NURSE 220 Unguided Intermediate Patient Case Results McHenry County College

NURSE 220 Unguided Intermediate Patient Case Results McHenry County College Intermediate Patient Case Results Edward Carter ShadowHealth Finding: Asked about orientation Finding: Oriented to own person (Available) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to state their name so you can determine their cognitive functioning. Example Question: Can you tell me who you are? Finding: Oriented to place (Available) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to identify where they are so you can determine their cognitive functioning. Example Question: Do you know where you are right now? Finding: Oriented to situation ( ) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to identify their reason for being here so you can determine their cognitive functioning. Example Question: Do you know why you are here today? Finding: Oriented to time (Available) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to identify the date and year so you can determine their cognitive functioning. Example Question: What is the date and year? When did you start seeing blood in your urine? Finding: Reports pain has been constant (Available) Pro Tip: Determining patterns of pain helps you understand patient context; constant pain can affect a patient's ability to answer questions or make decisions. Example Question: Is your pain constant? Finding: Followed up on urinary frequency Finding: Reports urinating about once an hour ( ) Pro Tip: Asking a patient with increased urinary frequency how often they use the bathroom allow you to assess the condition's potential causes and its affect on the patient. Example Question: How often do you urinate? Finding: Reports waking up to use the bathroom (Available) Pro Tip: Asking a patient with increased urinary frequency if they use the bathroom at night allow you to assess the condition's potential causes and its affect on the patient. Example Question: Do you have to wake up to urinate? Finding: Reports waking up four to five times a night to use the bathroom (Available) Pro Tip: Asking a patient with increased urinary frequency how often they use the bathroom at night allow you to assess the condition's potential causes and its affect on the patient. Example Question: How many times a night do you have to wake up to urinate? Finding: Asked about location of pain Finding: Reports pain is in lower left side (flank pain) ( ) Pro Tip: Establishing the location of a patient's pain can provide insight into its cause, and help you determine if the pain progresses or migrates. Example Question: Where is your pain? Finding: Denies radiating pain (Available) Pro Tip: Determining if a patient's pain radiates can indicate its cause or the course of an infection. Example Question: Does the pain radiate? Finding: Asked about characteristics of pain Finding: Describes pain as sharp and shooting ( ) Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain. Example Question: How would you describe your pain? Finding: Asked about aggravating factors of pain Finding: Reports nothing makes the pain worse ( ) Pro Tip: Aggravating factors are conditions that worsen a patient's pain, such as activities of living like eating or movement. Identifying these conditions helps you avoid them while the patient is in your care. Example Question: Does anything make your pain worse? Finding: Asked about treatment and relieving factors of pain Finding: Denies home treatment of pain ( ) Pro Tip: Discovering how a patient has been medicating for pain at home is essential to prevent contraindications during hospital treatment. Example Question: Did you try to treat your pain at home? Finding: Reports hydromorphone has significantly reduced pain ( ) Pro Tip: It's important to understand which treatments are effective for relieving a patient's pain. Example Question: What relieves your pain? Finding: Asked about severity of pain Finding: Reports current pain level is 2/10 ( ) Pro Tip: Asking your patient to rate his pain on a scale of 0 to 10 will give you data to determine if the patient needs pain medication, and if so, which drug and dose. Example Question: Can you rate your current pain level on a scale of 0 to 10? Finding: Reports pain level before medication was a 9/10 ( ) Pro Tip: A patient's pain level without medication can help you understand patterns of pain, and give context to why a patient may be prescribed certain types of powerful painkillers. Example Question: