Shadow Health - Tina Jones, Health History
Health History Tips & Tricks: ans -
Student: Hello! ans -Diana Shadow: Hi. I'm Preceptor Diana. I will
... [Show More] 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? ans -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? ans -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 preexisting 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? ans -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? ans -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? ans -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? ans -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. ans -
Patient Exam - Vital Signs: ans -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: ans -
Student: Hello, my name is Catlain, I am your nurse today. ans -Tina Jones: Hey.
Student: Can you confirm your name? ans -Tina Jones: Tina Jones:.
Student: Why did you come in today? ans -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? ans -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? ans -Tina Jones: ...Like a 7. It hurts a
lot, but whatever pain med the ER gave me is helping a little bit.
Student: Please describe the pain. ans -Tina Jones: It's throbbing and like, sharp if I try to put weight on
it.
Student: How did you hurt your foot? ans -Tina Jones: I was changing a light bulb, and I had to use our
little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how
sharp the edge was!
Student: Has your foot been draining any liquids? ans -Tina Jones: Yeah, there's definitely pus.
Student: What color was the pus? ans -Tina Jones: It's... white or maybe off-white.
Student: How have you treated the wound? ans -Tina Jones: I've been taking Advil for my foot for a few
days.
Student: What did you do to treat your foot after your accident? ans -Tina Jones: I made sure to clean it
and keep it bandaged. And I put Neosporin on it.
Student: How effective was the Neosporin? ans -Tina Jones: Well, I'm here, so I guess it didn't do its job.
Student: Can you walk with your foot being injured? ans -Tina Jones: No, I can't. I can't put any weight
on it without like, shooting pain.
Student: What preexisting medical conditions do you have? ans -Tina Jones: I mean, I have asthma and
diabetes, but right I now I just care about my foot!
Student: I understand your foot hurts, but I need to know this information to make sure I take care of
the problem correctly. ans -Tina Jones: Thanks.
Student: When were you diagnosed with diabetes? ans -Tina Jones: I was diagnosed when I was 24.
Student: What do you do to manage your asthma? ans -Tina Jones: I try to avoid things that give me
breathing problems, but when my asthma starts to act up, I just use my inhaler.
Student: What medications did you take for your diabetes? ans -Tina Jones: It was metformin.
Student: Do you currently take medicine for your diabetes? ans -Tina Jones: No, I don't take anything for
my diabetes anymore.
Student: What made you stop taking medication for your diabetes? ans -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? ans -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? ans -Tina Jones: I don't know. Every hour or two when I'm
awake?
Student: What is your current diet? ans -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? ans -Tina Jones: Yeah, lately I've definitely been much
hungrier than usual.
Student: Has your weight changed? ans -Tina Jones: Yeah, I've lost some weight recently.
Student: Do you know why you lost weight? ans -Tina Jones: I don't know what caused it, I just lost
weight.
Student: How often do you have asthma exacerbations? ans -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? ans -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? ans -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? ans -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? ans -Tina Jones: I'm allergic to cats.
Student: When did you realize you were allergic to cats? ans -Tina Jones: For as long as I've been around.
Student: How effective was your pain medication at home? ans -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? ans -Tina Jones: I'm allergic to penicillin.
Student: What food allergies do you have? ans -Tina Jones: I don't have any food allergies that I know of.
Student: Are you allergic to dust, mold, or pollen? ans -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? ans -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? ans -Tina Jones: No.
Student: Have you had any prior hospitalizations? ans -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? ans -Tina Jones: No. I've never really had stomach
or bowel problems.
Student: Do you have a family history of psychiatric illness? ans -Tina Jones: No. They're crazy, but
nobody's diagnosed with anything.
Student: Do you have any neck, throat or gland problems? ans -Tina Jones: No, not that I noticed.
Student: Do you have any problems with your head? ans -Tina Jones: I don't think I have any problems. I
get headaches sometimes, but that's all.
Student: Any problems with your ears? ans -Tina Jones: No.
Student: Any problems with your eyes and vision? ans -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? ans -Tina Jones: My nose is fine right now. Sometimes it runs,
but not very often.
Student: Do you have problems with your mouth? ans -Tina Jones: No.
Student: Do you have a history of cardiovascular problems? ans -Tina Jones: My heart's fine, thank God!
Student: Any problems with your heart? ans -Tina Jones: No, my heart's always been fine.
Student: Have you had any problems with your breasts? ans -Tina Jones: I haven't noticed any pain
there.
Student: Have you had any reproductive problems? ans -Tina Jones: I don't think I have problems in that
area. I just get really bad periods, that's all.
Student: Have you had any neurological problems? ans -Tina Jones: No, I haven't.
Student: Have you had any musculoskeletal problems? ans -Tina Jones: No.
Student: Do you have a history of skin disease? ans -Tina Jones: Um, I have acne, if that counts.
Student: Does your paternal grandfather have any health problems? ans -Tina Jones: Grandpa Jones had
colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and...I'm
pretty sure he had diabetes. And high cholesterol like everyone else in my family.
Student: Does your mother have any health problems? ans -Tina Jones: Mom has high cholesterol and
blood pressure, I think. She seems to be doing okay though.
Student: Does your father have any health problems? ans -Tina Jones: Well, he passed away. But he had
a couple things... Type 2 diabetes, like me, and high cholesterol and blood pressure.
Student: How did your father die? ans -Tina Jones: He died in a car accident.
Student: Where is your wound located? ans -Tina Jones: It's on the ball of my foot.
Student: Do you get thirsty often? ans -Tina Jones: You know, I did notice lately that I've been really
thirsty.
Student: What happened with your father's car accident? ans -Tina Jones: It was last year... I guess a
little over a year ago.
Student: How long ago was your dad's car accident? ans -Tina Jones: It was last year... I guess a little
over a year ago.
Student: How did you cope with your fathers death? ans -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? ans -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? ans -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? ans -Tina Jones: Grandpa Jones passed away when I
was really little.
Student: How is your maternal grandfather's health? ans -Tina Jones: Well, Poppa died about five years
ago.
Student: How is your maternal grandmother's health? ans -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? ans -Tina Jones: He's a healthy guy. Kind of big like me.
Student: How is your sister's health? ans -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? ans -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? ans -Tina Jones: No, I don't think so.
Student: Does your family have a history of substance abuse? ans -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? ans -Tina Jones: No, not that I know of.
Student: How much alcohol do you drink? ans -Tina Jones: I only have a few drinks when I go out.
Student: What is your level of education? ans -Tina Jones: Well, I'm finishing up my bachelor's degree
right now.
Student: What are stressors? ans -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. ans -Tina Jones: Thanks.
Student: Where do you live? ans -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? ans -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? ans -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? ans -Tina Jones: Well, I used to smoke pot. . . but I don't do that
anymore.
Student: What type of drugs did you use? ans -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? ans -Tina Jones: No.
Student: When did you last use drugs? ans -Tina Jones: I haven't smoked pot since I was twenty or
twenty-one.
Student: Have you ever smoked cigarettes? ans -Tina Jones: No. I think it's gross.
Student: Have you been around people that are smoking? ans -Tina Jones: Some of my friend's smoke
when we go out drinking. But I don't smoke, and nobody at home smokes [Show Less]