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Shadow Health - Tina Jones, Health History
Health History Tips & Tricks:
TJ Health Interview
Student: Hello! Diana Shadow: 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. Student: What is the situation? Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Student: What are my objectives in this assessment? Diana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre-existing conditions. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones' overall health. 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. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with 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. After obtaining Ms. Jones' health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. Student: What else will this exam involve? Diana Shadow: 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. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation. Student: How will I be evaluated? Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on
whether you promptly respond after identifying a moment worthy of therapeutic communication. 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. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically. Student: How does this assignment prepare me for the real world? Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses. Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient's complete health history? Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition. Diana Shadow: Time to begin. Patient Exam - Vital Signs: Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98% Patient Exam - Interview: Student: Hello, my name is Catlain, I am your nurse today. Tina Jones: Hey. Student: Can you confirm your name? Tina Jones: Tina Jones:. Student: Why did you come in today? Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me. Student: What additional symptoms have you experienced? Tina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on. Student: Can you rate your current pain level on a scale of 0 to 10?
Student: What made you stop taking medication for your diabetes? Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Student: Do you monitor your blood glucose? Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Student: How frequently do you urinate? Tina Jones: I don't know. Every hour or two when I'm awake? Student: What is your current diet? Tina Jones: It's pretty good, I think. I'm not a huge health nut or anything. Student: Have you had any change in appetite? Tina Jones: Yeah, lately I've definitely been much hungrier than usual. Student: Has your weight changed? Tina Jones: Yeah, I've lost some weight recently. Student: Do you know why you lost weight? Tina Jones: I don't know what caused it, I just lost weight. Student: How often do you have asthma exacerbations? Tina Jones: I haven't had a full attack in years. But my breathing definitely acts up.. .not always. Max twice a week. Student: What asthma symptoms have you experienced? Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs. Student: How many puffs do you take when using your asthma inhaler? Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are some things that trigger your asthma? Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: What allergies do you have? Tina Jones: I'm allergic to cats. Student: When did you realize you were allergic to cats? Tina Jones: For as long as I've been around.
Student: How effective was your pain medication at home? Tina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn't doing much for me -- it would only last a couple of hours. Student: What medication allergies do you have? Tina Jones: I'm allergic to penicillin. Student: What food allergies do you have? Tina Jones: I don't have any food allergies that I know of. Student: Are you allergic to dust, mold, or pollen? Tina Jones: Well... I don't know if it's allergies, but sometimes my asthma acts up around dust. Student: What immunizations have you received? Tina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college...I'm sure I have a record somewhere at home. Student: Have you received a flu vaccine? Tina Jones: No. Student: Have you had any prior hospitalizations? Tina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I've been in the hospital since I was probably sixteen, though. Student: Have you had any gastrointestinal problems? Tina Jones: No. I've never really had stomach or bowel problems. Student: Do you have a family history of psychiatric illness? Tina Jones: No. They're crazy, but nobody's diagnosed with anything. Student: Do you have any neck, throat or gland problems? Tina Jones: No, not that I noticed. Student: Do you have any problems with your head? Tina Jones: I don't think I have any problems. I get headaches sometimes, but that's all. Student: Any problems with your ears? Tina Jones: No. Student: Any problems with your eyes and vision? Tina Jones: I've actually been noticing problems lately. When I'm reading or studying I'll notice that things start to get kind of blurry. Student: Any problems with your nose? Tina Jones: My nose is fine right now. Sometimes it runs, but not very often.
Student: What happened with your father's car accident? Tina Jones: It was last year... I guess a little over a year ago. Student: How long ago was your dad's car accident? Tina Jones: It was last year... I guess a little over a year ago. Student: How did you cope with your fathers death? Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kind of depressed. So, I guess at first I just focused on getting things done--groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months. Student: What caused your dads accident? Tina Jones: He was driving to work, and it was raining...and his car hydroplaned. And hit a tree. So, it was really sudden. Student: How is your paternal grandmother's health? Tina Jones: Granny's doing good. She's still living on her own. She's slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy. Student: How is your paternal grandfather's health? Tina Jones: Grandpa Jones passed away when I was really little. Student: How is your maternal grandfather's health? Tina Jones: Well, Poppa died about five years ago. Student: How is your maternal grandmother's health? Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. Student: How is your brother's health? Tina Jones: He's a healthy guy. Kind of big like me. Student: How is your sister's health? Tina Jones: She's pretty healthy. She has asthma too, but she almost never has attacks. Student: Does your family have a history of obesity? Tina Jones: No, I don't think so. My brother and my dad are kind of big, but I wouldn't say they were obese or anything.
Student: Does your family have a history thyroid issue? Tina Jones: No, I don't think so. Student: Does your family have a history of substance abuse? Tina Jones: One person in the family, my dad's brother, has an alcohol problem, but we never see him. Student: Does your family have a history of headaches? Tina Jones: No, not that I know of. Student: How much alcohol do you drink? Tina Jones: I only have a few drinks when I go out. Student: What is your level of education? Tina Jones: Well, I'm finishing up my bachelor's degree right now. Student: What are stressors? Tina Jones: I feel really stressed out right now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too. Student: We are going to take care of everything as quickly as possible. Tina Jones: Thanks. Student: Where do you live? Tina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. It's like a half hour from here. Student: What is your belief system? Tina Jones: I'm Baptist. My faith is a big part of my life--when things get hard like they've been this past year, I know I can trust that God's looking out for me. I've been going to the same church since I was a kid, too, so the people at church are practically part of my family. Student: Have you experienced abuse? Tina Jones: I've never had been in any kind of situation like that... It's scary to think about. Student: Have you used illicit drugs? Tina Jones: Well, I used to smoke pot... but I don't do that anymore. Student: What type of drugs did you use? Tina Jones: Um...I've smoked pot before. In high school, and after high school... I definitely don't anymore, though. Student: Have you used drugs other than marijuana? Tina Jones: No.
Finding: Reports foot wound (Found)Pro Tip: If a patient mentions pain, it's important to determine what specifically is causing her pain, if she knows. Example Question: What's causing your pain? History of Presenting Illness Finding: Asked to rate current pain level on a scale Finding: Reports current pain is 7/10 (Found)Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care. Example Question: Can you rate the pain on a scale of 0 to 10? Finding: Asked for details about the pain Finding: Reports pain is throbbing (Found)Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain. Example Question: Can you please describe the pain? Finding: Reports pain is sharp when she attempts to stand (Found)Pro Tip: Determining what physical activities and movements exacerbate the patient's pain can help you better understand the problems and assess treatment needs. This can also alert you if a patient's activities of daily living are hindered. Example Question: What is the pain like when you stand on your foot? Finding: Reports pain has increased in the past 2 days (Available)Pro Tip:Finding out how the patient's pain has changed will give you insight into the acceleration of infection. Example Question: How has the pain changed over time? Finding: Reports feeling pain radiating into ankle (Available)Pro Tip: Asking about where else the patient's pain radiates can help determine the progression of infection. Example Question: Does the pain radiate anywhere else? Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care. Example Question: Can you bear weight on your foot? Finding: Asked location of wound Finding: Reports right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patient's safety. Example Question: Which foot is in pain?
Finding: Reports wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient's biggest complaint. Example Question: Where is the wound? Finding: Asked details of the injury Finding: Reports she scraped foot on bottom rung of a step stool (Found)Pro Tip: Discovering how an injury happened helps to assess your patient's risk factors for injury. Example Question: How did your injury happen? Finding: Reports injury occurred 1 week ago (Available)Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute. Example Question: When did your injury occur? Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. Example Question: Did you injure anything besides your foot? Finding: Reports being barefoot at the time of injury (Available)Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances. Example Question: Were you wearing shoes when you fell? Finding: Denies seeing a healthcare provider for the injury until now (Available)Pro Tip: It's crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound. Example Question: Have you seen a healthcare provider for this injury? Finding: Asked about drainage from the foot wound Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound. Example Question: Did your foot bleed? Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. Example Question: Did you notice any discharge from the wound? Finding: Reports noticing pus 2 days ago (Available)Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began. Example Question: When did you first notice the pus?
Finding: Reports swelling worsened in the past 2 days (Available)Pro Tip:Finding out how long swelling appeared will help you understand the timeline for the infection progression. Example Question: How long have you noticed swelling around the wound? Finding: Reports redness around the wound (Found)Pro Tip: Asking about redness will help you understand the timeline for the infection progression. Example Question: Did you notice any redness around the wound? Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression. Example Question: Does the wound feel warm? Finding: Explored impact of patient's foot injury on activities of daily living Finding: Reports pain affects ability to walk (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can walk or not, as a lack of mobility can compromise quality of life. Example Question: Does your injury impact your ability to walk? Finding: Reports pain affects ability to stand at work for long periods of time (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance. Example Question: Does your foot pain affect your work? Finding: Reports pain prevented her from being able to walk to class (Available)Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don't fall behind. Example Question: Has your injury prevented you from going to class? Past Medical History Finding: Asked about preexisting medical conditions Finding: Reports diabetes (Found)Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. In Tina's case, it is important to identify her diabetes diagnosis because that condition has a direct relationship with her current foot infection. Example Question: Do you have any existing conditions?
Finding: Reports asthma (Found)Pro Tip: It is important to identify any existing medical conditions, such as Tina's asthma, because that information is an integral part of her health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. Example Question: Do you have any other conditions? Finding: Followed up on diabetes diagnosis Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patient's illness is an essential element of the illnesses history. Example Question: At what age were you diagnosed with diabetes? Finding: Reports that her diabetes is Type 2 (Available)Pro Tip: The type of diabetes your patient has will drastically affect how you care for her. Example Question: Do you know what type of diabetes you have? Finding: Asked about diabetes management through lifestyle changes Finding: Reports staying away from sweets (Available)Pro Tip: Asking your patient specifically about sugar intake can help you understand the history of her diabetes as well as her health literacy. Example Question: Tell me more about any sugars you consume. Finding: Reports drinking diet coke instead of regular (Available)Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider. Example Question: Do you drink sugary drinks? Finding: Asked about current diabetes medication use Finding: Reports that she does not currently take medication for diabetes (Found)Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control. Example Question: Do you take prescribed medication for your diabetes? Finding: Asked about past diabetes medication use Finding: Reports that she used to take diabetes medication (Found)Pro Tip: Asking about Tina's medication history for asthma will provide a timeline of treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. Example Question: Have you ever taken medication for your diabetes?
Finding: Reports increased thirst (Found)Pro Tip: Your patient's thirst can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Example Question: Have you been more thirsty lately? Finding: Reports increased water intake (Available)Pro Tip: Your patient's fluid intake can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Example Question: Are you drinking more water than normal? Finding: Asked about frequency of urination Finding: Reports more frequent urination (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Example Question: Have you been urinating more often than usual? Finding: Reports urinating every hour or two during the day (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Example Question: How often do you urinate during the day? Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health. Example Question: How often do you wake up at night to urinate? Finding: Asked about diet Finding: Reports eating a bowl of cereal for breakfast yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. Example Question: What did you eat for breakfast yesterday? Finding: Reports eating mac and cheese for lunch yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. Example Question: What did you eat for lunch yesterday? Finding: Reports eating chicken and roll for dinner yesterday (Available)Pro Tip:Finding out the foods a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status and can affect medications given while in your care. Example Question: What did you eat for your last meal? Finding: Asked about change in appetite
Finding: Reports increased appetite (Found)Pro Tip: Identifying if a patient has recently experienced a change in appetite is important, as it could indicate an underlying endocrine or psychiatric condition. Example Question: Have you noticed an increase in appetite? Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions. Example Question: When did you notice the increase in your appetite? Finding: Asked about weight change Finding: Reports recent loss of 10 lbs (Available)Pro Tip: Determining the exact amount of weight loss can indicate whether it's within expected ranges, or extreme, which may indicate an underlying health problem. Example Question: How much weight have you lost? Finding: Reports weight loss occurred over the past month (Available)Pro Tip:Finding out the timeline for weight loss can indicate if it's sudden or gradual. Example Question: How long did it take you to lose 10 pounds? Finding: Followed up on reason for weight change Finding: Reports weight loss was unintentional (Found)Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan. Example Question: Was your weight loss intentional? Finding: Asked about history of asthma exacerbations Finding: Reports last asthma attack was in high school (Available)Pro Tip: Discovering the patient's most recent asthma attack can provide a timeline of exacerbations and help you better understand the patient's condition and effectiveness of any treatments. Example Question: When was your last asthma attack? Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient's most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient's condition and effectiveness of any treatments. Example Question: When did you last have issues with asthma? Finding: Asked about asthma symptoms
Finding: Reports specific age of diagnosis is 2.5 years old (Available)Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the patient's history of the condition, including the age of diagnosis. Example Question: At what age were you diagnosed with asthma? Finding: Asked about asthma management Finding: Reports using an inhaler (Found)Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy. Example Question: How do you manage your asthma? Finding: Reports inhaler is albuterol (Proventil) (Found)Pro Tip: Finding out the specific medication type or brand is essential in understanding whether it's a maintenance or rescue medication. Example Question: What is the name of the inhaler prescription? Finding: Reports last use of inhaler was 3 days ago (Available)Pro Tip: Determining the patient's last use of an inhaler clues you in to any recent breathing problems. Example Question: When did you last use your inhaler? Finding: Reports using inhaler no more than 2 times per week (Available)Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition. Example Question: How often do you use your inhaler? Finding: Asked about number of puffs when using asthma inhaler Finding: Reports recommended dose is 1-3 puffs as needed (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. Example Question: How many puffs of your inhaler are you prescribed? Finding: Reports typically taking 2 puffs (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. Example Question: How many puffs do you typically take? Finding: Reports sometimes needing 3 puffs to control symptoms (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. Example Question: What's the most puffs you ever take? Finding: Asked about asthma triggers
Finding: Reports asthma triggered by cats (Found)Pro Tip: Discovering occasional environmental triggers, such as animal allergies, gives you insight into exacerbating factors of your patient's condition. Example Question: What triggers your asthma problems? Finding: Reports asthma triggered by dust (Found)Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. Example Question: Does dust trigger your asthma? Finding: Denies seasonal triggers (Available)Pro Tip: Asking about seasonal triggers can help you understand a patient's complete set of asthma triggers over the course of a year. Example Question: Do you have seasonal asthma triggers? Finding: Asked about general allergies Finding: Reports allergy to cats (Found)Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies. Example Question: What allergies do you have? Finding: Followed up on cat allergy symptoms Finding: Reports sneezing, itchy eyes, and wheezing (Available)Pro Tip: Determining a patient's reaction to an allergen is essential to gauge if the allergy is life-threatening. Example Question: What is your reaction to cats? Finding: Asked about latex allergy Finding: Denies latex allergy (Available)Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts. Example Question: Are you allergic to latex? Finding: Asked about medication allergies Finding: Reports penicillin allergy (Found)Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient's safety while she is in your care, as it affects what medications will be safe and appropriate. Example Question: What medication allergies do you have? Finding: Asked about penicillin reaction
