foot wound to her pre-existing conditions. You will also want to review Ms.
assessment? 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 Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You
this exam involve? 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 Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as
evaluated? 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 acti vity. 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 Diana Shadow: In this assessment, you will become familiarized with the structure and content of a
assignment prepare me health history exam so that with real-life patients, you can: º ask effective and comprehensive
for the real world? 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 Student: So that you understand if there are any problems related to their chief complaint. Also, to help
sentences, answer this treat their current condition.
question to help prepare
for the upcoming exam:
Why is it important to
obtain a patient’s
complete health history?
Diana Shadow: Time to …
begin.
Patient Exam – Vital Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood
Signs: pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%
Patient Exam – …
Interview:
Student: Hello, my name Tina Jones: Hey.
is Catlain, I am your
nurse today.
,Student: Can you Tina Jones: Tina Jones:.
confirm your name?
Student: Why did you Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It’s killing me.
come in today?
Student: What additional 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
symptoms have you that going on.
experienced?
Student: Can you rate Tina Jones: …Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit.
your current pain level
on a scale of 0 to 10?
Student: Please describe Tina Jones: It’s throbbing and like, sharp if I try to put weight on it.
the pain.
Student: How did you Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off
hurt your foot? the bottom step and it got all scraped up. I didn’t realize how sharp the edge was!
Student: Has your foot Tina Jones: Yeah, there’s definitely pus.
been draining any
liquids?
Student: What color was Tina Jones: It’s… white or maybe off-white.
the pus?
Student: How have you Tina Jones: I’ve been taking Advil for my foot for a few days.
treated the wound?
Student: What did you Tina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it.
do to treat your foot after
your accident?
Student: How effective Tina Jones: Well, I’m here, so I guess it didn’t do its job.
was the Neosporin?
Student: Can you walk Tina Jones: No, I can’t. I can’t put any weight on it without like, shooting pain.
with your foot being
injured?
Student: What Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot!
preexisting medical
conditions do you have?
Student: I understand Tina Jones: Thanks.
your foot hurts, but I
need to know this
information to make sure
I take care of the
problem correctly.
Student: When were you Tina Jones: I was diagnosed when I was 24.
diagnosed with
diabetes?
Student: What do you do Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up,
to manage your asthma? I just use my inhaler.
Student: What Tina Jones: It was metformin.
medications did you take
for your diabetes?
Student: Do you Tina Jones: No, I don’t take anything for my diabetes anymore.
currently take medicine
for your diabetes?
Student: What made you Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming,
stop taking medication remembering to take pills and check my sugar. I feel a lot better now that I’m just eating healthier than I
for your diabetes? did when I was taking the pills.
Student: Do you monitor Tina Jones: I have a monitor at home, but to be honest I don’t really use it that often.
your blood glucose?
Student: How frequently Tina Jones: I don’t know. Every hour or two when I’m awake?
do you urinate?
Student: What is your Tina Jones: It’s pretty good, I think. I’m not a huge health nut or anything.
current diet?
, Student: Have you had Tina Jones: Yeah, lately I’ve definitely been much hungrier than usual.
any change in appetite?
Student: Has your weight Tina Jones: Yeah, I’ve lost some weight recently.
changed?
Student: Do you know Tina Jones: I don’t know what caused it, I just lost weight.
why you lost weight?
Student: How often do Tina Jones: I haven’t had a full attack in years. But my breathing definitely acts up. . .not always. Max
you have asthma twice a week.
exacerbations?
Student: What asthma Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can’t take in air, like I
symptoms have you can’t get enough air into my lungs.
experienced?
Student: How many Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with
puffs do you take when Pharmacy: albuterol 90mcg/spray MDI]
using your asthma
inhaler?
Student: What are some Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad,
things that trigger your too.
asthma?
Student: What allergies Tina Jones: I’m allergic to cats.
do you have?
Student: When did you Tina Jones: For as long as I’ve been around.
realize you were allergic
to cats?
Student: How effective Tina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking
was your pain Advil. For the past few days, the Advil wasn’t doing much for me — it would only last a couple of hours.
medication at home?
Student: What Tina Jones: I’m allergic to penicillin.
medication allergies do
you have?
Student: What food Tina Jones: I don’t have any food allergies that I know of.
allergies do you have?
Student: Are you allergic Tina Jones: Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust.
to dust, mold, or pollen?
Student: What Tina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required
immunizations have you ones when I was a kid, and for college…I’m sure I have a record somewhere at home.
received?
Student: Have you Tina Jones: No.
received a flu vaccine?
Student: Have you had Tina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. This is the
any prior first time I’ve been in the hospital since I was probably sixteen, though.
hospitalizations?
Student: Have you had Tina Jones: No. I’ve never really had stomach or bowel problems.
any gastrointestinal
problems?
Student: Do you have a Tina Jones: No. They’re crazy, but nobody’s diagnosed with anything.
family history of
psychiatric illness?
Student: Do you have Tina Jones: No, not that I noticed.
any neck, throat or gland
problems?
Student: Do you have Tina Jones: I don’t think I have any problems. I get headaches sometimes, but that’s all.
any problems with your
head?
Student: Any problems Tina Jones: No.
with your ears?
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