NURS PEDS 602 Anita pneumonia shadow health
Experience Overview
Patient: Anita Douglas
Digital Clinical Experience Score84.2%
This score measures your
... [Show More] performance on the Student Performance Index in relation to
other students in comparable academic programs. Your instructor has chosen to scale
your Student Performance Index score so that the average score on the index is a
80.0%. This score may not be your fnal grade if your instructor chooses to include
additional components, such as documentation or time spent.
Student Performance Index
46
out of
62
Profciency Level:
Beginning
Beginning
Developing
Profcient
Students rated as “beginning” are starting to develop their advanced practice
competencies and clinical reasoning skills. In comparable programs, 50% of students
perform at the level of a beginning practitioner. Review your results in the tabs on the
left side of the page to identify areas for improvement.
Subjective Data Collection
27
out of
29
Medication Selection
1
out of
9
Education and Empathy
1
out of
5
Patient Teaching7
out of
9
Prescription Writing
10
out of
10
Time
52 minutes total spent in assignment
Interaction with patient
52 minutes
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
Subjective Data Collection: 27 of 29
(93.1%)
Hover To Reveal...
Hover over the Patient Data items below to reveal important information,
including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview
with this patient.Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following
details are facts of the patient's case.
Chief Complaint
Finding:
Established chief complaint and reason for admittance
Finding:
Reports fever
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are
presenting. Asking about the chief complaint will allow the patient to voice any
concerns or symptoms the patient may have.
Example Question:
Do you have a fever?
Finding:
Reports chest pain
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are
presenting. Asking about the chief complaint will allow the patient to voice any
concerns or symptoms the patient may have.
Example Question:
Do you have chest pain?
Finding:
Reports cough
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are
presenting. Asking about the chief complaint will allow the patient to voice any
concerns or symptoms the patient may have.
Example Question:
Do you have a cough?
History of Present Illness
Finding:
Asked about additional symptoms
Finding:
Reports fatigue
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Are you fatigued?
Finding:
Reports coughing up sputum
(Found)Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you cough anything up?
Finding:
Reports sinus congestion
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Are you feeling congested?
Finding:
Reports muscle soreness
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Are your muscles sore?
Finding:
Asked about onset and duration of symptoms
Finding:
Reports fatigue began 3 days ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your fatigue start?
Finding:
Reports chest pain began 3 days ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your chest pain start?
Finding:
Reports productive cough began 3 days ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:When did your cough start?
Finding:
Reports sinus congestion began 3 days ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your congestion start?
Finding:
Reports fever began 1 day ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your fever start?
Finding:
Asked about frequency of symptoms
Finding:
Reports fatigue is constant(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often are you fatigued?
Finding:
Reports fever is constant
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Is the fever constant?
Finding:
Reports congestion is constant
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often are you congested?
Finding:Reports less severe chest pain is constant
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often do you have less severe chest pain?
Finding:
Reports more severe chest pain occurs with coughing
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often do you have more severe chest pain?
Finding:
Reports coughing every few minutes
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often do you cough?
Finding:
Followed up on location of pain
Finding:
Reports pain in lower right side of chest
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Where is your pain located?
Finding:
Followed up on characteristics of pain
Finding:
Reports chest pain is dull
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
What is the pain like?
Finding:Followed up on characteristics of discharge
Finding:
Reports coughing up rust-colored sputum
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Can you describe your mucus?
Finding:
Reports nasal mucus varies from yellow to green in color
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Can you describe your mucus?
Finding:
Asked about aggravating factors
Finding:
Reports deep breathing aggravates chest pain(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does deep breathing hurt your chest?
Finding:
Reports speaking aggravates chest pain
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does speaking hurt your chest?
Finding:
Reports physical exertion aggravates chest pain and fatigue
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does exertion make your symptoms worse?
Finding:Asked about non-medicational relieving factors
Finding:
Reports resting provides relief
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does resting help your symptoms?
Finding:
Reports tea provides relief
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you drink tea?
Finding:
Reports humidifer steam provides slight relief
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you use a humidifer?
Finding:
Asked about severity of pain
Finding:
Reports chest pain when not coughing is 2 out of 10
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
How severe is your chest pain when you're not coughing?
Finding:
Reports chest pain during normal coughing is 5 out of 10
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
How severe is your chest pain when coughing?
Past Medical History
Finding:
Asked about pre-existing health conditions
Finding:
Reports chronic kidney disease stage 2
(Found)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and
previous conditions or concerns. Information about the patient's existing health
conditions, a timeline of diagnosis, symptoms, and allergies can indicate where
you should follow-up for further care and treatment.
Example Question:
Do you have any existing health conditions?
Finding:
Reports hypertension
(Found)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and
previous conditions or concerns. Information about the patient's existing health
conditions, a timeline of diagnosis, symptoms, and allergies can indicate where
you should follow-up for further care and treatment.
Example Question:
Do you have any existing health conditions?
Finding:
Asked about onset and duration of pre-existing health conditions
Finding:Reports chronic kidney disease was diagnosed 9 years ago
(Available)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and
previous conditions or concerns. Information about the patient's existing health
conditions, a timeline of diagnosis, symptoms, and allergies can indicate where
you should follow-up for further care and treatment.
Example Question:
When were you diagnosed with chronic kidney disease?
Finding:
Reports hypertension was diagnosed 14 years ago
(Found)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and
previous conditions or concerns. Information about the patient's existing health
conditions, a timeline of diagnosis, symptoms, and allergies can indicate where
you should follow-up for further care and treatment.
Example Question:
When were you diagnosed with hypertension?
Finding:
Asked about hospitalizations
Finding:
Denies recent hospitalizations
(Found)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and
previous conditions or concerns. Information about the patient's existing health
conditions, a timeline of diagnosis, symptoms, and allergies can indicate where
you should follow-up for further care and treatment.Example Question:
Have you been hospitalized recently?
Finding:
Asked about allergies
Finding:
Denies allergies
(Found)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and
previous conditions or concerns. Information about the patient's existing health
conditions, a timeline of diagnosis, symptoms, and allergies can indicate where
you should follow-up for further care and treatment.
Example Question:
Do you have any allergies?
Finding:
Asked about vaccines
Finding:
Reports receiving pneumococcal vaccine 12 years ago
(Found)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and
previous conditions or concerns. Information about the patient's existing health
conditions, a timeline of diagnosis, symptoms, and allergies can indicate where
you should follow-up for further care and treatment.
Example Question:Have you had the pneumococcal vaccine?
Finding:
Reports receiving flu vaccine 3 months ago
(Found)
Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and
previous conditions or concerns. Information about the patient's existing health
conditions, a timeline of diagnosis, symptoms, and allergies can indicate where
you should follow-up for further care and treatment.
Example Question:
Have you had the flu shot this year?
Home Medications
Finding:
Asked about home medications
Finding:
Reports taking trandolapril/verapamil combination drug
(Found)
Pro Tip: A patient's home medications can provide insight into the patient's
current treatment and its efcacy. Inquiring into medication history, dosage, and
frequency will help you understand the patient's background and how it may
affect their current situation.
Example Question:
Are you currently taking medications?
Finding:Reports taking chlorothiazide
(Found)
Pro Tip: A patient's home medications can provide insight into the patient's
current treatment and its efcacy. Inquiring into medication history, dosage, and
frequency will help you understand the patient's background and how it may
affect their current situation.
Example Question:
Are you currently taking medications?
Finding:
Reports taking aspirin
(Found)
Pro Tip: A patient's home medications can provide insight into the patient's
current treatment and its efcacy. Inquiring into medication history, dosage, and
frequency will help you understand the patient's background and how it may
affect their current situation.
Example Question:
Are you currently taking medications?
Finding:
Followed up on trandolapril/verapamil
Finding:
Reports taking trandolapril/verapamil for hypertension and chronic kidney
disease
(Found)
Pro Tip: A patient's home medications can provide insight into the patient's
current treatment and its efcacy. Inquiring into medication history, dosage, andfrequency will help you understand the patient's background and how it may
affect their current situation.
Example Question:
Why do you take trandolapril/verapamil?
Finding:
Reports pill contains 2 milligrams of trandolapril and 180 milligrams of verapamil
(Found)
Pro Tip: A patient's home medications can provide insight into the patient's
current treatment and its efcacy. Inquiring into medication history, dosage, and
frequency will help you understand the patient's background and how it may
affect their current situation.
Example Question:
What dosage is the trandolapril/verapamil?
Finding:
Reports taking trandolapril/verapamil pill once a day
(Found)
Pro Tip: A patient's home medications can provide insight into the patient's
current treatment and its efcacy. Inquiring into medication history, dosage, and [Show Less]