NURS 6512n Week 3 – Digital Clinical Experience Orientation – Patient: Tina Jones

adeptance

Feb 5, 2024 — 10 min read

Please describe what you look forward to most in your upcoming activities within the DCE.

Student Response: I look forward to completing a head-to-toe assessment and communicating with the patient.

Model Note: There are many opportunities to learn and practice your clinical skills within the DCE, and we hope you are looking forward to all of them!

Started: May 22, 2022 | Total Time: 104 min

Hello my name is xx . I’m here to interview and examine you

Greet
03/12/23 8:13 PM EDT

Hey.

how are you today?

Question
03/12/23 8:13 PM EDT

Not so great… My foot really hurts right now.

Tell me what’s going on ?

Question
03/12/23 8:14 PM 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!

on a scale of 0 to 10 how can you rate your pain? (Clarified to On a scale of 0-10 how would you rate the pain in your right foot?.)

Question
03/12/23 8:15 PM EDT

I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. (Clarified to how I would rate my foot pain on a scale.)

how long has this being going on?

Question
03/12/23 8:16 PM 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 does this happen?

Question
03/12/23 8:17 PM 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.

What have you been using on the your foot (Clarified to What have you been doing for the scrape?.)

Question
03/12/23 8:18 PM EDT

I made sure to clean it and just keep it bandaged. And I put Neosporin on it. (Clarified to what I have been doing for the scrape.)

Are you taking anything for the pain ?

Question
03/12/23 8:19 PM EDT

Yeah, I had to start taking pain medication.

what pain medication are you taking?

Question
03/12/23 8:19 PM EDT

It’s called tramadol.

besides the medication what else do you do to manage your pain?

Question
03/12/23 8:21 PM EDT

I just watch what I eat and try to stay away from sweets.

Tell me more about you medical history?

Question
03/12/23 8:21 PM EDT

I’ve had asthma since I was little, and I have sugar diabetes, too.

How long have you been diabetic

Question
03/12/23 8:22 PM EDT

I was diagnosed when I was 24.

what medications are you taking for your diabetes

Question
03/12/23 8:22 PM EDT

I don’t take medicine for it anymore.

I’m sorry you have to go through this pain but will see how i can help you feel better

Empathize
03/12/23 8:24 PM EDT

Thanks.

you welcome (No matching questions found.)

Question
03/12/23 8:24 PM EDT

you are welcome (No matching questions found.)

Question
03/12/23 8:24 PM EDT

are you able to move you foot

Question
03/12/23 8:25 PM EDT

Um, my ankle’s starting to hurt when I move it.

have you had any x-ray of you ankle

Question
03/12/23 8:25 PM EDT

Yeah, they did.

what was the result (Clarified to Do you know what the X-ray of your injured foot showed?.)

Question
03/12/23 8:26 PM EDT

The x-ray was normal. Nothing broken. (Clarified to what the foot xray showed.)

great (No matching questions found.)

Question
03/12/23 8:26 PM EDT

are you have fever

Question
03/12/23 8:27 PM EDT

I don’t feel feverish right now, but last night I had a high temperature.

what was your temperature last night

Question
03/12/23 8:27 PM EDT

Last night it got up to 102.

did you take any medication for your fever

Question
03/12/23 8:28 PM EDT

I really didn’t do much for it at home.

have you noticed any discharge on your wound (Clarified to Does your scrape have pus?.)

Question
03/12/23 8:28 PM EDT

Yeah, there’s definitely pus. (Clarified to if my scrape has pus.)

how often do you change your wound dress a day (Clarified to How often do you change your bandage?.)

Question
03/12/23 8:29 PM EDT

Every morning and night. I was keeping an eye on it. (Clarified to how often I change my bandage.)

whats the color of the drainage

Question
03/12/23 8:30 PM EDT

It’s… white or maybe off-white.

ok (No matching questions found.)

Question
03/12/23 8:30 PM EDT

have you taken any antibiotic for your wound

Question
03/12/23 8:34 PM EDT

No, the ER only prescribed the pain meds.

are you experiencing pain anywhere else besides your ankle (Clarified to Do you have pain elsewhere than your foot?.)

Question
03/12/23 8:35 PM EDT

The pain’s worse in my foot, but I feel it moving up into my ankle, too. (Clarified to if I have pain elsewhere than my foot.)

are you able to wiggle your toes?

Question
03/12/23 8:36 PM EDT

I guess I can wiggle my toes a little, but it really hurts a lot to move my foot any.

is you foot warm or cool to touch

Question
03/12/23 8:36 PM EDT

Yeah, it feels pretty warm.

describe your pain

Question
03/12/23 8:37 PM EDT

It’s throbbing and like, sharp if I try to put weight on it.

what other conditions have you been diagnosed with (Clarified to What is your past medical history?.)

Question
03/12/23 8:39 PM EDT

I’ve had asthma since I was little, and I have sugar diabetes, too. (Clarified to what health problems I have had.)

does the pain wake you up at night

Question
03/12/23 8:41 PM EDT

I feel the pain at night, but I have been able to get to sleep.

do your pain keep you from participate in activities or things you enjoy

Question
03/12/23 8:42 PM EDT

Well, with my church friends, we do Bible study or we have a meal. With my other friends, I’ll go over to one of their houses to watch our shows or just hang out. And on the weekends, we’ll go out to a bar or go dancing.

How has the pain making you feel about yourself (Clarified to How do you feel about your appearance?.)

Question
03/12/23 8:44 PM EDT

I am who I am, you know? I don’t like stressing out about what I look like or anything like that. (Clarified to how I feel about my appearance.)

are you still able to get out and socialize like you usually do (No matching questions found.)

Question
03/12/23 8:46 PM EDT

have your family and friends been helpful (No matching questions found.)

Question
03/12/23 8:47 PM EDT

keep the bandages dry between change

Educate
03/12/23 8:50 PM EDT

Thanks for telling me.

clean wound wound with a soapy washcloth. you may do this in the shower (Clarified to How are you cleaning the wound?.)

Question
03/12/23 8:51 PM 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. (Clarified to how I am cleaning the wound.)

wash wound with soapy washcloth (No matching questions found.)

Question
03/12/23 8:52 PM EDT

are you allergic to any medications

Educate
03/12/23 8:53 PM EDT

Thanks for telling me.

Are you allergic to any medication?

Question
03/12/23 8:53 PM EDT

Yeah, I’m allergic to penicillin.

any food allergies

Question
03/12/23 8:54 PM EDT

Nope, no food allergies that I know of.

are you allergic to latex

Question
03/12/23 8:54 PM EDT

Nope.

what pharmacy do you use

Question
03/12/23 8:55 PM EDT

I always fill my inhaler prescription at the pharmacy near Mom’s house.

do you know the name of the pharmacy (No matching questions found.)

Question
03/12/23 8:55 PM EDT

what pharmacy do you get your medications from?

Question
03/12/23 8:56 PM EDT

I always fill my inhaler prescription at the pharmacy near Mom’s house.

I want you to wash your wound with soapy water

Educate
03/12/23 8:59 PM EDT

Thanks for telling me.

dry wound gently with clean towel (No matching questions found.)

Question
03/12/23 8:59 PM EDT

dry wound gently with clean towel

Educate
03/12/23 9:00 PM EDT

Thanks for telling me.

apply antibiotic ointment to wound

Educate
03/12/23 9:00 PM EDT

Thanks for telling me.

apply a dry clean bange

Educate
03/12/23 9:01 PM EDT

Thanks for telling me.

do wound care twice a day

Question
03/12/23 9:02 PM EDT

I made sure to clean it and just keep it bandaged. And I put Neosporin on it.

take your medications , monitor your temperature , eat a balance meal, drink lots of fluids and plenty of rest

Educate
03/12/23 9:04 PM EDT

Thanks for telling me.

lets talk about your diabetes (Clarified to Tell me more about your diabetes..)

Question
03/12/23 9:05 PM EDT

I don’t think there’s a lot to say about it . . . it seems pretty under control, and it’s just type 2 anyway. (Clarified to to tell you about my diabetes.)

when was the last time you had a asthma attack

Question
03/12/23 9:09 PM EDT

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.

what did you take when you had the breathing problem (Clarified to Can you describe your breathing problems?.)

Question
03/12/23 9:09 PM EDT

When my asthma acts up, I feel like my chest is tight, like I can’t really take in air. And I usually wheeze. (Clarified to to describe my breathing problems.)

what medication are you taking for your Asthma

Question
03/12/23 9:10 PM EDT

It’s just a regular Proventil inhaler.

how often do you use your inhaler

Question
03/12/23 9:10 PM EDT

Not often. Maybe two or three times a week.

sorry about you have to go throw this

Empathize
03/12/23 9:14 PM EDT

Thanks.

Treating high cholesterol helps lower your risk of stroke

Educate
03/12/23 9:15 PM EDT

Thanks for telling me.

It sounds like that was a challenging time for you

Empathize
03/12/23 9:16 PM EDT

Thanks.

Examined right eye.

Exam Action
03/12/23 9:20 PM EDT

Examined left eye.

Exam Action
03/12/23 9:20 PM EDT

Percussed posterior left upper chest wall

Exam Action
03/12/23 9:22 PM EDT

Percussed posterior right upper chest wall

Exam Action
03/12/23 9:22 PM EDT

Percussed posterior right middle chest wall

Exam Action
03/12/23 9:22 PM EDT

Percussed posterior left middle chest wall

Exam Action
03/12/23 9:22 PM EDT

Percussed posterior left lower chest wall

Exam Action
03/12/23 9:22 PM EDT

Percussed posterior right lower chest wall

Exam Action
03/12/23 9:22 PM EDT

Percussed posterior right lower chest wall

Exam Action
03/12/23 9:23 PM EDT

Percussed posterior left lower chest wall

Exam Action
03/12/23 9:23 PM EDT

Percussed posterior left lower chest wall

Exam Action
03/12/23 9:23 PM EDT

Percussed posterior right lower chest wall

Exam Action
03/12/23 9:23 PM EDT

Percussed anterior right upper chest wall

Exam Action
03/12/23 9:23 PM EDT

Percussed anterior left upper chest wall

Exam Action
03/12/23 9:23 PM EDT

Percussed anterior right middle chest wall

Exam Action
03/12/23 9:23 PM EDT

Percussed anterior left middle chest wall

Exam Action
03/12/23 9:23 PM EDT

Percussed anterior right lower chest wall

Exam Action
03/12/23 9:23 PM EDT

Percussed anterior left lower chest wall

Exam Action
03/12/23 9:23 PM EDT

CompletedOrientation

Exam Action
03/12/23 9:27 PM EDT

hello my name is isatu, i’m here to interview and examine you

Greet
03/13/23 6:50 PM EDT

Hey.

what brings you in today?

Question
03/13/23 6:50 PM 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!

treating high cholesterol help lower your risk of stroke

Educate
03/13/23 6:52 PM EDT

Thanks for telling me.

It sounds like that was a challenging time for you

Empathize
03/13/23 6:53 PM EDT

Thanks.

Examined right eye.

Exam Action
03/13/23 6:55 PM EDT

Examined left eye.

Exam Action
03/13/23 6:55 PM EDT

Percussed posterior left upper chest wall