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Nurs 612 Shadow Health All Modules Cases Instructor Keys
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Nurs 612 Shadow Health All Modules Cases Instructor Keys
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lOMoARcPSD|45707609Nurs 612 Shadow Health All Modules Cases Instructor Keys
, lOMoARcPSD|45707609
A DVANCED H EALTH A SSESSMENT c c
Health cHistory c- cTINA c JONES™
“ I cgot cthis cscrape con cmy cfoot ca cwhile cago, cand cI
cthought
it cwould cheal cup con cits cown, cbut cnow cit’s
clookingcpretty cnasty. cAnd cthe cpain cis ckilling cme!
Module c1 c- cHealth cHistory
Ms. cJones cis ca cpleasant, c28-year-old cobese cAfrican cAmerican csingle cwoman cwho cpresents cto
cestablish ccare cand cwith ca crecent cright cfoot cinjury. cShe cis cthe cprimary csource cof cthe chistory.
cMs. cJones coffers cinformation cfreely cand cwithout ccontradiction. cSpeech cis cclear cand ccoherent.
cShe cmaintains ceye ccontact cthroughout cthe cinterview.
Timeframe: c1 cweek cafter cfall c(Age: c28)
Reason cfor cvisit: cPatient cpresents cfor can cinitial cprimary ccare cvisit ctoday ccomplaining cof can cinfected
cfoot cwound.
Learning cObjectives
Develop cstrong ccommunication cskills
• Interview cthe cpatient cto celicit csubjective chealth cinformation cabout cher chealth cand chealth chistory
• Ask crelevant cfollow-up cquestions cto cevaluate cpatient ccondition
• Demonstrate cempathy cfor cpatient cperspectives, cfeelings, cand csociocultural cbackground
• Identify copportunities cto ceducate cthe cpatient
Document caccurately cand cappropriately
• Document csubjective cdata cusing cprofessional cterminology
• Organize cappropriate cdocumentation cin cthe cEHR
Demonstrate cclinical creasoning cskills
• Organize call ccomponents cof can cinterview
• Assess crisk cfor cdisease, cinfection, cinjury, cand ccomplications
After ccompleting cthe cassessment, cyou cwill creflect con cpersonal cstrengths, climitations, cbeliefs, cprejudices,
cand cvalues.
Module cFeatures
• Information cProcessing cActivity
• Student cPerformance cIndex c- cThis cstyle cof crubric ccontains csubjective cand cobjective cdata
ccategories. cSubjective cdata ccategories cinclude cinterview cquestions cand cpatient cdata.
cObjective cdata ccategories cinclude cexamination cand cpatient cdata.
Underlying c ICD-10 c Diagnoses
High cPriorityLow cPriority:
• Acute cpain cof cthe cfoot • Acanthosis • Menorrhagia
• Local cinfection cof cskin cnigricans • Obesity
cand csubcutaneous ctissue • Asthma • Oligomenorrhea
cof cthe cfoot • Dysmenorrhea • Polycystic covarian csyndrome
• Uncontrolled ctype c2 • Hirsutism
cdiabetes cmellitus • Hypertension
© cShadow cHealth® c062015 c|| cShadowHealth.com
Downloaded cby cGichau cCaren
**For cinstructor cuse conly** c(gichaucaren@gmail.com)
, lOMoARcPSD|45707609
History cof cPresent cIllness
One cweek cafter csustaining cthe ccut, cTina cJones cdevelops can cinfection cin cthe ccut con cthe cbottom
cof cher cfoot; cshe cseeks ctreatment cwhen cthe cinfection cstarts cto cswell cand cproduce cpus.
Day c1 c(Onset): cTina cwas cat chome, cgoing cdown cthe cback csteps, cand cshe ctripped. cShe cturned
cher cankle cand cscraped cthe cbottom cof cher cfoot. cThe cwound cbled, cbut cshe cstopped cthe
cbleeding cquickly cand ccleaned cthe cwound. cShe cworried cthat cshe chad csprained cher cankle, cand
cher cmom cdrove cher cto cthe cER. c(“a cweek cago”)
The cER cdid can cxray c(no cbroken cbones), cgave cher ca cprescription cfor cTramadol, cand csent cher chome. cIn
cthe cfollowing cdays,
her cankle cseemed cfine c not cas cserious cas cshe cthought.
Day c2 c- c4: cShe ccleaned cthe cwound cdutifully, ctwice ca cday, cwith csoap cand cwater cor chydrogen
cperoxide, clet cit cdry, cput cNeosporin con cit, cand cbandaged cit. cThe cwound cwasn’t cgetting cworse,
cbut cit cwasn’t chealing, ceither. cShe cexpresses cthat cshe c“took creally cgood ccare cof cit.” cTina cwas
cable cto cgo cto cwork cand cattend cschool.
Day c4: cTina cwent cto cher ccousin’s chouse, cwhere cshe cencountered ccats cand cexperienced
cwheezing. cShe ctried ctwo cpuffs con cher calbuterol cinhaler, cand cshe chad cto cdo ca cthird cpuff. c(“three
cdays cago”)
Day c5 c- c6: cTina cnoticed cpus cin cthe cwound, cand cswelling, credness cand ca cwarm cfeeling cin cher
cfoot. cHer cpain cincreased cto cthe cpoint cshe cwas cunable cto cwalk. cShe cbegan cto ctake cthe
cTramadol cto ctry cto cmanage cthe cpain, cbut cit cdidn’t cresolve cthe cpain ccompletely. cShe cmissed
cclass cand cwork. c(“two cdays cago”)
On cthe cnight cof cDay c6: cTina cstarted cto crun ca cfever. cThey ctook cher ctemperature cat chome, cand ci
cwas c102. c(“last cnight”)
Morning cof cDay c7: cTina cfinally crecognizes cthat cher cfoot cinfection cis cnot cgoing cto cget cbetter, cand
cher cmom ctakes cher cto
the cnurse cpractitioner cto cget cthe cfoot clooked cat.
Subjective cand cObjective cModel cDocumentation
Printable c“Answer cKey” cavailable cwithin cthe cShadow cHealth cDCE.
Chief cComplaint
• Symptoms c- cFoot cpain cand cdischarge
• Diagnosis c- cInfected cfoot cwound
Vitals
• Weight c(kg) c- c88 • Denies cfood cand clatex callergies
• BMI c- c30.5 • Allergic cto ccats cand cdust. cWhen cshe cis
• Heart cRate c(HR) c- c82 cexposed cto callergens cshe cstates cthat cshe chas
crunny cnose, citchy cand cswollen ceyes, cand
• Respiratory cRate c(RR) c- c16
cincreased casthma csymptoms.
Medications
1. Acetaminophen c500-1000 cmg cPO cprn
c(headaches)
2. Ibuprofen c600 cmg cPO cTID cprn c(menstrual
ccramps)
3. Tramadol c50 cmg cPO cBID cprn c(foot cpain)
Allergies
• Penicillin: crash
Downloaded cby cGichau cCaren
c(gichaucaren@gmail.com)
, lOMoARcPSD|45707609
• Pulse cOximetry c- c99%
• Blood cPressure c(BP) c- c139/87
• Blood cGlucose c- c117 4. Albuterol c90 cmcg/spray cMDI c2 cpuffs cQ4H cprn
• Temperature c(F) c- c98.9 c(last
use: c“a cfew cmonths cago”)
© cShadow cHealth® c062015 c|| cShadowHealth.com
**For cinstructor cuse conly**
Page c1 cof c3
Downloaded cby cGichau cCaren
c(gichaucaren@gmail.com)
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