Description

Shadow Health: Renal System Hourly Rounds Arturo Perez

Assignment Description: This assignment provides the opportunity to conduct a renal-related visit with a patient in a medical surgical setting. You will interview and examine the patient, document your findings, and complete nursing care activities.

• Estimated Time to Complete: 60 minutes

• •  Results At Completion: Your faculty has chosen to make your detailed results available as soon as you complete this assignment.
  •  First ‘Turn In’: The first attempt you complete will be turned in to your instructor automatically.

  Solution:Shadow Health: Renal System Hourly Rounds Arturo Perez

  

  

• Category

  Scored Items

  Experts selected these topics as essential components of a strong, thorough interview with this patient.

  Patient Data

  Not Scored

  A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

  Patient Check In

  • 
    

    Finding:

    Asked about chief complaint

  • 
    

    Finding:

    Reports shortness of breath

    (Found)

    Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.

    Example Question:

    What brings you to the hospital?
  • 
    

    Finding:

    Reports swelling

    (Found)

    Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.

    Example Question:

    What brings you to the hospital?

  History of Present Illness

  • 
    

    Finding:

    Asked about onset of symptoms

  • 
    

    Finding:

    Reports shortness of breath started within the last day

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    When did your shortness of breath begin?
  • 
    

    Finding:

    Reports swelling started within the last day

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    When did your swelling begin?
  • 
    

    Finding:

    Asked about location of symptoms

  • 
    

    Finding:

    Reports swelling in lower extremities

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    Where is your swelling located?
  • 
    

    Finding:

    Asked about aggravating factors for symptoms

  • 
    

    Finding:

    Reports symptoms exacerbated by activity

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    What makes your symptoms worse?
  • 
    

    Finding:

    Reports shortness of breath exacerbated by lying down

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    What makes your shortness of breath worse?
  • 
    

    Finding:

    Asked about relieving factors for symptoms

  • 
    

    Finding:

    Reports shortness of breath relieved some by sitting up

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    What relieves your shortness of breath?
  • 
    

    Finding:

    Reports swelling alleviated some by elevation

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    What relieves your swelling?
  • 
    

    Finding:

    Asked about duration of symptoms

  • 
    

    Finding:

    Reports shortness of breath is constant

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    When does your shortness of breath occur?
  • 
    

    Finding:

    Reports swelling is constant

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    When does your swelling occur?
  • 
    

    Finding:

    Asked about pain

  • 
    

    Finding:

    Denies pain

    (Found)

    Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location or timing of their symptoms.

    Example Question:

    Are you in any pain?

  Past Medical History

  • 
    

    Finding:

    Asked about existing health conditions

  • 
    

    Finding:

    Reports diabetes

    (Found)

    Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

    Example Question:

    What existing health conditions do you have?
  • 
    

    Finding:

    Reports hypertension

    (Found)

    Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

    Example Question:

    What existing health conditions do you have?
  • 
    

    Finding:

    Reports coronary artery disease

    (Found)

    Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

    Example Question:

    What existing health conditions do you have?
  • 
    

    Finding:

    Reports end-stage renal disease

    (Found)

    Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

    Example Question:

    What existing health conditions do you have?
  • 
    

    Finding:

    Asked about diabetes type

  • 
    

    Finding:

    Reports type 2 diabetes

    (Found)

    Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

    Example Question:

    What type of diabetes do you have?
  • 
    

    Finding:

    Asked about allergies

  • 
    

    Finding:

    Denies food allergies

    (Available)

    Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

    Example Question:

    Do you have any food allergies?
  • 
    

    Finding:

    Denies environmental allergies

    (Available)

    Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

    Example Question:

    Do you have any environmental allergies?
  • 
    

    Finding:

    Denies latex allergy

    (Available)

    Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

    Example Question:

    Are you allergic to latex?
  • 
    

    Finding:

    Denies medication allergies

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