NURSING 301 Shadow Health HEENT Transcript NEWEST, Exams of Nursing

Download NURSING 301 Shadow Health HEENT Transcript NEWEST and more Exams Nursing in PDF only on Docsity! NURSING 301 Shadow Health HEENT Transcript NEWEST NURSING 301 Shadow Health HEENT Transcript NEWEST 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. You may complete the exam activities in any order and move between them as needed. What else will this exam involve? You will complete nursing tasks to protect the patients safety, privacy, and health. 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. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation. How will I be evaluated? Question 11/01/20 5:12 PM EST Question 11/01/20 5:13 PM EST In this assignment, you will be evaluated on your Subjective and Objective Data Collection. 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. This assignment on average takes between 60 and 75 minutes. You can pause and resume the assignment at any time; your work is always saved automatically. How does this assignment prepare me for the real world? In this assessment, you will become familiarized with the structure and content of HEENT exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient's risk of disease, infection, injury, and complications º and obtain and assess objective data. Question 11/01/20 5:14 PM EST I'm 28. I am going to lift your bed rails to ensure your safety. Thanks for telling me. I am going to check your vitals. Educate 11/01/20 5:21 PM EST Educate 11/01/20 5:22 PM EST Thanks for telling me. Checked vitals What is your pain level on a scale of 0-10, 0=no pain and 10=worst pain ever (Clarified to Can you rate your current pain level on a scale of 0 to 10?.) I'd say it's down to around a 6 out of 10 now. (Clarified to how I would rate my pain on a scale.) Exam Action 11/01/20 5:22 PM EST Question 11/01/20 5:25 PM EST Do you have any problems with your head? Just like in general? I get headaches sometimes. How often do you get headaches? Maybe every week? I usually do a lot of my school work at once, so I'll study for like, 5 or 6 hours. I usually end up with a headache by the end of the night. How long do your headaches last? Question 11/01/20 5:52 PM EST Question 11/01/20 5:52 PM EST Question 11/01/20 5:53 PM EST Yeah, maybe so. I've noticed my vision getting sort of blurry when I read. It seems like it's getting a little worse -- I notice it more. When did you first notice your vision getting blurry? I'm not sure -- Maybe over the last year or so. How often does your vision get blurry? Question 11/01/20 5:56 PM EST Question 11/01/20 5:56 PM EST Maybe. . . once a week I usually do a lot of my school work at once, so I'll study for like, 5 or 6 hours. I usually end up noticing it then. Does anything relieve the blurry vision? Usually if I stop studying and rest it gets a better. Do you see a doctor about your blurry vision? (Clarified to Have you seen a doctor about your vision?.) Question 11/01/20 5:57 PM EST Question 11/01/20 5:57 PM EST Never. I know that when I was a kid, the school nurse did those little vision checks every year, but I haven't gotten an eye exam since then. (Clarified to if I have seen a doctor about my vision.) Do you have any other problems with your eyes? No. Is there anything that triggers your vision to get blurry? Question 11/01/20 5:58 PM EST Question 11/01/20 5:58 PM EST My sinuses are fine right now. Is there anything that triggers your runny nose? (Clarified to Did anything trigger your runny nose?.) Cats or dust are usually what does it. (Clarified to if anything triggered my nose running.) Do you drink alcohol? Question 11/01/20 6:03 PM EST Question 11/01/20 6:03 PM EST I do sometimes, yeah, when I go out with my friends. How often? (No matching questions found.) How often do you drink alcohol with your friends?? Not much. I never go out more than once or twice a week. [AUDIO COMING SOON] How many drinks do you have? Question 11/01/20 6:04 PM EST Question 11/01/20 6:04 PM EST Question 11/01/20 6:04 PM EST Just a few. I'm not a big drinker. Do you use tobacco products? No. I think it's gross. Do you have any ear problems? Question 11/01/20 6:04 PM EST Question 11/01/20 6:05 PM EST No, my throat has been fine. Do you have any problems with lymph nodes? Not that I've noticed. Do you have any problems with your thyroid? Question 11/01/20 6:08 PM EST Question 11/01/20 6:08 PM EST No, I never have. Do you have a family history of head problems? No, not really. Do you have a family history of eye problems? Question 11/01/20 6:10 PM EST Question 11/01/20 6:10 PM EST No. Do you have a family history of ear problems? No. Do you have a family history of nasal problems? Question 11/01/20 6:10 PM EST Question 11/01/20 6:10 PM EST Thanks for telling me. Inspected general face Inspected right side of face Inspected general face Inspected nose and mouth Inspected forehead and scalp Exam Action 11/01/20 6:12 PM EST Exam Action 11/01/20 6:12 PM EST Exam Action 11/01/20 6:12 PM EST Exam Action 11/01/20 6:12 PM EST Exam Action 11/01/20 6:12 PM EST 6:13 PM EST Inspected nose and mouth Inspected right side of face Inspected general face Inspected upper conjunctiva Inspected lower conjunctiva Inspected right orbital area and sclera Inspected left orbital area and sclera Performed otoscopic examination of right 6:13 PM EST Exam Action 11/01/20 6:12 PM EST Exam Action 11/01/20 6:12 PM EST Exam Action 11/01/20 6:13 PM EST Exam Action 11/01/20 6:13 PM EST Exam Action 11/01/20 6:13 PM EST Exam Action 11/01/20 6:13 PM EST Exam Action 11/01/20 6:13 PM EST Exam Action 11/01/20 6:19 PM EST Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Palpated frontal sinuses: No tenderness reported Palpated maxillary sinuses: No tenderness reported Palpated right carotid artery: No thrill, 2+ Palpated left carotid artery: No thrill, 2+ Palpated jaw: Full range of motion, no popping or clicking Palpated lymph nodes of head and neck: Not palpable Palpated supraclavicular lymph nodes: Not 6:19 PM EST Exam Action 11/01/20 6:16 PM EST Exam Action 11/01/20 6:16 PM EST Exam Action 11/01/20 6:16 PM EST Exam Action 11/01/20 6:17 PM EST Exam Action 11/01/20 6:17 PM EST Exam Action 11/01/20 6:18 PM EST Exam Action 11/01/20 6:19 PM EST Exam Action 6:19 PM EST 11/01/20 Ok. Tested EOM to the upper center Tested convergence to the center Tested EOM to the lower center Tested EOM to the upper right Tested EOM to the lower right Exam Action 11/01/20 6:30 PM EST Exam Action 11/01/20 6:30 PM EST Exam Action 11/01/20 6:30 PM EST Exam Action 11/01/20 6:30 PM EST Exam Action 11/01/20 6:30 PM EST Tested convergence to the center Tested EOM to the upper left Tested EOM to the lower left Tested EOM to the lower center Tell me when you can no longer see my fingers. Ok, I will. Exam Action 11/01/20 6:31 PM EST Exam Action 11/01/20 6:31 PM EST Exam Action 11/01/20 6:31 PM EST Exam Action 11/01/20 6:31 PM EST Question 11/01/20 6:31 PM EST Tested peripheral vision Now. Examined fundus of right eye Examined fundus of left eye L P E D Exam Action 11/01/20 6:31 PM EST Exam Action 11/01/20 6:32 PM EST Exam Action 11/01/20 6:32 PM EST F E L O P Z D That's... I can't really tell. D E F P O T E C Tested visual acuity of left eye (right eye covered) D E F P O T E C Tested visual acuity of left eye (right eye covered) That's... I can't really tell. Exam Action 11/01/20 6:41 PM EST Exam Action 11/01/20 6:41 PM EST Um, that one's kind of blurry. E D E O X F P E C F D Eight. Eight. W. W. Performed whisper test in right ear Question 11/01/20 6:43 PM EST Question 11/01/20 6:43 PM EST Exam Action 11/01/20 6:43 PM EST Inspected general face Performed otoscopic examination of right naris Performed otoscopic examination of left naris Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Do you have any tenderness on your scalp? No, I keep my scalp healthy. Exam Action 11/01/20 6:46 PM EST Exam Action 11/01/20 6:48 PM EST Exam Action 11/01/20 6:48 PM EST Exam Action 11/01/20 7:21 PM EST Question 11/01/20 7:21 PM EST Palpated frontal sinuses: No tenderness reported Palpated maxillary sinuses: No tenderness reported Palpated right carotid artery: No thrill, 2+ Palpated left carotid artery: No thrill, 2+ Palpated jaw: Full range of motion, no popping or clicking Palpated lymph nodes of head and neck: Not palpable Palpated supraclavicular lymph nodes: Not palpable Palpated axillary lymph nodes: Not palpable Exam Action 11/01/20 7:21 PM EST Exam Action 11/01/20 7:21 PM EST Exam Action 11/01/20 7:22 PM EST Exam Action 11/01/20 7:22 PM EST Exam Action 11/01/20 7:22 PM EST Exam Action 11/01/20 7:23 PM EST Exam Action 11/01/20 7:23 PM EST Exam Action 11/01/20 7:23 PM EST