NURS 6512N Week 4 – Health History, Tina Jones Shadow Health

In this assessment, each relevant diagnosis is evaluated using a four-point scale:

Table of Contents

Priority (1 point): The correct priority of the diagnosis was chosen.

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Evidence (up to 2 points): The strength of the patient cue(s) selected as evidence for the identified diagnosis.

Required Evidence: Selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points.

Supporting Evidence: Selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 point.

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Planning (1 point): The plan proposed to address the diagnosis includes at least one correct component.

Relevant Diagnoses

1. Acute pain of the foot – 4 of 4 points
– Priority – 1 / 1
– Student Response: High
– Correct Priority: High
– Priority Pro Tip: Managing acute pain is an immediate high priority because other health concerns cannot be effectively addressed while a patient experiences severe pain.
– Evidence – 2 / 2
– Relevant
– “I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.” – Required Evidence
– Evidence Pro Tip: Tina reports intense pain and rates her pain on a numerical scale. She also reports characteristics of the pain, including its duration of one week; this timespan defines her pain as acute.
– Planning – 1 / 1
– Relevant
– Intervene – Prescribe: Prescribe medications to treat pain.
– Educate – Medication: Educate the patient on medications used for pain relief.
– Educate – Medication: Educate the patient on non-pharmaceutical methods to reduce pain intensity.
– Planning Pro Tip: Intervene to reduce the pain by prescribing an appropriate analgesic and educating the patient on its effective use and potential side effects. Provide the patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation).

2. Local infection of skin and subcutaneous tissue of the foot – 4 of 4 points

3. Uncontrolled type 2 diabetes mellitus – 4 of 4 points

4. Asthma – 4 of 4 points
– Priority – 1 / 1
– Student Response: Low
– Correct Priority: Low
– Priority Pro Tip: Although Tina requires education to better manage her asthma, she does not report active respiratory complaints, making this a lower priority diagnosis.
– Evidence – 2 / 2
– Relevant
– “Um, the only things I know I’m diagnosed with are diabetes. And asthma.” – Required Evidence
– “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.” – Required Evidence
– Evidence Pro Tip: Tina reports a personal history of asthma, including past hospitalizations for asthma attacks, as well as her use of an albuterol inhaler. Her sibling’s asthma is of interest, given the strong genetic and environmental factors in the development of asthma.
– Planning – 1 / 1
– Relevant
– Assess – Respiratory: Assess lung sounds with auscultation.
– Assess – Respiratory: Assess pulmonary function using spirometry.
– Assess – Respiratory: Assess respirations (rate, rhythm, depth, quality).
– Educate – Health Maintenance: Educate the patient on avoiding triggers of asthma.
– Educate – Health Maintenance: Educate the patient on enacting her asthma action plan, including proper use of a rescue inhaler.
– Planning Pro Tip: Because Tina does not report treatment for maintenance of her asthma, instead relying on a rescue inhaler for sporadic attacks, educate her on developing and enacting a proactive plan to manage the disease. Though Tina does not report an active respiratory complaint, it is valuable to assess for abnormal findings that she may not report.

5. Dysmenorrhea – 4 of 4 points

6. Hypertension – 4 of 4 points

7. Menorrhagia – 4 of 4 points

8. Obesity – 4 of 4 points

9. Oligomenorrhea – 4 of 4 points
– Priority – 1 / 1
– Student Response: Low
– Correct Priority: Low
– Priority Pro Tip: Oligomenorrhea is an irregular menstrual cycle that can result from a range of causes, many of which are not immediately life-threatening. Therefore, this is a lower priority diagnosis.
– Evidence – 2 / 2
– Relevant
– “My periods have been kinda weird too, but they’ve always been all over the place, so it’s no big deal.” – Required Evidence
– Evidence Pro Tip: Tina reports an irregular menstrual cycle, suggesting oligomenorrhea, which can result from a variety of causes including polycystic ovary syndrome and hormonal imbalances.
– Planning – 1 / 1
– Relevant
– Assess – Reproductive: Assess the patient’s menstrual history.
– Educate – Reproductive: Educate the patient on normal menstrual patterns and the potential impact of oligomenorrhea.
– Planning Pro Tip: Assess Tina’s menstrual history to identify potential underlying causes of her oligomenorrhea, and educate her on the potential implications for her overall health and fertility.

NURS 6512N Week 4 – Health History, Tina Jones Shadow Health

Each relevant diagnosis is scored on a four-point scale:

Priority (1 point): the correct priority of the diagnosis was chosen
Evidence (up to 2 points): the strength of the patient cue(s) selected as evidence for the identified diagnosis
- Required Evidence: selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points
- Supporting Evidence: selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 point
Planning (1 point): the plan proposed to address the diagnosis includes at least one correct component

1. Acute pain of the foot

4 of 4 points

Priority 1 / 1
Student Response: High Correct Priority: High	Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain.
Evidence 2 / 2
Relevant “I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.” Required Evidence Irrelevant (None provided)	Evidence Pro Tip: Tina reports intense pain and rates her pain on a numerical scale. She also reports characteristics of the pain, including its duration of one week; this timespan defines her pain as acute. NURS 6512N Week 4 – Health History, Tina Jones Shadow Health
Planning 1 / 1
Relevant Intervene – Prescribe: Prescribe medications to treat pain. Educate – Medication: Educate the patient on medications used for pain relief. Educate – Medication: Educate the patient on non-pharmaceutical methods to reduce pain intensity. Irrelevant (None provided)	Planning Pro Tip: Intervene to reduce the pain by prescribing an appropriate analgesic and educating the patient on its effective use and potential side effects. Provide the patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation).

2. Local infection of skin and subcutaneous tissue of the foot

4 of 4 points

3. Uncontrolled type 2 diabetes mellitus

4 of 4 points

4. Asthma

4 of 4 points

Priority 1 / 1
Student Response: Low Correct Priority: Low	Priority Pro Tip: Although Tina requires education to better manage her asthma, she does not report active respiratory complaints, making this a lower priority diagnosis.
Evidence 2 / 2
Relevant “Um, the only things I know I’m diagnosed with are diabetes. And asthma.” Required Evidence “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.” Required Evidence Irrelevant (None provided)	Evidence Pro Tip: Tina reports a personal history of asthma, including past hospitalizations for asthma attacks, as well as her use of an albuterol inhaler. Her sibling’s asthma is of interest, given the strong genetic and environmental factors in the development of asthma.
Planning 1 / 1
Relevant Assess – Respiratory: Assess lung sounds with auscultation. Assess – Respiratory: Assess pulmonary function using spirometry. Assess – Respiratory: Assess respirations (rate, rhythm, depth, quality). Educate – Health Maintenance: Educate the patient on avoiding triggers of asthma. Educate – Health Maintenance: Educate the patient on enacting her asthma action plan including proper use of rescue inhaler. Irrelevant (None provided)	Planning Pro Tip: Because Tina does not report treatment for maintenance of her asthma, instead relying on a rescue inhaler for sporadic attacks, educate her on developing and enacting a proactive plan to manage the disease. Though Tina does not report an active respiratory complaint, it is valuable to assess for abnormal findings that she may not report.

5. Dysmenorrhea

4 of 4 points

6. Hypertension

4 of 4 points

7. Menorrhagia

4 of 4 points

8. Obesity

4 of 4 points

9. Oligomenorrhea

4 of 4 points

Priority 1 / 1
Student Response: Low Correct Priority: Low	Priority Pro Tip: Oligomenorrhea is a secondary issue caused by Tina’s endocrine and metabolic disorders and thus is a lower priority diagnosis.
Evidence 2 / 2
Relevant “It’s not regular. Sometimes it’s every month, but sometimes it’s more like every two months. I don’t write it down or anything. I probably get…six periods a year.” Required Evidence Irrelevant (None provided)	Evidence Pro Tip: Tina reports having about 6 periods per year, meeting the criteria for oligomenorrhea, which are periods more than 35 days apart or 9 per year. Her periods occur fewer than 90 days apart, making oligomenorrhea the correct diagnosis rather than amenorrhea.
Planning 1 / 1
Relevant Assess – Integumentary: Assess for presence of axillary and pubic hair by inspection. Assess – Integumentary: Assess severity of hair growth at areas including upper lip, chin, chest, thighs, upper arm, forearm, back, abdomen. Intervene – Labs: Order a follicle-stimulating hormone test. Intervene – Labs: Order a test of free androgen index. Intervene – Labs: Order a test of free testosterone. Intervene – Labs: Order a test of thyroid stimulating hormone. Educate – Health Maintenance: Educate the patient to keep a menstrual calendar to assist assessing her pattern. Irrelevant (None provided)	Planning Pro Tip: Endocrine disorders are the cause of Tina’s irregular menstruation, so order labs to evaluate for poly-cystic ovarian syndrome and thyroid disease. Inspect for both hair growth indicative of excessive androgen production and that indicative of deficient production, and inspect for acanthosis nigricans. Educate your patient on keeping a menstrual calendar to more precisely identify irregularities in her cycle.

10. Polycystic ovarian syndrome

4 of 4 points

(No other diagnoses were identified)

Started: Mar 19, 2023 | Total Time: 403 min

	Weight: 90 kg	Exam Action 03/19/23 2:01 AM EDT
	BMI: 31	Exam Action 03/19/23 2:01 AM EDT
	Random blood glucose: 238	Exam Action 03/19/23 2:01 AM EDT
	Blood pressure: 142/82	Exam Action 03/19/23 2:01 AM EDT
	Respiratory rate: 19	Exam Action 03/19/23 2:01 AM EDT
	O2 sat: 99%	Exam Action 03/19/23 2:01 AM EDT
	Heart rate: 86	Exam Action 03/19/23 2:01 AM EDT
	Height: 170.2 cm	Exam Action 03/19/23 2:01 AM EDT
	Temperature: 38.4 °C	Exam Action 03/19/23 2:01 AM EDT
	Hello. Am NURS 6512N Week 4 – Health History, Tina Jones Shadow Health , i will interview and examine you.	Greet 03/19/23 2:02 AM EDT
	Hey.
	What is your name?	Question 03/19/23 2:07 AM EDT
	Tina Jones.
	why are you here today?	Question 03/19/23 2:07 AM EDT
	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!
	Am sorry to hear that	Empathize 03/19/23 2:07 AM EDT
	I appreciate you telling me that.
	When did you get the scrape?	Question 03/19/23 2:09 AM EDT
	Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
	How severe is the pain?	Question 03/19/23 2:10 AM EDT
	It’s really bad.
	Can you describe the pain?	Question 03/19/23 2:12 AM EDT
	It’s throbbing and like, sharp if I try to put weight on it.
	Did you hurt any other part? (Clarified to Did you hurt anything else during the fall?.)	Question 03/19/23 2:12 AM EDT
	Well, at first I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it, because the ankle felt pretty okay the next day and it wasn’t a problem all week. (Clarified to if I hurt anything else during the fall.)
	How has the pain changed over time?	Question 03/19/23 2:13 AM EDT
	At first, it seemed like it was healing up fine and it didn’t give me a lot of pain. But the last two days, the pain got way worse.
	Does the pain radiate anywhere else?	Question 03/19/23 2:13 AM EDT
	The pain’s worse in my foot, but I feel it moving up into my ankle, too.
	How did you hurt your ankle?	Question 03/19/23 2:14 AM EDT
	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.
	Is it possible for you to stand on your foot?	Question 03/19/23 2:14 AM EDT
	No, I can’t put weight on my foot without really sharp pain.
	Can you rate your current pain level on a scale of 0 to 10?	Question 03/19/23 2:15 AM EDT
	I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.
	Can you tell me where the pain is located?	Question 03/19/23 2:19 AM EDT
	It feels like the pain is just centered around the scrape, like around the ball of my foot. That’s where it hurts the most, but my whole foot feels some pain.
	Which foot did you injure?	Question 03/19/23 2:19 AM EDT
	My right foot.
	Were you wearing shoes?	Question 03/19/23 2:20 AM EDT
	No, I was barefoot.
	Did you have any alcoholic drinks before the injury?	Question 03/19/23 2:20 AM EDT
	No, I was stone-cold sober. It was the middle of the day.
	Did you use home remedies for your foot?	Question 03/19/23 2:21 AM EDT
	Yeah, I made sure to clean it and keep it bandaged.
	What did you use to clean the er? (No matching questions found.)	Question 03/19/23 2:21 AM EDT
	What did you use to clean it?	Question 03/19/23 2:22 AM EDT
	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.
	When did you go to the er?	Question 03/19/23 2:22 AM EDT
	I went about an hour after I fell, I think.
	Did you get any medication at the ER?	Question 03/19/23 2:23 AM EDT
	Yes, they wrote me a prescription for some pain pills.
	Do you know the name of the pain pills?	Question 03/19/23 2:23 AM EDT
	It’s called tramadol.
	What dosage of tramadol?	Question 03/19/23 2:24 AM EDT
	I’m not 100% sure, but I think they’re 50 milligrams.
	How often were you taking the tramadol?	Question 03/19/23 2:24 AM EDT
	I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
	Did tramadol relieve pain?	Question 03/19/23 2:25 AM EDT
	I’ve only been taking the pain pills the ER gave me and staying off it. . . and keeping the wound clean.
	Has your foot bled since the injury?	Question 03/19/23 2:25 AM EDT
	It’s not bleeding anymore. It only bled right after I scraped it.
	What happened after you scraped your foot NURS 6512N Week 4 – Health History, Tina Jones Shadow Health	Question 03/19/23 2:26 AM EDT
	I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
	Its good to seek medical attention.	Educate 03/19/23 2:26 AM EDT
	That makes sense.
	Did the ER prescribe the pain pills?	Question 03/19/23 2:30 AM EDT
	Yes, they wrote me a prescription for some pain pills.
	Which pain pills were prescribed?	Question 03/19/23 2:31 AM EDT
	It’s called tramadol.
	How effective is the pain medication?	Question 03/19/23 2:32 AM EDT
	They only help for a few hours at a time.
	Am sorry to hear that.	Educate 03/19/23 2:32 AM EDT
	Thanks for telling me.
	How have you cared for the scrape?	Question 03/19/23 2:32 AM EDT
	I made sure to clean it and just keep it bandaged. And I put Neosporin on it.
	What happens after applying Neosporin?	Question 03/19/23 2:33 AM EDT
	I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
	How effective is neosporin? (Clarified to How effective was the neosporin?.)	Question 03/19/23 2:33 AM EDT
	Well, I had to come back to get my foot checked out even though I used the ointment. [AUDIO COMING SOON] (Clarified to how effective the neosporin was.)
	How often have you been cleaning the scrape?	Question 03/19/23 2:34 AM EDT
	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.
	Its good to keep it clean.	Educate 03/19/23 2:35 AM EDT
	Alright, thanks for letting me know.
	Is the wound swollen? (Clarified to Is it swollen around the wound?.)	Question 03/19/23 2:35 AM EDT
	Yeah, it looks swollen around the scrape. (Clarified to if it is swollen around the wound.)
	Does your scrape have an odor?	Question 03/19/23 2:36 AM EDT
	Um, no, not that I know of… That sounds gross.
	Does the scrape have pus?	Question 03/19/23 2:36 AM EDT
	Yeah, there’s definitely pus.
	What color is the pus?	Question 03/19/23 2:37 AM EDT
	It’s… white or maybe off-white.
	Is the scrape red?	Question 03/19/23 2:38 AM EDT
	Yeah, it’s red all around the scrape.
	Any temperature change around the scrape?	Question 03/19/23 2:38 AM EDT
	No.
	Are you having trouble getting around?	Question 03/19/23 2:38 AM EDT
	Yes! I mean, I literally can’t put weight on my foot, the pain is so sharp.
	Am sorry to hear that.	Empathize 03/19/23 2:39 AM EDT
	Thanks for saying that.
	Who has been helping you at home since you hurt your foot?	Question 03/19/23 2:40 AM ED

NURS 6512N Week 4 – Health History, Tina Jones Shadow Health