I notice a little heartburn here and there, too. Electronic Health Record. I have two medications to treat my atrial fib, and I take another for blood Adventitious Sounds: no adventitious sounds, Heart Sounds: S1 and S2 audible Rate and Rhythm: regular rate and rhythm, Location: present at midclavicular line and 5th intercostal space Indicates an item that you while medications may help urinary symptoms; and reminding the array of the symptoms' characteristics. non-pain symptom, his impaired . pdf, Fundamentals of Nursing 9th Edition Taylor Test Bank-1-10, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Health and Illness Across the Lifespan (NUR2214). Example Questions. You will also touch on the health history of Mr. Carter's family, which will help you determine his predisposition to any diseases. ), Have you had any respiratory side effects from your hydromorphone? What are the two medications you take for your Atrial fib? during the patient interview, you will perform a physical exam on Mr. Carter to gather Hello Mr Carter. frequent urination frequent urination Edward's urinary habits are impacted communication skills in interaction with patients, colleagues and members of the health Focused Exam Pain Completed Shadow Health Subjective.pdf. controlled In 1 or 2 sentences, explain how your selected interventions work to accomplish your goal. Reports recent fall d.d.d. ensures he isn't at risk for falling while Your concern about taking many In this assignment, you will become familiarized with an assessment of pharmacological symptoms so you can assess the Focused Exam Pain Results Completed Edward Carter Subjective Data Collection, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, This study resource wasshared via CourseHero.com, This study source was downloaded by 100000833497846 from CourseHero.com on 10-19-2021 18:04:48 GMT -05:00, https://www.coursehero.com/file/107815426/Focused-Exam-Pain-Results-Completed-Edward-Carter-Subjective-Data-Collectionpdf/, Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Skin Characteristics and Hair Growth: no abnormal findings, Breath Sounds: clear in all areas instead of every hour. Neurological problems? questions found. Now is my chance to help others. Do you have any existing health conditions? impact urinary habits, and produce get you some relief with your frequency. It's (Clarified to how I Patients should not be Abigail Harris is an 86-year-old Black woman who appears in the Mental Health module. Time to Complete Test: greater than 12 seconds (increased likelihood of falls), Shadow Health: Pharmacology | Unguided Interm, Shadow Health - Edward Carter - Pain - Object, 1a personal del singular l'imperfet de subjun, Shadow Health - Edward Carter - Pain - Subjec, Shadow Health - Esther Park - Cognition - Obj, Shadow Health - Regina Walker - End of Life -, Shadow Health - Esther Park - Cognition - Sub, Shadow Health - Robert Hall - Mobility - Obje, Shadow Health - Robert Hall - Mobility - Subj, The Language of Composition: Reading, Writing, Rhetoric, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses, Literature and Composition: Reading, Writing,Thinking, Carol Jago, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses. -bony swelling appropriate time to address Edward's Denies chills Have you ever had any neurological side effects from your hydromorphone? patients own perception allows you to Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination, Shadow Health Pain Transcript- Edward Carter, Shadow Health Pain Transcript- Edward Carter (MEDSURG201), MED SURG 201 Shadow Health Pain Transcript. At the end of this prebrief, you will answer a short question about the Yes, this is oxycodone. appropriate medication can symptoms and the patient's experiences of them. I'm diagnosed with chronic kidney disease, and I have some typical old and "needing to rest much more than usual" It's a medication that is used for treating severe pain like you are experiencing now. While Denies wheezing, Asked about review of systems for Nursing Diagnoses: Definitions & Classifications 2018-2020 NANDA-International, 2017 used by arrangement with Thieme Medical man stuff: high blood pressure, and atrial fib. around administering tamsulosin, The treatment for your impaired urinary elimination is centered around administering tamsulosin, a medication that can help relax your bladder, aid the passing of kidney stones, and reduce urinary frequency. Y algunos de ellos tienen cuatro patas enormes y dos cabezas, una de animal y otra de hombre. Karen. keep you here until your kidney urine, and reduce the frequency to at least every two hours instead of every hour. Some of the possible side eects you may experience is dizziness when standing up, headache, fever, and chills. Oriented to person Oriented to place Oriented to time Oriented to situation, Reports pain Reports recent fall Reports worry about worsening symptoms, Reports recent episode of severe pain started this morning Reports pain has been getting progressively worse in the last few weeks, Describes pain as aching Describes pain as "deep", Reports occasional "grating" sensation in joints, Reports current pain is a 1 Reports pain before medication was a 9, Asked about non-medication relieving factors of pain, Reports that rest typically relieves the pain Reports not using any non-medication treatments to treat this morning's pain Reports occasional use of moist heat as treatment, on hips Reports using range of motion exercises for knees Reports wearing elastic supports on knees, bilaterally Denies use of ice as treatment, Reports that exercise exacerbates pain and stiness Reports that weight bearing exacerbates pain and stiness Reports that pain and stiness are worse in the morning Reports that changes in weather exacerbate pain and stiness, Reports falling getting out of bed Reports hitting his back on bed frame Denies dizziness, syncope, or vertigo at time of, fall Denies substance use that could have related to the fall, Reports osteoarthritis diagnosis Reports hypertension diagnosis Reports chronic kidney disease diagnosis Reports atrial fibrillation diagnosis, Followed up about osteoarthritis diagnosis, Followed up about osteoarthritis symptoms and ADLs, Reports increasing problems with gait Reports increasing problems with exercise, Diagnosed at age 55 Reports belief that blood pressure is well-, controlled Reports typical blood pressure as 130/85 Reports eating a low sodium diet, Followed up about atrial fibrillation diagnosis, Diagnosed at age 61 Denies recent episodes of palpitations or problems, Denies pacemaker or surgical intervention, Reports medication for osteoarthritis Reports medications for atrial fibrillation Reports medication for hypertension Denies medication for chronic kidney disease Denies pain medication at home Denies taking vitamins Denies taking herbal supplements, Reports using a pillbox to organize medications Denies missing doses of medication Denies missing doses of medication because of, side eects Denies diculty obtaining medications because of nances Denies diculty obtaining medications because of transportation, Followed up on last dose of home medications, Reports taking naproxen at 5 am this morning to try to relieve pain Denies taking other medications today, Followed up on anticoagulant medication for atrial fibrillation, Reports taking apixaban Reports apixaban dosage: 2.5 mg Reports apixaban frequency: 1x daily Denies apixaban side eects, Followed up on calcium channel blocker medication for atrial fibrillation, Reports taking verapamil Reports verapamil dosage: 80 mg Reports verapamil frequency: 3x daily Denies verapamil side eects, Followed up on combination ARB / diuretic for hypertension, Reports taking Hyzaar (losartan and hydrochlorothiazide combination) Reports Hyzaar dosage: 100 losartan /25 mg hydrochlorothiazide Reports Hyzaar frequency: 1x daily Denies Hyzaar side eects, Followed up on oral medication for osteoarthritis, Reports taking naproxen Reports naproxen dosage: 220 mg Reports naproxen frequency: 2x daily Denies naproxen side eects, Reports that naproxen is typically eective at reducing pain Reports that naproxen is OTC, Followed up on injections for osteoarthritis, Reports injections are kenalog (triamcinolone) Reports kenalog dosage: 10 mg/mL Reports kenalog frequency: 4 times per year Reports kenalog location: Injected into each hip, and knee joint Denies side eects Reports that injections are eective in reducing, pain Reports that last injection was "at least" 3 months ago, Asked about medication administered in ER, Reports receiving morphine Reports morphine has been eective, Asked about substance use Denies recent alcohol use Denies illicit drug use Denies use of tobacco and nicotine products, Asked about relevant family history Denies family history of osteoarthritis Denies family history of kidney stones Denies family history of chronic kidney disease Denies family history of atrial fibrillation Reports father and mother had hypertension, Denies fever Denies chills Denies night sweats, Denies impaired hearing Denies vision problems, Asked about review of systems for respiratory, Denies cough Denies shortness of breath Denies dyspnea on exertion Denies wheezing, Asked about review of systems for cardiovascular, Denies chest pain Denies palpitations Denies edema Denies claudication, Asked about review of systems for gastrointestinal, Denies abdominal pain Denies diculty swallowing Denies nausea Denies vomiting Denies constipation Denies diarrhea Denies changes in stool or bowel patterns, Asked about review of systems for neurological, Reports weakness in lower extremities Reports sore lower back Denies frequent headaches Denies numbness or tingling Denies changes in coordination Denies changes in memory, Asked about review of systems for musculoskeletal, Denies predisposing traumatic injuries Reports limited range of motion in joints Denies muscle spasms, Asked about review of systems for psychological, Denies mood change Denies suicidal thoughts, Reports living at home Reports living with wife Reports appropriate levels of privacy Reports enjoying his home life Denies loneliness, Reports being able to bathe independently Reports being able to reach all parts of his body Reports being able to get out of shower safely by, Reports being able to retrieve clothing Reports being able to put on clothes Denies diculty with buttons and zippers Denies diculty tying shoes, Reports being able to get up from the toilet with support (uses bathroom sink for support) Reports being able to arrange clothing during toileting Reports being able to clean genital area without help, Reports diculty getting out of bed in the morning, Reports some diculty getting out of chairs Reports occasional use of cane to transfer, Reports full control over bowels Reports full control over bladder, Reports being fully able to eat and feed himself Reports being fully able to get food from plate to mouth Reports being able to prepare food, Reports that sleep is good Denies insomnia Denies frequent waking Denies oversleeping, Denies previous falls Denies dizziness, syncope, or vertigo, Reports some problems with gait Denies bedrest Denies use of wheelchair Reports occasional use of cane to walk Reports occasional use of furniture as support, while walking Reports occasional problems with balance because of arthritis pain, Reports that his skin seems thin Denies open wounds Denies rashes or lesions Denies bruising (may have bruising on back from, fall, but it hasn't appeared yet) Denies pruritus, Denies tooth problems and dental pain Denies issues with mouth, jaw, or gums Reports no issues with being able to chew food, Denies changes in appetite Denies feeling full quickly, Asked about eects of health on social activity, Reports that social activity has remained the same, although he has to sit through some events Reports feeling worried about reduced mobility and independence, Asked about patient's perception of health, Asked about tiredness, energy levels, and fatigue, Reports increased fatigue and low energy Describes fatigue as "having hardly any energy", and "needing to rest much more than usual" Reports fatigue occurs in the afternoons Reports fatigue for the last 3 months, Asked about recent ER visits or hospitalizations, Denies ER visits or hospitalization in the last 3 months Reports last hospitalization was 3 years ago Reports last hospitalization was for kidney stones, Help Desk (https://support.shadowhealth.com/) Terms of Service (/static/terms_of_service) Privacy Policy (/static/privacy_policy) Patents (800) 860-3241 | ()| | | (https://www.shadowhealth.com/patents), Focused Exam: Pain | Completed | Shadow Health, https://app.shadowhealth.com/assignment_attempts/9122494, Nursing Care of Older Adults - Spring 2021, NUR 260, The detailed results of your assignment attempt ar, Experts selected these topics as essential components, A combination of open and closed questions will yield, better patient data. 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