Description

Shadow Health:Complex Assessment: End Stage Heart Failure Vandana Kumar

Assignment Description: This assignment provides the opportunity to conduct a focused assessment with a patient in an emergency department setting. You will interview and examine the patient, document your findings, select a suspected problem, and complete a provider SBAR. On average, this assignment should take 60 minutes to complete. This assignment may contain synthesized voices.

• 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.

  Patient Exam In this assignment, you will conduct a focused assessment on a patient in an emergency department setting. You will interview and examine the patient, document your findings, formulate a diagnosis, and deliver an SBAR. On average, this assignment should take 60 minutes to complete.

  Solution: Shadow Health:Complex Assessment: End Stage Heart Failure Vandana Kumar

  

   

  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 at rest

    (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 in to the hospital?
  • 
    

    Finding:

    Reports low appetite

    (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 in 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 in to the hospital?
  • 
    

    Finding:

    Reports discomfort

    (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 in to the hospital?
  • 
    

    Finding:

    Reports difficulty breathing

    (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 in to the hospital?
  • 
    

    Finding:

    Asked about orientation

  • 
    

    Finding:

    Oriented to place

    (Found)

    Pro Tip: Asking a patient to orient themselves in time and space will help you assess their current condition and determine if any immediate interventions would be required.

    Example Question:

    Do you know where you are?
  • 
    

    Finding:

    Oriented to time

    (Available)

    Pro Tip: Asking a patient to orient themselves in time and space will help you assess their current condition and determine if any immediate interventions would be required.

    Example Question:

    Do you know what time it is?
  • 
    

    Finding:

    Oriented to person

    (Available)

    Pro Tip: Asking a patient to orient themselves in time and space will help you assess their current condition and determine if any immediate interventions would be required.

    Example Question:

    Can you tell me your name?
  • 
    

    Finding:

    Oriented to situation

    (Found)

    Pro Tip: Asking a patient to orient themselves in time and space will help you assess their current condition and determine if any immediate interventions would be required.

    Example Question:

    Do you know why you are here?
  • 
    

    Finding:

    Asked about pain level

  • 
    

    Finding:

    Denies pain

    (Found)

    Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical and comfort needs met.

    Example Question:

    Are you in any pain?
  • 
    

    Finding:

    Asked about cultural or spiritual needs

  • 
    

    Finding:

    Reports wanting a female care provider present

    (Found)

    Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical and comfort needs met.

    Example Question:

    Do you have any spiritual needs I can assist with?
  • 
    

    Finding:

    Asked about preferences for hospice care

  • 
    

    Finding:

    Reports wanting to be in hospice care

    (Available)

    Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical and comfort needs met.

    Example Question:

    Should you be near death would you rather die in hospice care?
  • 
    

    Finding:

    Followed up on hospice preferences

  • 
    

    Finding:

    Reports wanting hospice care at home

    (Found)

    Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical and comfort needs met.

    Example Question:

    Do you have any preferences for your hospice care?
  • 
    

    Finding:

    Denies wanting medication that compromises mental acuity

    (Found)

    Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical and comfort needs met.

    Example Question:

    Do you have any preferences for your hospice care?

  History of Present Illness

  • 
    

    Finding:

    Asked about onset of symptoms

  • 
    

    Finding:

    Reports exacerbation began 2 weeks ago

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms, asking a wide variety of follow-up questions can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    When did your symptoms begin?
  • 
    

    Finding:

    Asked about aggravating factors

  • 
    

    Finding:

    Reports exertion aggravates shortness of breath

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms, asking a wide variety of follow-up questions can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    Does anything aggravate your symptoms?
  • 
    

    Finding:

    Reports eating aggravates shortness of breath

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms, asking a wide variety of follow-up questions can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    Does anything aggravate your symptoms?
  • 
    

    Finding:

    Asked about relieving factors

  • 
    

    Finding:

    Reports rest slightly relieves condition

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms, asking a wide variety of follow-up questions can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    Does resting relieve your symptoms?
  • 
    

    Finding:

    Asked about treatment

  • 
    

    Finding:

    Reports resting constantly

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms, asking a wide variety of follow-up questions can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    What treatment have you tried?
  • 
    

    Finding:

    Reports medication for chronic conditions

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms, asking a wide variety of follow-up questions can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    What treatment have you tried?
  • 
    

    Finding:

    Asked about timing of symptoms

  • 
    

    Finding:

    Reports symptoms are constant

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms, asking a wide variety of follow-up questions can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    When do your symptoms occur?
  • 
    

    Finding:

    Followed up on treatment

  • 
    

    Finding:

    Denies that medication for chronic conditions treats current symptoms

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms, asking a wide variety of follow-up questions can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    Has your treatment been effective?
  • 
    

    Finding:

    Reports feeling tired after sleeping

  

• 
• 

Add to cart to get subjective data, objective data, provider call, family conversation, suspected problem, and actvity debrief

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