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End of Life Shadow Health Complete (Regina Walker)- Subjective Data
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End of Life Shadow Health Complete (Regina Walker)- Subjective Data
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By: DrTOPNOTCH • 1 month ago
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End of Life Shadow Health Complete (Regina Walker)-Subjective Data
Focused Exam: End of Life Results | Turned In
Medical Surgical Nursing: Promoting Wellness in the Older Adult (Los Angeles)
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Your Results La b P a s s
Overview
Subjective Data Collection: 52 of 52 (100.0%)
Transcript
Subjective Data Collection Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
Objective Data Collection
below to reveal important information, found.
including Pro Tips and Example
Education & Empathy
Questions.
QSEN Competencies
Documentation Category Scored Items Patient Data
Not Scored
SBAR
Experts selected these topics as essential A combination of open and closed questions
Reflections
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports pain
Orientation
Established orientation Oriented to person
Oriented to place
Oriented to time
Oriented to situation
Patient Comfort and Status
Asked about fluid intake and hydration Denies current thirst
Reports very little water intake in the past
week
, Reports a few sips of ginger ale today
Asked about urinary comfort Reports last urination was around 10 AM
Denies pain or burning with urination
Asked about most recent meal Denies current hunger
Reports no food intake today
Last meal was a few bites of yogurt last
night
Asked about preferences for hospice Reports wanting to be in hospice care
care
Asked about advanced directives Reports having an advanced directive
History of Present Illness
Asked about onset and duration of pain Pain became unbearable 2 days ago
Reports pain increasing over the past 2
days
Reports experiencing some pain most of
the time
Asked about location of pain Reports bone pain
Reports pain in legs
Reports pain in ribs
Asked about characteristics of pain Describes pain as sharp
Asked about aggravating factors of pain Reports that pain is constant - no periods
of relief or worsening
Asked about treatment and relieving Reports that nothing relieves her current
factors of pain pain
Reports prescription pain pill
Asked about severity of pain Reports current pain is a 4/10
Reports pain before medication was a 9/10
Past Medical History
Asked about existing health conditions Reports stage IV breast cancer with liver
metastasis
Reports hypertension diagnosis
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