315 shadow health Edward Carter Unguided Intermediate Patient Case Results | Turned In Ph, Exams of Nursing

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315 shadow health Edward Carter

Unguided Intermediate Patient Case Results |

Turned In Pharmacology II - bsn_

Patient: Edward Carter

Digital Clinical Experience Score

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale

Your patient is Edward Carter, a 65-year-old African American man who has been admitted to Shadow General Hospital for back pain, blood in his urine, and increased urinary frequency. In this unguided assignment, your role is that of a practicing nurse. You must decide what data is necessary to gather during the assessment so that you may determine the safety and efficacy of his current and pending medications. What are my objectives in this assessment? In your interview with Edward Carter, you will ask about his past and present medical issues, including general symptoms and any adverse reactions to medications, so that you may better understand his pharmacological needs. You will also inquire into his current status with regards to inputs and outputs (Is and Os) which will help you determine the safety and efficacy of his medications. 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. You will also touch on the health history of Mr. Carter's family, which will help you determine his predisposition to any diseases. Throughout the conversation, you should educate and empathize with Mr. Carter when appropriate to increase his health literacy and sense of well-being. In addition to collecting subjective data during the patient interview, you will perform a physical exam on Mr. Carter to gather objective data about his health and physiology. 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. Subjective Data findings should be listed in the Nursing Admitting Note. You may complete the exam activities in any order and move between them as needed. Question 05/11/ 7:57 AM MDT What else will this exam involve? Question 05/11/ 59 AM

You will complete nursing tasks to protect the patient's safety, privacy, and health. You will assess the Orders, MAR, and labs in the Electronic Health Record to determine which medications are due. 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. After the exam, you will continue the patient's care using a Care Plan , in which you will select an appropriate diagnosis , plan a healthcare goal and interventions to achieve it , and evaluate your success. How will I be evaluated? In this assignment, you will be evaluated on your Subjective and Objective Data Collection, Education and Empathy, and your Care Plan. 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. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. The evaluation of your Care Plan is based on how successfully you identify the most appropriate diagnosis , select a meaningful healthcare goal, interventions, and data collections , and evaluate the results of your nursing actions. Other activities, such as Documentation, provide valuable practice for their real-world counterparts, but are not automatically evaluated by the simulation. This assignment takes on average 75 to 85 minutes. You can pause and resume the assignment at any time; your work is always saved automatically. Once you've finished your assignment, you will receive feedback developed by the QSEN Institute on how your performance demonstrated your clinical competency in patient MDT Question 05/11/ 8:03 AM MDT

Time to begin. Hello, My name is and I am your nurse today Hello. Could you tell me your name and date of birth please Edward Carter. January 1... [Mr. Carter reports the correct birth year.] Hi mr carter, could you tell me what your concerns and issues are (Clarified to What seems to be the problem?.) The doctor says I have a kidney stone. (Clarified to what is the matter with me.) do you know where you are at? I'm at Shadow General Hospital. When was the onset of your pain Question 05/11/ 8:05 AM MDT Question 05/11/ 8:05 AM MDT Question 05/11/ 8:06 AM MDT Question 05/11/ 8:08 AM MDT Question 05/11/ 8:08 AM MDT

The pain started three days ago. It was more subtle then, and built up over the past few days. how long has the pain been The pain first started three days ago. It was more subtle then, and built up over the past few days. what is your level of pain Right now, it's... a 2. Thank God for the medication. how often are you urinating Typically, not that often. But lately I've been urinating what seems like too often -- once an hour? where is the pain at? In my lower back -- on the left side. can you tell me what the pain feel like Question 05/11/ 8:08 AM MDT Question 05/11/ 8:09 AM MDT Question 05/11/ 8:09 AM MDT Question 05/11/ 8:09 AM MDT Question 05/11/ 8:09 AM MDT

OK, I understand. Thank you. do you have high blood pressure? Yes, I've been diagnosed with high blood pressure. how long ago were you diagnosed with high blood pressure? I was 55 -- that was ten years ago. are you taking medications for high blood pressure? Yes, I take a combo drug for blood pressure. do you have a family history of high blood pressure Now that's something I know my mother and father both had. It is important to know your family history, I am glad you know that MDT Question 05/11/ 8:12 AM MDT Question 05/11/ 8:12 AM MDT Question 05/11/ 8:12 AM MDT Question 05/11/ 8:13 AM MDT Educate 05/11/ 8:13 AM MDT

That seems sensible. have you had any heart issues? (Clarified to Do you have a history of heart problems?.) Yes, I've been diagnosed with atrial fib. (Clarified to if I have a history of heart problems.) how long ago were you diagnosed with atrial fib? I was... 61 when I got that diagnosis. Four years ago. have it giving you any issues? (No matching questions found.) has atrial fib given you any issues? (Clarified to Any family history of atrial fibrillation?.) No, no atrial fibrillation in the family... (Clarified to if I have a family history of atrial fibrillation.) do you have any known allergies>? No, I don't have any allergies. Question 05/11/ 8:14 AM MDT Question 05/11/ 8:14 AM MDT Question 05/11/ 8:14 AM MDT Question 05/11/ 8:15 AM MDT Question 05/11/ 8:15 AM MDT

do you take medications for your atrial fib Yes, I take two medications for it. do you know the name of those medications Well, there's quite a few. I take warfarin, verapamil... and Hyzaar. Sometimes I take Tums. do you have any side effects with your meds (Clarified to Are you experiencing any side effects with the dilaudid?.) I'm not sure what I should be looking for, but I don't think I've had any side effects. (Clarified to if I am experiencing side effects from the hydromorphone.) how often do you take your tums Sometimes every day... sometimes a few times a day, depending on how my heartburn comes and goes. does tums help with your heartburn (Clarified to Do you take heartburn medication?.) I take the chewable Tums. (Clarified to if I take heartburn medication.) Question 05/11/ 8:17 AM MDT Question 05/11/ 8:17 AM MDT Question 05/11/ 8:17 AM MDT Question 05/11/ 8:18 AM MDT Question 05/11/ 8:18 AM MDT

what is your typical fluid and hydration intake each day (Clarified to How is your typical fluid intake and hydration?.) I probably don't drink enough of it to be honest. Maybe a few glasses a day. I just drink if I feel thirsty, which doesn't seem to be that often. (Clarified to how my typical fluid intake and hydration is.) when was the last time you took your home meds The last time I took any of my regular medications was last night. I usually take most of them in the morning, but I didn't get a chance to yet today. Im sorry you have heartburn, those can we awful I appreciate that. Thanks. do you have a history of substance use No. I never once tried drugs. do you have a family history of substance use No. Question 05/11/ 8:18 AM MDT Question 05/11/ 8:19 AM MDT Empathize 05/11/ 8:19 AM MDT Question 05/11/ 8:20 AM MDT Question 05/11/ 8:20 AM MDT

how is your constitutional health Oh, I think my health is pretty good for a guy my age. I have some diagnosed problems, but I follow the doctor's orders and live a healthy life. are all your diagnosed problems being taken care of (No matching questions found.) lets go back to your fluid intake how much have you had in the past 24 hours (No matching questions found.) how much fluids have you had in the past 24 hours It seems like I've been drinking a lot more water ever since last night, but typically I try to drink at least a few glasses a day. are you a diabetic? No. when you urinate, does it hurt No -- Oddly, it doesn't hurt or burn when I urinate. Question 05/11/ 8:24 AM MDT Question 05/11/ 8:24 AM MDT Question 05/11/ 8:25 AM MDT Question 05/11/ 8:25 AM MDT Question 05/11/ 8:25 AM MDT Question 05/11/ 8:25 AM MDT

when was your last meal My last meal was dinner last night -- I haven't eaten yet today. are you hungry I guess I could eat a little something, but I wouldn't say I'm hungry. The pain I had earlier and this whole situation have killed my appetite. you can ask the staff for food once i am done with you I understand that. do you have any issues with your new meds I'm not sure what I should be looking for, but I don't think I've had any side effects. do you know how to take your meds Hello. Question 05/11/ 8:26 AM MDT Question 05/11/ 8:26 AM MDT Educate 05/11/ 8:26 AM MDT Question 05/11/ 8:27 AM MDT Greet 05/11/ 8:32 AM MDT

do you take meds with food (Clarified to At what time do you usually take your medications?.) I usually take them in the morning. (Clarified to when I take my medications.) what are your experience with taking mew meds I don't believe I've ever taken it before. [AUDIO COMING SOON] Mr Carter, I will begin your assessments, may i take your vital signs Do whatever you need to do. thank you for being aware of your medical needs Thank you. Assessed vitals your vitals look good Question 05/11/ 8:34 AM MDT Question 05/11/ 8:34 AM MDT Question 05/11/ 8:35 AM MDT Empathize 05/11/ 8:35 AM MDT Exam Action 05/11/ 8:35 AM MDT Educate 05/11/ 8:37 AM MDT

OK, I understand. Thank you. do you feel hot? (Clarified to Do you feel weak?.) I'm tired now, because I didn't sleep well last night. I usually have a lot of energy. (Clarified to if I feel weak.) are you having any issues breathing (Clarified to Do you have breathing problems?.) My breathing is alright. (Clarified to if I have breathing problems.) Assessed IV bag Assessed IV pump Assessed IV bag Assessed IV pump Question 05/11/ 8:38 AM MDT Question 05/11/ 8:38 AM MDT Exam Action 05/11/ 8:38 AM MDT Exam Action 05/11/ 8:38 AM MDT Exam Action 05/11/ 8:39 AM MDT Exam Action 05/11/ 8:39 AM MDT