NURS 6512n Week 3 Digital Clinical Experience Orientation Patient: Tina Jones Case Study Assignment
NURS 6512n Week 3 Digital Clinical Experience Orientation Patient: Tina Jones Case Study Assignment
Open Text QuestionActivity Time: 3 min
Please describe what you look forward to most in your upcoming activities within the DCE.
Student Response: I look forward to completing a head-to-toe assessment and communicating with the patient.
Model Note: There are many opportunities to learn and practice your clinical skills within the DCE, and we hope you are looking forward to all of them!
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Transcript
Hello my name is xx . I’m here to interview and examine you
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Greet |
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Hey.
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how are you today?
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Not so great… My foot really hurts right now.
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Tell me what’s going on ?
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I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!
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on a scale of 0 to 10 how can you rate your pain? (Clarified to On a scale of 0-10 how would you rate the pain in your right foot?.)
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I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. (Clarified to how I would rate my foot pain on a scale.)
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how long has this being going on?
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Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
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How does this happen?
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I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step.
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What have you been using on the your foot (Clarified to What have you been doing for the scrape?.)
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I made sure to clean it and just keep it bandaged. And I put Neosporin on it. (Clarified to what I have been doing for the scrape.)
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Are you taking anything for the pain ?
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Yeah, I had to start taking pain medication.
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what pain medication are you taking?
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It’s called tramadol.
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besides the medication what else do you do to manage your pain?
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I just watch what I eat and try to stay away from sweets.
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Tell me more about you medical history?
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I’ve had asthma since I was little, and I have sugar diabetes, too.
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How long have you been diabetic
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I was diagnosed when I was 24.
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what medications are you taking for your diabetes
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I don’t take medicine for it anymore.
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I’m sorry you have to go through this pain but will see how i can help you feel better
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Empathize |
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Thanks.
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you welcome (No matching questions found.)
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you are welcome (No matching questions found.)
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are you able to move you foot
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Um, my ankle’s starting to hurt when I move it.
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have you had any x-ray of you ankle
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Yeah, they did.
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what was the result (Clarified to Do you know what the X-ray of your injured foot showed?.)
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The x-ray was normal. Nothing broken. (Clarified to what the foot xray showed.)
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great (No matching questions found.)
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are you have fever
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I don’t feel feverish right now, but last night I had a high temperature.
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what was your temperature last night
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Last night it got up to 102.
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did you take any medication for your fever
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I really didn’t do much for it at home.
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have you noticed any discharge on your wound (Clarified to Does your scrape have pus?.)
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Yeah, there’s definitely pus. (Clarified to if my scrape has pus.)
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how often do you change your wound dress a day (Clarified to How often do you change your bandage?.)
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Every morning and night. I was keeping an eye on it. (Clarified to how often I change my bandage.)
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whats the color of the drainage
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It’s… white or maybe off-white.
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ok (No matching questions found.)
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have you taken any antibiotic for your wound
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No, the ER only prescribed the pain meds.
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are you experiencing pain anywhere else besides your ankle (Clarified to Do you have pain elsewhere than your foot?.)
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The pain’s worse in my foot, but I feel it moving up into my ankle, too. (Clarified to if I have pain elsewhere than my foot.)
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are you able to wiggle your toes?
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I guess I can wiggle my toes a little, but it really hurts a lot to move my foot any.
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is you foot warm or cool to touch
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Yeah, it feels pretty warm.
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describe your pain
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It’s throbbing and like, sharp if I try to put weight on it.
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what other conditions have you been diagnosed with (Clarified to What is your past medical history?.)
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I’ve had asthma since I was little, and I have sugar diabetes, too. (Clarified to what health problems I have had.)
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does the pain wake you up at night
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I feel the pain at night, but I have been able to get to sleep.
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do your pain keep you from participate in activities or things you enjoy
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Well, with my church friends, we do Bible study or we have a meal. With my other friends, I’ll go over to one of their houses to watch our shows or just hang out. And on the weekends, we’ll go out to a bar or go dancing.
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How has the pain making you feel about yourself (Clarified to How do you feel about your appearance?.)
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I am who I am, you know? I don’t like stressing out about what I look like or anything like that. (Clarified to how I feel about my appearance.)
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are you still able to get out and socialize like you usually do (No matching questions found.)
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have your family and friends been helpful (No matching questions found.)
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Question |
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keep the bandages dry between change
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Educate |
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Thanks for telling me.
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clean wound wound with a soapy washcloth. you may do this in the shower (Clarified to How are you cleaning the wound?.)
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Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off. (Clarified to how I am cleaning the wound.)
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wash wound with soapy washcloth (No matching questions found.)
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are you allergic to any medications
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Educate |
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Thanks for telling me.
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Are you allergic to any medication?
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Yeah, I’m allergic to penicillin.
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any food allergies
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Nope, no food allergies that I know of.
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are you allergic to latex
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Nope.
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what pharmacy do you use
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I always fill my inhaler prescription at the pharmacy near Mom’s house.
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do you know the name of the pharmacy (No matching questions found.)
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what pharmacy do you get your medications from?
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I always fill my inhaler prescription at the pharmacy near Mom’s house.
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I want you to wash your wound with soapy water
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Educate |
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Thanks for telling me.
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dry wound gently with clean towel (No matching questions found.)
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dry wound gently with clean towel
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Educate |
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Thanks for telling me.
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apply antibiotic ointment to wound
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Educate |
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Thanks for telling me.
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apply a dry clean bange
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Educate |
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Thanks for telling me.
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do wound care twice a day
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I made sure to clean it and just keep it bandaged. And I put Neosporin on it.
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take your medications , monitor your temperature , eat a balance meal, drink lots of fluids and plenty of rest
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Educate |
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Thanks for telling me.
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lets talk about your diabetes (Clarified to Tell me more about your diabetes..)
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I don’t think there’s a lot to say about it . . . it seems pretty under control, and it’s just type 2 anyway. (Clarified to to tell you about my diabetes.)
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when was the last time you had a asthma attack
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It’s really rare for me to have an attack now. Three days ago I had some breathing problems, but I guess probably my last full attack was in high school.
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what did you take when you had the breathing problem (Clarified to Can you describe your breathing problems?.)
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When my asthma acts up, I feel like my chest is tight, like I can’t really take in air. And I usually wheeze. (Clarified to to describe my breathing problems.)
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what medication are you taking for your Asthma
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It’s just a regular Proventil inhaler.
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how often do you use your inhaler
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Not often. Maybe two or three times a week.
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sorry about you have to go throw this
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Empathize |
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Thanks.
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Treating high cholesterol helps lower your risk of stroke
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Educate |
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Thanks for telling me.
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It sounds like that was a challenging time for you
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Empathize |
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Thanks.
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Examined right eye.
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Exam Action |
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Examined left eye.
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Exam Action |
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Percussed posterior left upper chest wall
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Exam Action |
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Percussed posterior right upper chest wall
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Exam Action |
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Percussed posterior right middle chest wall
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Exam Action |
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Percussed posterior left middle chest wall
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Exam Action |
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Percussed posterior left lower chest wall
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Exam Action |
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Percussed posterior right lower chest wall
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Exam Action |
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Percussed posterior right lower chest wall
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Exam Action |
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Percussed posterior left lower chest wall
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Exam Action |
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Percussed posterior left lower chest wall
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Exam Action |
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Percussed posterior right lower chest wall
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Exam Action |
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Percussed anterior right upper chest wall
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Exam Action |
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Percussed anterior left upper chest wall
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Exam Action |
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Percussed anterior right middle chest wall
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Exam Action |
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Percussed anterior left middle chest wall
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Exam Action |
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Percussed anterior right lower chest wall
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Exam Action |
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Percussed anterior left lower chest wall
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Exam Action |
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CompletedOrientation
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Exam Action |
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hello my name is isatu, i’m here to interview and examine you
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Greet |
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Hey.
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what brings you in today?
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Question |
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I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!
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treating high cholesterol help lower your risk of stroke
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Educate |
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Thanks for telling me.
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It sounds like that was a challenging time for you
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Empathize |
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Thanks.
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Examined right eye.
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Exam Action |
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Examined left eye.
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Exam Action |
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Percussed posterior left upper chest wall
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Exam Action |
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Percussed posterior right upper chest wall
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Exam Action |
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Percussed posterior left middle chest wall
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Exam Action |
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Percussed posterior right middle chest wall
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Exam Action |
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Percussed posterior left lower chest wall
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Exam Action |
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Percussed posterior right lower chest wall
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Exam Action |
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Percussed posterior left lower chest wall
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Exam Action |
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Percussed posterior right lower chest wall
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Exam Action |
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Percussed posterior left lower chest wall
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Exam Action |
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Percussed posterior right lower chest wall
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Exam Action |
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Percussed posterior right lower chest wall
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Exam Action |
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Percussed posterior left lower chest wall
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Exam Action |
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Percussed posterior right lower chest wall
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Exam Action |
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Percussed posterior left lower chest wall
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Exam Action |
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Percussed anterior right upper chest wall
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Exam Action |
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Percussed anterior left upper chest wall
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Exam Action |
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Percussed anterior right middle chest wall
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Exam Action |
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Percussed anterior left middle chest wall
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Exam Action |
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Percussed anterior right lower chest wall
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Exam Action |
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Percussed anterior left lower chest wall
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Exam Action |
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Percussed anterior left lower chest wall
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Exam Action |
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Percussed anterior right lower chest wall
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Exam Action |
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Completed Orientation
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Exam Action |