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! HEENT Results | Turned InHolistic Health Assessment - NUR 301 Return to Assignment Your Results Lab Pass  Overview  Transcript  Subjective Data Collection  Objective Data Collection  Documentation Transcript All Lines (132)Interview Questions (57)Statements (4)Exam Actions (71) Hello! Question 11/01/20 5:05 PM EST Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. What is the situation? Question 11/01/20 5:08 PM EST It's 8 a.m. on Tina Jones' first morning as a patient here at Shadow General Hospital. When Ms. Jones was admitted at midnight last night for a foot wound, she mentioned a history of headaches and allergies. Your role in this simulation is that of a healthcare provider who will perform an examination of Ms. Jones' HEENT systems: Head, Eyes, Ears, Nose, and Throat. Examination of all of these systems is often necessary to examine any one of them, given their close proximity and physiological relationships. What are my objectives in this assessment? Question 11/01/20 5:11 PM EST In your interview with Ms. Jones, you will ask about the health of her HEENT systems so that you can identify any issues and document findings accurately. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. You will also inquire into the health history of Ms. Jones' family with regards to HEENT systems so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her HEENT systems. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones' HEENT systems to gather objective data about the systems' health and physiology. While you should communicate with In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What physical exam findings would you look for in a patient with allergies? A patient with allergies might present with symptoms such as swelling in the throat and drainage. Statement 11/01/20 5:18 PM EST Time to begin. Hello, my name is Jennifer and I am the nursing student that will interview you today. Greet 11/01/20 5:18 PM EST Hey. Can you tell me your name and date of birth? Question 11/01/20 5:20 PM EST My name's Tina Jones, and my birthday's February 17th. How old are you? Question 11/01/20 5:20 PM EST I'm 28. I am going to lift your bed rails to ensure your safety. Educate 11/01/20 5:21 PM EST Thanks for telling me. I am going to check your vitals. Educate 11/01/20 5:22 PM EST A few hours, I guess. Where are your headaches located? Question 11/01/20 5:53 PM EST It's kind of behind my forehead. Can you rate your headache pain on a scale of 0-10? Question 11/01/20 5:54 PM EST Not too bad. . . I'd say about 2. Or a 3 if I really push it. Do you take any medicATION FOR YOUR HEADACHES? Question 11/01/20 5:54 PM EST Yeah. Usually I'll take a Tylenol and go to bed, and that'll get rid of it. dO YOU HAVE ANY TROUBLE WITH YOUR VISION? Question 11/01/20 5:55 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? Question 11/01/20 5:56 PM EST 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 It definitely gets blurry or kind of fuzzy when I read. But that's the only time I notice that. Are there any triggers for your eye symptoms? Question 11/01/20 5:58 PM EST Just when I'm around a cat, which isn't very often. Sometimes dust will do it, too. [AUDIO COMING SOON] Do you get any treatment for your eye symptoms? (Clarified to What treatment do you use for your eye symptoms?.) Question 11/01/20 5:59 PM EST If I'm having an allergic reaction, I just rinse my eyes out in the shower. [AUDIO COMING SOON] (Clarified to what treatment I use for my eye symptoms.) Do you have any nasal problems? Question 11/01/20 6:00 PM EST Sometimes my nose gets runny. It's fine right now, though. [AUDIO COMING SOON] Do you have any sinus problems? Question 11/01/20 6:02 PM EST My sinuses are fine right now. Is there anything that triggers your runny nose? (Clarified to Did anything trigger your runny nose?.) Question 11/01/20 6:03 PM EST 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 No, my ears are fine right now. Do you have any trouble hearing? Question 11/01/20 6:05 PM EST No. Do you have any moth problems? (No matching questions found.) Question 11/01/20 6:05 PM EST Do you have any mouth problems? Question 11/01/20 6:05 PM EST No. Do you have any dental problems? Question 11/01/20 6:07 PM EST No, I've got good teeth. They don't give me any problems. Do you have any problems with your throat? Question 11/01/20 6:08 PM EST No, my throat has been fine. Do you have any problems with lymph nodes? Question 11/01/20 6:08 PM EST Not that I've noticed. Do you have any problems with your thyroid? Question 11/01/20 6:08 PM EST Yeah, my sister gets hay fever, so every spring she sneezes and her nose runs. She has to take something over-the-counter for it. Do you have a family history of mouth problems? Question 11/01/20 6:11 PM EST No, not really. Do you have a family history of throat problems? Question 11/01/20 6:11 PM EST No. Do you have a family history of gland problems? Question 11/01/20 6:11 PM EST I don't think so. I am now going to examine you. Educate 11/01/20 6:12 PM EST Thanks for telling me. Inspected general face Exam Action 11/01/20 6:12 PM EST Inspected right side of face Exam Action 11/01/20 6:12 PM EST Inspected general face Exam Action 11/01/20 6:12 PM EST Inspected nose and mouth Exam Action 11/01/20 6:12 PM EST Inspected forehead and scalp Exam Action 11/01/20 6:12 PM EST Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported Exam Action 11/01/20 6:16 PM EST Palpated frontal sinuses: No tenderness reported Exam Action 11/01/20 6:16 PM EST Palpated maxillary sinuses: No tenderness reported Exam Action 11/01/20 6:16 PM EST Palpated right carotid artery: No thrill, 2+ Exam Action 11/01/20 6:17 PM EST Palpated left carotid artery: No thrill, 2+ Exam Action 11/01/20 6:17 PM EST Palpated jaw: Full range of motion, no popping or clicking Exam Action 11/01/20 6:18 PM EST Palpated lymph nodes of head and neck: Not palpable Exam Action 11/01/20 6:19 PM EST Palpated supraclavicular lymph nodes: Not palpable Exam Action 11/01/20 6:19 PM EST Palpated axillary lymph nodes: Not palpable Exam Action 11/01/20 6:19 PM EST Auscultated right carotid artery Exam Action 11/01/20 6:20 PM EST Auscultated left carotid artery Exam Action 11/01/20 6:20 PM EST Auscultated right carotid artery Exam Action 11/01/20 6:28 PM EST Auscultated left carotid artery Exam Action 11/01/20 6:28 PM EST Tested left pupillary reaction with penlight Exam Action 11/01/20 6:29 PM EST Tested right pupillary reaction with penlight Exam Action 11/01/20 6:29 PM EST Please follow my finger with just your eyes. Question 11/01/20 6:30 PM EST Ok. Tested EOM to the upper center Exam Action 11/01/20 6:30 PM EST Tested convergence to the center Exam Action 11/01/20 6:30 PM EST Tested EOM to the lower center Exam Action 11/01/20 6:30 PM EST Tested EOM to the upper right Exam Action 11/01/20 6:30 PM EST Tested EOM to the lower right Exam Action 11/01/20 6:30 PM EST L P E D P E C F D Tested visual acuity of right eye (left eye covered) Exam Action 11/01/20 6:39 PM EST E D E O X F E D F C Z P F E L O P Z D 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 right eye (left eye covered) Exam Action 11/01/20 6:42 PM EST Four Question 11/01/20 6:43 PM EST Four. R. Question 11/01/20 6:43 PM EST R. Nine Question 11/01/20 6:43 PM EST Nine. Performed whisper test in left ear Exam Action 11/01/20 6:43 PM EST F. Question 11/01/20 6:43 PM EST F. Eight. Question 11/01/20 6:43 PM EST Eight. W. Question 11/01/20 6:43 PM EST W. Performed whisper test in right ear Exam Action 11/01/20 6:43 PM EST Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported Exam Action 11/01/20 7:24 PM EST Auscultated right carotid artery Exam Action 11/01/20 7:25 PM EST Auscultated left carotid artery Exam Action 11/01/20 7:25 PM EST What brings you in today? Question 11/01/20 7:48 PM EST Well, I came in last night for my foot. It just wasn't healing right, and it really hurt. I am sorry you are having pain. Empathize 11/01/20 7:49 PM EST Thanks. Checked vitals