Complex Patient Case Results
Doris Turner ShadowHealth
Patient Assessment
Finding:
Checked blood glucose before giving medication
Pro Tip: Since your patient is receiving insulin for her diabetes, it is important to assess her
blood sugar before and after administration monitor for intended therapeutic effect and
hypoglycemia.
Example Question:
Finding:
Asked sulfa reaction type
Pro Tip: Assessing the reaction type and severity of a stated allergy may help inform your
care plan and determine which medications are appropriate to administer.
Example Question:
How does your body react to sulfa?
Finding:
Asked for patient identification
Pro Tip: Proper identification is critical for the protection of your patient. It is recommended to
check two identifiers before interacting with the patient.
Example Question:
What is your name and birthday?
Finding:
Asked about general experience with side effects
Pro Tip: When administering routine medications, understanding the side effects that the
patient generally experiences can shape your care plan to ensure patient safety and comfort.
, Example Question:
What medication side effects have you experienced?
Finding:
Asked about medication allergies
Pro Tip: Patients may have allergies that are not included in their documentation, so asking
for verbal confirmation can prevent serious adverse events.
Example Question:
Do you have medication allergies?
Finding:
Checked vitals before giving medication
Pro Tip: Assessing the patient's vitals may impact your care plan and the safe administration
of ordered medications.
Example Question:
Finding:
Asked about breathing
Pro Tip: As your patient is suffering from pneumonia, it is important to assess breathing
status to identify worsening symptoms or life-threatening respiratory complications.
Example Question:
Have you had breathing problems lately?
Finding:
RLL with crackles, all other lobes clear to auscultation before medication
Pro Tip: Auscultation of your patient's lungs is important to assess for worsening symptoms
of her pneumonia.
Example Question:
Finding:
Asked about orientation to place and time
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