Shadow Health - Tina Jones, Health History

Diana Shadow: Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.

Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process.

Diana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre-existing conditions. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones' overall health. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. Jones' health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses.

Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation.

Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically.

Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses.

Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition.

Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%

Tina Jones: Hey.

Tina Jones: Tina Jones:.

Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me.

Tina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on.

Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit.

Tina Jones: It's throbbing and like, sharp if I try to put weight on it.

Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was!

Tina Jones: Yeah, there's definitely pus.

Tina Jones: It's... white or maybe off-white.

Tina Jones: I've been taking Advil for my foot for a few days.

Tina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it.

Tina Jones: Well, I'm here, so I guess it didn't do its job.

Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain.

Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot!

Tina Jones: Thanks.

Tina Jones: I was diagnosed when I was 24.

Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

Tina Jones: It was metformin.

Tina Jones: No, I don't take anything for my diabetes anymore.

Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills.

Tina Jones: I have a monitor at home, but to be honest I don't really use it that often.

Tina Jones: I don't know. Every hour or two when I'm awake?

Tina Jones: It's pretty good, I think. I'm not a huge health nut or anything.

Tina Jones: Yeah, lately I've definitely been much hungrier than usual.

Tina Jones: Yeah, I've lost some weight recently.

Tina Jones: I don't know what caused it, I just lost weight.

Tina Jones: I haven't had a full attack in years. But my breathing definitely acts up. . .not always. Max twice a week.

Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs.

Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]

Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too.

Tina Jones: I'm allergic to cats.

Tina Jones: For as long as I've been around.

Tina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn't doing much for me -- it would only last a couple of hours.

Tina Jones: I'm allergic to penicillin.

Tina Jones: I don't have any food allergies that I know of.

Tina Jones: Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust.

Tina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college...I'm sure I have a record somewhere at home.

Tina Jones: No.

Tina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I've been in the hospital since I was probably sixteen, though.

Tina Jones: No. I've never really had stomach or bowel problems.

Tina Jones: No. They're crazy, but nobody's diagnosed with anything.

Tina Jones: No, not that I noticed.

Tina Jones: I don't think I have any problems. I get headaches sometimes, but that's all.

Tina Jones: No.

Tina Jones: I've actually been noticing problems lately. When I'm reading or studying I'll notice that things start to get kind of blurry.

Tina Jones: My nose is fine right now. Sometimes it runs, but not very often.

Tina Jones: No.

Tina Jones: My heart's fine, thank God!

Tina Jones: No, my heart's always been fine.

Tina Jones: I haven't noticed any pain there.

Tina Jones: I don't think I have problems in that area. I just get really bad periods, that's all.

Tina Jones: No, I haven't.

Tina Jones: No.

Tina Jones: Um, I have acne, if that counts.

Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and...I'm pretty sure he had diabetes. And high cholesterol like everyone else in my family.

Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

Tina Jones: Well, he passed away. But he had a couple things... Type 2 diabetes, like me, and high cholesterol and blood pressure.

Tina Jones: He died in a car accident.

Tina Jones: It's on the ball of my foot.

Tina Jones: You know, I did notice lately that I've been really thirsty.

Tina Jones: It was last year... I guess a little over a year ago.

Tina Jones: It was last year... I guess a little over a year ago.

Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kind of depressed. So, I guess at first I just focused on getting things done--groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months.

Tina Jones: He was driving to work, and it was raining...and his car hydroplaned. And hit a tree. So, it was really sudden.

Tina Jones: Granny's doing good. She's still living on her own. She's slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy.

Tina Jones: Grandpa Jones passed away when I was really little.

Tina Jones: Well, Poppa died about five years ago.

Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.

Tina Jones: He's a healthy guy. Kind of big like me.

Tina Jones: She's pretty healthy. She has asthma too, but she almost never has attacks.

Tina Jones: No, I don't think so. My brother and my dad are kind of big, but I wouldn't say they were obese or anything.

Tina Jones: No, I don't think so.

Tina Jones: One person in the family, my dad's brother, has an alcohol problem, but we never see him.

Tina Jones: No, not that I know of.

Tina Jones: I only have a few drinks when I go out.

Tina Jones: Well, I'm finishing up my bachelor's degree right now.

Tina Jones: I feel really stressed out right now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too.

Tina Jones: Thanks.

Tina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. It's like a half hour from here.

Tina Jones: I'm Baptist. My faith is a big part of my life--when things get hard like they've been this past year, I know I can trust that God's looking out for me. I've been going to the same church since I was a kid, too, so the people at church are practically part of my family.

Tina Jones: I've never had been in any kind of situation like that... It's scary to think about.

Tina Jones: Well, I used to smoke pot. . . but I don't do that anymore.

Tina Jones: Um...I've smoked pot before. In high school, and after high school... I definitely don't anymore, though.

Tina Jones: No.

Tina Jones: I haven't smoked pot since I was twenty or twenty-one.

Tina Jones: No. I think it's gross.

Tina Jones: Some of my friend's smoke when we go out drinking. But I don't smoke, and nobody at home smokes.

Tina Jones: He died last year, so I was 27.

Tina Jones: He died in a car accident.

Tina Jones: He had high blood pressure and cholesterol. And diabetes -- we have diabetes in common.

Tina Jones: Thanks.

Tina Jones: Dad was a little stricter than Mom growing up. . . he would sometimes get kind of mad at us when we did something wrong. But he never hit us or anything. He would just get really calm and quiet and tell us to go to our rooms without supper, or that we were grounded when we were older. Or like, he'd make us rake the yard or wash his car or something. It's pretty sad to

Tina Jones: Last year when Dad passed, he was only 58.

Example Question: Do you have any pain?

Example Question: What's causing your pain?

Example Question: Can you rate the pain on a scale of 0 to 10?

Example Question: Can you please describe the pain?

Example Question: What is the pain like when you stand on your foot?

Example Question: How has the pain changed over time?

Example Question: Does the pain radiate anywhere else?

Example Question: Can you bear weight on your foot?

Example Question: Which foot is in pain?

Example Question: Where is the wound?

Example Question: How did your injury happen?

Example Question: When did your injury occur?

Example Question: Did you injure anything besides your foot?

Example Question: Were you wearing shoes when you fell?

Example Question: Have you seen a healthcare provider for this injury?

Example Question: Did your foot bleed?

Example Question: Did you notice any discharge from the wound?

Example Question: When did you first notice the pus?

Example Question: What color is the drainage from your wound?

Example Question: Does the wound have an odor?

Example Question: How often do you change your bandage?

Example Question: How often did you clean the wound?

Example Question: Did you use any ointment on the wound?

Example Question: Did the ointment help?

Example Question: Is there swelling around the wound?

Example Question: How long have you noticed swelling around the wound?

Example Question: Did you notice any redness around the wound?

Example Question: Does the wound feel warm?

Example Question: Does your injury impact your ability to walk?

Example Question: Does your foot pain affect your work?

Example Question: Has your injury prevented you from going to class?

Example Question: Do you have any existing conditions?

Example Question: Do you have any other conditions?

Example Question: At what age were you diagnosed with diabetes?

Example Question: Do you know what type of diabetes you have?

Example Question: Tell me more about any sugars you consume.

Example Question: Do you drink sugary drinks?

Example Question: Do you take prescribed medication for your diabetes?

Example Question: Have you ever taken medication for your diabetes?

Example Question: Do you remember what you were prescribed for diabetes?

Example Question: When was the last time you took your diabetes medication on a regular basis?

Example Question: Did the metformin cause any side effects?

Example Question: What's preventing you from taking your diabetes medication?

Example Question: Tell me about your blood sugar monitoring.

Example Question: How often do you check your blood sugar?

Example Question: What are your usual blood sugar levels?

Example Question: Have you been more thirsty lately?

Example Question: Are you drinking more water than normal?

Example Question: Have you been urinating more often than usual?

Example Question: How often do you urinate during the day?

Example Question: How often do you wake up at night to urinate?

Example Question: What did you eat for breakfast yesterday?

Example Question: What did you eat for lunch yesterday?

Example Question: What did you eat for your last meal?

Example Question: Have you noticed an increase in appetite?

Example Question: When did you notice the increase in your appetite?

Example Question: How long did it take you to lose 10 pounds?

Example Question: Was your weight loss intentional?

Example Question: When was your last asthma attack?

Example Question: When did you last have issues with asthma?

Example Question: What do your asthma symptoms feel like?

Example Question: Do you have trouble breathing?

Example Question: Do you ever wheeze?

Example Question: Have you been hospitalized in the past?

Example Question: Why were you hospitalized last time?

Example Question: When was your last hospitalization?

Example Question: How many times have you been hospitalized?

Example Question: Have you ever used a nebulizer?

Example Question: At what age were you diagnosed with asthma?

Example Question: How do you manage your asthma?

Example Question: What is the name of the inhaler prescription?

Example Question: When did you last use your inhaler?

Example Question: How often do you use your inhaler?

Example Question: How many puffs of your inhaler are you prescribed?

Example Question: How many puffs do you typically take?

Example Question: What's the most puffs you ever take?

Example Question: What triggers your asthma problems?

Example Question: Does dust trigger your asthma?

Example Question: Do you have seasonal asthma triggers?

Example Question: What allergies do you have?

Example Question: What is your reaction to cats?

Example Question: Are you allergic to latex?

Example Question: What medication allergies do you have?

Example Question: What is your reaction to penicillin?

Example Question: When was your last penicillin reaction?

Example Question: Do you have any food allergies?

Example Question: Do you have any reaction to dust?

Example Question: Do you have any environmental allergies?

Example Question: Do you have any seasonal allergies?

Example Question: Are your immunizations current?

Example Question: Did you receive the measles vaccine?

Example Question: Did you receive the polio vaccine?

Example Question: Did you receive the chicken pox vaccine?

Example Question: Did you receive the Hepatitis vaccine?

Example Question: Did you receive the meningitis vaccine?

Example Question: Did you receive the HPV vaccine?

Example Question: Did you get a flu shot this year?

Example Question: When was your last tetanus booster?

Example Question: What pain medication have you been taking?

Example Question: Have you taken any prescription pain medications?

Example Question: How many days have you needed pain medication?

Example Question: How many times a day do you take pain medication?

Example Question: How many pain pills do you take at a time?

Example Question: What is the dose of the pain medication?

Example Question: How effective is the pain medication?

Example Question: How long does the pain medication last?

Example Question: What prescription medications do you take?

Example Question: Do you take any over the counter medications?

Example Question: Do you take any over the counter medications?

Example Question: Do you take any supplements?

Example Question: Do you take any herbal supplements?

Example Question: What is your highest level of education?

Example Question: What do you study?

Example Question: Can you tell me about your stress level?

Example Question: Does anyone live at home with you?

Example Question: Do you live in a house?

Example Question: How many stories is your house?

Example Question: Tell me more about living at home.

Example Question: What is your religious affiliation?

Example Question: Have you experienced any type of abuse?

Example Question: Have you ever smoked marijuana?

Example Question: When did you last smoke marijuana?

Example Question: When was your last alcoholic drink?

Example Question: How many alcoholic drinks do you have in one sitting?

Example Question: How many nights a week do you drink alcohol?

Example Question: Have you ever smoked cigarettes?

Example Question: Do you vape?

Example Question: Are you ever exposed to secondhand smoke?

Example Question: Does your mother have health conditions?

Example Question: Does your mother have health conditions?

Example Question: Does your father have health conditions?

Example Question: Does your father have health conditions?

Example Question: Does your father have health conditions?

Example Question: How old was your father when he died?

Example Question: What caused your father's death?

Example Question: How are you coping with your father's death?

Example Question: How are you coping now?

Example Question: Does your paternal grandfather have health conditions?

Example Question: Does your paternal grandfather have health conditions?

Example Question: Does your paternal grandfather have health conditions?

Example Question: Have you had any family members with cancer?

Example Question: Does your paternal grandmother have health conditions?

Example Question: Does your maternal grandfather have health conditions?

Example Question: Does your maternal grandfather have health conditions?

Example Question: Does your maternal grandmother have health conditions?

Example Question: Does your maternal grandmother have health conditions?

Example Question: Does your brother have health conditions?

Example Question: Does your sister have health conditions?

Example Question: Does obesity run in your family?

Example Question: Do you have a family history of thyroid problems?

Example Question: Do you have relatives with addiction problems?

Example Question: Do you have a family history of headaches?

Example Question: Are you fatigued?

Example Question: Have you noticed changes in your sleep?

Example Question: Are you feeling feverish right now?

Example Question: Have you had chills?

Example Question: Have you had night sweats?

Example Question: Do you have a history of depression?

Example Question: Do you have a history of suicidal thinking?

Example Question: Do you ever get headaches?

Example Question: Do you have a headache?

Example Question: Have you had any head injuries?

Example Question: Has your hearing changed?

Example Question: Do you ever have ringing in your ears?

Example Question: Have you had ear pain?

Example Question: Have you had ear discharge?

Example Question: Have you noticed any changes in your vision?

Example Question: Do you wear glasses or contacts?

Example Question: Have you had itchy eyes?

Example Question: Have you had red eyes?

Example Question: Have you had eye pain?

Example Question: Have you had dry eyes?

Example Question: Do you have any nose problems right now?

Example Question: Have you had a runny nose?

Example Question: Have you had problems with your sinuses?

Example Question: Have you had nosebleeds?

Example Question: Has your sense of smell changed?

Example Question: Do you have any mouth problems?

Example Question: When did you last see a dentist?

Example Question: Has your sense of taste changed?

Example Question: Have you had dry mouth?

Example Question: Have you had mouth pain?

Example Question: Have you had mouth sores?

Example Question: Have you had gum problems?

Example Question: Have you had tongue problems?

Example Question: Have you had jaw problems?

Example Question: Have you had difficulty swallowing?

Example Question: Have you had a sore throat?

Example Question: How are your lymph nodes?

Example Question: Do you have any throat problems?

Example Question: Do you have any swollen glands?

Example Question: Have you had voice changes?

Example Question: Do you perform breast self-examinations?

Example Question: Do you have any breast swelling?

Example Question: Do you have a rash on your breasts?

Example Question: Do you have any lumps in your breasts?

Example Question: Have you experienced nipple discharge?

Example Question: Have you had a mammogram?

Example Question: Have you had breast cancer?

Example Question: Have you had breathing problems?

Example Question: Have you been wheezing?

Example Question: Have you had chest tightness?

Example Question: Does it hurt when you breathe?

Example Question: Have you been coughing?

Example Question: Do you ever have chest pain?

Example Question: Have you had palpitations?

Example Question: Has your heartbeat been irregular?

Example Question: Have you noticed bruising more than usual?

Example Question: Have you noticed any swelling in your legs?

Example Question: Do you have circulation problems?

Example Question: Have you had nausea?

Example Question: Have you been vomiting?

Example Question: Do you have stomach pain?

Example Question: Have you had changes in your bowel movements?

Example Question: Do you ever get heartburn?

Example Question: Do you have constipation?

Example Question: Do you have diarrhea?

Example Question: Does it hurt when you urinate?

Example Question: Do you wake up at night to urinate?

Example Question: Do you urinate frequently?

Example Question: Do you ever notice blood in your urine?

Example Question: Do you have flank pain?

Example Question: Have you ever had a urinary infection?

Example Question: When was your last period?

Example Question: Are your periods regular?

Example Question: Have you ever been pregnant?

Example Question: Do you experience vaginal burning?

Example Question: What is your vaginal discharge like?

Example Question: Have you ever been diagnosed with a sexually transmitted infection?

Example Question: Do you use condoms when you are sexually active?

Example Question: Are you currently on birth control?

Example Question: Do you have muscle pain?

Example Question: Do you have joint pain?

Example Question: Do you have muscle weakness?

Example Question: Do you have muscle swelling?

Example Question: Do you get dizzy?

Example Question: Do you get light-headed?

Example Question: Do you ever get tingling?

Example Question: Do you notice being more clumsy than usual?

Example Question: Do you have a loss of sensation anywhere?

Example Question: Have you ever had a seizure?

Example Question: Do you lose your balance often?

Example Question: Do you still have acne?

Example Question: Do you have facial hair?

Example Question: Do you have any skin discoloration?

xample Question: Have your moles changed?

Example Question: Do you have dandruff?

Example Question: Have you noticed any hair loss?

Example Question: Do you have nail fungus?

Example Question: Do you have dry skin?

Description: Tina expresses frustration about her level of pain. Student: How effective was the Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job. Student: Can you walk with your foot being injured? Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain. Student: What preexisting medical conditions do you have? Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot! Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. Tina Jones: Thanks. Model Statement: "I'm sorry to hear that your pain is returning. We want you to be in as little pain as possible. I can give you some Advil at this time, and in a few hours, you can have more tramadol. I can also walk through some pain management exercises with you that don't involve medication, if you are interested."

Description: Tina brings up her pain and frustration at how being unable to bear weight on her foot impacts her life. Student: What are stressors? Tina Jones: I feel really stressed out right now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too. Student: We are going to take care of everything as quickly as possible. Tina Jones: Thanks. Model Statement: "This sounds like a challenging time for you. I understand your frustration at having your life interrupted by foot pain. Please let me know if there is anything I can help you with, such as contacting your employer or asking a family member to bring your schoolwork. We'll do our best to get you feeling better and, on your way, home as soon as possible."

Description: Tina describes controlling her diabetes by avoiding "sweets." Model Statement: "Staying away from sugar is a great start. I can give you some more information on what a balanced diet looks like for someone with diabetes. For example, many starchy foods break down into glucose in the body, like pasta, and so you can eat those in moderation, too. Most people with diabetes feel better when they limit all starches, eat protein, and take regular medication."

Description: Tina reveals that she does not treat her diabetes with medication. Student: Do you currently take medicine for your diabetes? Tina Jones: No, I don't take anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Model Statement: "I understand that it can be challenging to keep up with daily medication. But it's important to keep your blood sugar under control to prevent long-term damage to your health, and medication can really help. I'd like to talk with you more about getting back onto a prescription. We could start you at a low dose, which reduces the side effects."

Description: Tina reveals that she does not check her blood sugar. Student: Do you monitor your blood glucose? Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Model Statement: "I understand how it can feel like a frustrating chore to check your sugar every day. But it is important to keeping your diabetes under control. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. And keeping your sugar down will help your foot wound heal quickly, too. If you would like, I can help you find a monitor that is as painless as possible. I can also teach you more about what the numbers mean."

Description: Tina describes increased inhaler use and decreased effectiveness, indicating that her asthma is uncontrolled. Student: How many puffs do you take when using your asthma inhaler? Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are some things that trigger your asthma? Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: What allergies do you have? Tina Jones: I'm allergic to cats. Model Statement: "It sounds like your asthma is giving you some problems, and you're not getting full relief from your inhaler. I would like to talk with you about changing your medication and your regimen, to reduce your frequent breathing problems, so that you feel better day-to-day. Most patients find that using a daily inhaler is an easy way to reduce your asthma symptoms even more."

Description: Tina shares information about her father dying. Student: Why don't you have your dad's income? Tina Jones: Um...well, my dad died in a car accident, about a year ago. Model Statement: "I'm sorry to hear about your father's passing. That sounds like a difficult situation."

Description: Tina discusses her past history of marijuana smoking. Student: Have you used illicit drugs? Tina Jones: Well, I used to smoke pot. . . but I don't do that anymore. Student: What type of drugs did you use? Tina Jones: Um...I've smoked pot before. In high school, and after high school... I definitely don't anymore, though. Student: Have you used drugs other than marijuana? Tina Jones: No. Student: When did you last use drugs? Tina Jones: I haven't smoked pot since I was twenty or twenty-one. Model Statement: "Thank you for sharing that information. It's good to hear that you no longer smoke pot. It's better for your asthma and your overall health."

Priority: High Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain. Evidence - Relevant: "...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit." "It's throbbing and like, sharp if I try to put weight on it." Evidence Pro Tip: Tina expresses pain, which is the strongest evidence for this problem. She reports intense pain on a numerical scale and describes pain characteristics. The presence of a physical injury supports her susceptibility to acute pain. Planning - Relevant: Assess - Pain: Assess the patient's pain at regular intervals and with each assessment of vital signs. Assess - Pain: Assess the patient's response to pain medication. Educate - Medication: Educate the patient on medications used for pain relief. Educate - Pain: Educate the patient on non-pharmaceutical methods to reduce pain intensity. Intervene - Pain: Administer non-pharmacologic interventions to reduce pain. Intervene - Pain: Administer prescribed analgesics to provide optimal pain relief. Planning Pro Tip: To reduce the patient's pain, assess her current rating. Provide an appropriate intervention (pharmaceutical or otherwise) and educate the patient. After an appropriate time interval, assess pain levels again to see how the intervention affected the pain.

Priority: High Priority Pro Tip: This is a high priority. The infection is the most immediate threat to the patient's health, and the wound is at risk for delayed healing because of the patient's uncontrolled blood glucose. Evidence - Relevant: Evidence Pro Tip: As Tina discusses symptoms of her wound, including symptoms such as discharge, redness, warmth, and swelling, she reports strong evidence of impaired skin integrity. Planning - Relevant: Planning Pro Tip: Because wound infections impact the patient's overall health, it's important to assess perfusion, hydration, and swelling. Assess the status of the wound itself and ensure proper cleaning and dressing per the physician's order. Prevent worsening infection by educating the patient about wound care and self-monitoring.

Priority - High Priority Pro Tip: This is a high priority. The patient is unable to bear weight on her affected leg, which prevents walking. This impacts her daily life and increases her risk for falls and deep-vein thrombosis. Evidence - Relevant: "I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on." "I got this scrape on my foot a while ago, and it got really infected. It's killing me." "No, I can't. I can't put any weight on it without like, shooting pain." Evidence Pro Tip: The strongest evidence of impaired walking is that Tina directly reports she can't bear weight or walk on her affected foot. Other supporting data points are the presence of her foot wound and her general reports of pain. Planning - Relevant: Assess - Musculoskeletal: Assess the patient's ability to bear weight and gait. Assess - Musculoskeletal: Assess the patient's mobility. Consult / Refer: Consult with physical therapist to develop a plan to improve the patient's mobility. Intervene - Mobility: Assist the patient as needed with mobility. Intervene - Mobility: Provide assistive devices to facilitate mobility (crutches, therapeutic boot to minimize pressure on plantar surface, wheelchair). Planning Pro Tip: Assess how well the patient can bear weight and walk. While the patient is in your care, work with other healthcare professionals to keep the pain managed and improve the patient's mobility. Provide assistance with activities such as toileting and ensure that the patient can access and use assistive devices.

Priority - High Priority Pro Tip: Poorly managed diabetes and uncontrolled blood glucose complicate wound healing. As the underlying cause for delayed healing and infection, they must be addressed. Evidence - Relevant: "No, I don't take anything for my diabetes anymore." "I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills." "I have a monitor at home, but to be honest I don't really use it that often." Evidence Pro Tip: Tina directly reports ineffective diabetes management when discussing her lack of treatment. She expresses gaps in health literacy about the risk of ceasing prescribed medication and blood glucose monitoring. Supporting evidence comes from her inability to incorporate meaningful dietary changes or increase her exercise. Planning - Relevant: Assess - Health Literacy and Patterns: Assess the patient's knowledge related to diabetic disease process, assess personal/social supports. Assess - Health Literacy and Patterns: Assess the patient's perceived barriers to adherence to the prescribed regimen (cost, adverse effects, lack of knowledge). Assess - Health Literacy and Patterns: Assess the patient's readiness for change/education. Educate - Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. Planning Pro Tip: To gain a deep understanding of your patient's situation, determine her level of health literacy, her feelings and beliefs about the disease, and the motivation behind her choices. Educate the patient about what risks are, and what good diabetes care looks like. Most importantly, ask about her goals and changes she may be willing to make.

Priority - High Priority Pro Tip: The patient's foot wound impairs her walking, which in turn increases her risk for falls while she is an admitted patient. Her past history of injury also adds to this risk. Evidence - Relevant: Evidence Pro Tip: The strongest evidence of Tina's fall risk is reports of being unable to bear weight or walk on her foot. Other supporting evidence is her recent injury caused by falling. Planning - Relevant: Planning Pro Tip: Protect your patient by taking all fall precautions, and educate your patient about how to be safe as she goes through her daily activities at the hospital. Make sure that the patient feels comfortable asking for your assistance.

Priority - High Priority Pro Tip: Uncontrolled blood glucose levels delay or prevent wound healing, and must be addressed to resolve the infection. Unstable blood glucose levels could increase the patient's risk for falls. Evidence - Relevant: "Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent blood glucose monitoring and a general lack of diabetes management, which increases her risk for fluctuating blood glucose levels. Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are significantly higher than her baseline. Planning - Relevant: Assess - Vitals: Assess the patient's blood glucose levels according to orders. Educate - Disease Process: Educate the patient on the signs and symptoms of hyper- and hypoglycemia. Intervene - Diet: Provide the patient a diet without concentrated sweets. Intervene - Hypoglycemia: Administer insulin and/or oral hypoglycemics, per physician orders. Planning Pro Tip: First, gauge your patient's current status by checking hydration, vital signs, and perfusion. Measure the patient's blood glucose and provide medication as per the physician's orders. While the patient is in your care, ensure that their meals align with a low glycemic diet, and educate the patient on monitoring her own health status.

Priority - Low Priority Pro Tip: A BMI greater than 30 indicates obesity, but this diagnosis is a low priority at present. Obesity is a long-term health concern that cannot be addressed in a single visit. Evidence - Relevant: "BMI: 31" Evidence Pro Tip: Tina's BMI is 31, which is in the obese range. This numerical evidence is required to establish obesity. Other contributing factors are her family history of diabetes mellitus and a lack of physical exercise. Planning - Relevant: Educate - Diet: Educate the patient on balanced nutritional intake. Educate - Disease Process: Educate the patient on health risks related to obesity. Educate - Exercise: Educate the patient about the benefits of exercise. Planning Pro Tip: To help your patient address her obesity, which is often a sensitive topic, use therapeutic communication techniques. First, gain a deep understanding of your patient's situation. Determine her level of health literacy, her feelings and beliefs related to the disease, and the motivation behind their choices. Then educate the patient on risks of obesity, recommended dietary changes, and healthy exercise.

Priority - Low Priority Pro Tip: When caring for a patient diagnosed with asthma, it's important to be aware of the possibility of emerging respiratory symptoms. However, for a patient with no active respiratory complaints, this problem does not need to be addressed immediately. Evidence - Relevant: Evidence Pro Tip: Tina's asthma puts her at general risk for breathing problems. She also reports sometimes needing more puffs to resolve symptoms. Contributing factors are a past history of hospitalization and asthma attacks, as well as sedentary lifestyle and obesity. Planning - Relevant: Planning Pro Tip: Take a general survey of the patient for changes in skin color, and assess respiratory rate, rhythm, depth, and quality to confirm there are no acute breathing issues. Gather data on the patient's breathing status by checking pulse and blood pressure. Auscultate the lungs to listen for abnormal sounds. While the patient is in your care, educate her on the cause and symptoms of shortness of breath so that she can let you know about emerging problems. Empower the patient to take part in her own care by educating her on controlled breathing techniques.

Priority - Low Priority Pro Tip: A patient's sedentary lifestyle compromises her overall health and problems such as diabetes. However, this issue is low priority for a patient with acute pain and a wound that prevents her from walking. Evidence - Relevant: Evidence Pro Tip: Tina directly reports that she doesn't exercise, which is the primary evidence for a sedentary lifestyle. She describes being too busy to exercise and reports that her primary activity is being on her feet at work, a belief which demonstrates her misunderstanding of exercise. Planning - Relevant: Planning Pro Tip: Interview the patient to determine her level of health literacy, and her attitudes and beliefs toward exercise. Educate the patient about the benefits to overall health and blood sugar control and finding an appropriate form of exercise. Ask the patient questions about what changes she may be willing to make.