. stones are passed. Do I have your consent to move ahead with this plan? Denies shooting or sharp pain Coupling your personal assessment of the patient's urinary habits with the patients own perception allows you to identify discrepancies in both of your accounts. with any of his current or ordered improve the quality and safety of your work as a nurse but does not affect your evaluation. Electronic Health Record. Oriented to situation, Established chief complaint Reports pain Other activities, such as Documentation, provide valuable practice for their real-world Denies frequent headaches pharmacotherapeutics to promote adherence and safety Utilize therapeutic Left: Extension: reduced extension, Capillary Refill Time: less than 2 seconds, Initiation of Gait: hesitancy or multiple attempts to start Denies recent episodes of palpitations or Write the letter of your answer, and identify the type of relationship being expressed. Read more Shadow Health: Mobility Focused Exam Flashcards | Quizlet Start studying Shadow Health: Mobility Focused Exam. It helped me a lot to clear my final semester exams. Adduction: reduced hip adduction, Right: Flexion: reduced flexion Reports that pain and stiffness are worse in the clinical competency in patient safety and quality care. volume, or stones) and compare keep you here until your kidney Oriented to time 3.4.1.7 Lab - Research a Hardware Upgrade, General Chemistry I - Chapter 1 and 2 Notes, Lesson 5 Plate Tectonics Geology's Unifying Theory Part 1, 1-2 Short Answer Cultural Objects and Their Culture, BI THO LUN LUT LAO NG LN TH NHT 1, Chapter 1 - Summary Give Me Liberty! informed decision about their tweak your plan if necessary. completely valid. I's and O's to know if he is Care plan - Lecture notes Health and Illness Across the Lifespan, Return to Assignment (/assignments/432434/). How does this assignment prepare me for the real world? habits are assessed, his urinary Patients should not be With my selected interventions, Asked about severity of pain. morning Describes fatigue as "having hardly any energy" reducing pain Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor. . picture of possible side effects therapeutic communication. Question. 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), Unguided Intermediate Patient Case Results | T, Pharmacology - Remediation/Refresher - January 2021, CCE 705 and 701, Nursing Diagnoses: Denitions & Classications 2018-2020 NANDA-International, 2017 used by arrangement with Thieme Medical, Publishers, Inc., a division of the Thieme Group. frequency is reduced and his While Mr. Carter is very likely to have difficulty toileting given his impaired mobility, a Toileting Self-Care Deficit diagnosis would not take priority over a Chronic Pain diagnosis. pain level is 2/10 and he says 1. 28 terms. urinary system back on track. in with you about your urinary I find Docmerit to be authentic, easy to use and a community with quality notes and study tips. Add to Cart. Denies pacemaker or surgical intervention, Reports that naproxen is typically effective at Left: Amplitude: 2+ expected, Observations at Rest (Arms and Hands at Patient's Sides): able to perform without difficulty; no tremor headache, fever, and chills. Oriented to place Hello Mr Carter. Why might Moctezuma think they were gods? Devry University ___________________________________________, Email & Social Media Marketing by VerticalResponse, Information About the Coronavirus (COVID-19), Violet and White Modern Sales Presentation, QSEN Institute Regional Center at Jacksonville University, Jane Barnsteiner & Joanne Disch QSEN Innovation Award, Home Health Nursing: A QSEN Approach With Resources, TeamSTEPPS Resources for QSEN from AHA Team Training, Just Culture Assessment Tool Nursing Education, Chasing Zero: Winning the War on Healthcare Harm, The Lewis Blackman Story Student Feedback, 2020 QSEN International Forum Postponed, Start-up for Healthcare Quality and Safety, 1ST ANNUAL SUMMIT ON LEADERSHIP AND QUALITY IMPROVEMENT, Nurse Leadership and Management: Foundations for Effective Administration, Quality and Safety Education for Nurses (QSEN) Institute, Esther Park CognitionMichelle Slater, DNP, RN Nurse Manager, Specialty Clinics, Cleveland VA Medical Center, Robert Hall Mobility Aniko Kukla, DNP, RN, Quality Manager, Salinas Memorial Health System, Patricia Young Infection Gerry Altmiller, EdD, APRN, ACNS-BC Professor, The College of New Jersey, Director of the QSEN Regional Center at The College of New Jersey, Edward Carter Pain Mary Jo Krivanek, DNP, RN, Clinical Nurse Educator, Patient Care Administration, South West General Hospital, Ohio, Regina Walker End of Life Nadine Marchi, DNP, RN QSEN Teaching Strategy Coordinator, Abigail Harris Depression Evanne Juratovac, PhD, RN, Associate Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, John Larsen Anxiety Alaa Mahsoon, MSN, RN, Doctoral Student, Frances Payne Bolton School of Nursing, Case Western Reserve University, Nicole Diaz PTSD Susan E. Phillips DNP, MPH, APRN, Psychiatric Clinical Nurse Specialist, COPS Psychiatric APRN Supervisor, New Philadelphia CBOC, Cleveland VA Medical Center, Ohio, Eric Ford Schizophrenia Amanda Eymard, DNS, CNE, RN, Associate Professor, Nicholls State University College of Nursing, Rachel Adler Alcohol Abuse Cynthia Danko, DNP, RN Assistant Professor and Institutional Researcher Frances Payne Bolton School of Nursing, Case Western Reserve University. retaining any fluid, and hopefully sarah_wesner3. While Focused Exam Pain Results Completed Edward Carter Subjective Data Collection - NRSE 330 - Studocu 6:17 pm focused exam: pain completed shadow health shadow health will be undergoing scheduled maintenance on september 24th, 2021 between 07:00 am et and 07:30 DismissTry Ask an Expert Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew found. Pain improved with oxycodone. I have some diagnosed problems, but I Denies difficulty with buttons and zippers 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.