Description

Shadow Health: Complex Assessment: Generalized Weakness Minerva Garcia

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.

  Solution: Shadow Health: Complex Assessment: Generalized Weakness Minerva Garcia

  

   

• 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 feeling sick

    (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:

    How are you feeling?
  • 
    

    Finding:

    Asked about orientation

  • 
    

    Finding:

    Oriented to place

    (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 where you are?
  • 
    

    Finding:

    Not 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:

    Not oriented to situation

    (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 why you are here?
  • 
    

    Finding:

    Asked about pain level

  • 
    

    Finding:

    Denies current pain

    (Found)

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

    Example Question:

    Are you in any pain?
  • 
    

    Finding:

    Asked about cultural or spiritual needs

  • 
    

    Finding:

    Reports wanting a rosary

    (Found)

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

    Example Question:

    Do you have any spiritual needs I can assist with?

  History of Present Illness

  • 
    

    Finding:

    Asked about elimination

  • 
    

    Finding:

    Reports difficulty urinating

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    Are you having any trouble urinating?
  • 
    

    Finding:

    Asked about onset of symptoms

  • 
    

    Finding:

    Reports sickness started two days ago

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    When did you start to feel sick?
  • 
    

    Finding:

    Asked about location of symptoms

  • 
    

    Finding:

    Reports lower abdominal discomfort

    (Available)

    Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    Where are your symptoms located?
  • 
    

    Finding:

    Reports feeling sick all over

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    Where are your symptoms located?
  • 
    

    Finding:

    Asked about aggravating factors

  • 
    

    Finding:

    Denies any aggravating factors

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This 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 applying heating pad

    (Found)

    Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

    Example Question:

    Does anything relieve your symptoms?
  • 
    

    Finding:

    Asked about timing of symptoms

  • 
    

    Finding:

    Reports symptoms are constant

• Add to cart to get subjective data, objective data, reassessment, suspected problem, and SBAR

Related:Completed) Shadow Health: Complex Assessment: Unresponsive Taylor Herndon