Focused Exam: End of Life | Completed | Shadow Health 3/1/20, 7:41 PM
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Focused Exam: End of Life Results | Turned In
Medical Surgical Nursing: Promoting Wellness in the Older Adult - January 2020, nurs201-da_nurs201_202001spi_befghjk
Return to Assignment (/assignments/304563/)
Your Results Lab Pass (/assignment_attempts/6051807/lab_pass.pdf)
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er as
Overview
Subjective Data Collection: 49 of 52 (94.2%)
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Transcript
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Subjective Data Collection
Indicates an item that you
Objective Data Collection
rs e Hover To Reveal...
found.
ou urc
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
QSEN Competencies
Example Questions.
o
Documentation
aC s
SBAR
vi y re
Category Scored Items Patient Data
Reflections
Not Scored
Student Survey Experts selected these topics as essential components A combination of open and closed questions will yield
of a strong, thorough interview with this patient. better patient data. The following details are facts of the
ed d
patient's case.
ar stu
Chief Complaint
Established chief complaint Reports pain
is
Th
Orientation
Established orientation Oriented to person
sh
Oriented to place
Oriented to time
Oriented to situation
Patient Comfort and Status
Asked about fluid intake and hydration Denies current thirst
https://westcoast.shadowhealth.com/assignment_attempts/6051807 Page 1 of 6
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, Focused Exam: End of Life | Completed | Shadow Health 3/1/20, 7:41 PM
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 care Reports wanting to be in hospice care
Asked about advanced directives Reports having an advanced directive
History of Present Illness
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Asked about onset and duration of pain Pain became unbearable 2 days ago
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Reports pain increasing over the past 2 days
Reports experiencing some pain most of the time
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o.
Asked about location of pain Reports bone pain
rs e Reports pain in legs
Reports pain in ribs
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Asked about characteristics of pain Describes pain as sharp
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aC s
Asked about aggravating factors of pain Reports that pain is constant - no periods of relief
vi y re
or worsening
Asked about treatment and relieving factors of Reports that nothing relieves her current pain
pain Reports prescription pain pill
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ar stu
Asked about severity of pain Reports current pain is a 4/10
Reports pain before medication was a 9/10
is
Past Medical History
Th
Asked about existing health conditions Reports stage IV breast cancer with liver
metastasis
Reports hypertension diagnosis
sh
Asked about allergies Denies general allergies
Denies latex allergy
Asked specifically about medication allergies Reports allergy to penicillin
https://westcoast.shadowhealth.com/assignment_attempts/6051807 Page 2 of 6
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