Shadow Health – Tina Jones, Health
History
Health History Tips & Tricks:
(Ans- TJ Health Interview
Student: Hello!
(Ans- 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?
(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
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?
(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.
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:
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.