Health History Tina Jones information Processing
Health History Tina Jones information Processing
Information Processing : 40 of 40 (100.0%)
Each relevant diagnosis is scored on a four-point scale:
Priority (1 point): the correct priority of the diagnosis was chosen
Evidence (up to 2 points): the strength of the patient cue(s) selected as evidence for the identified diagnosis
Required Evidence: selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points
Supporting Evidence: selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 point
Planning (1 point): the plan proposed to address the diagnosis includes at least one correct component
Relevant Diagnoses
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1. Acute pain of the foot
4 of 4 points
Priority 1 / 1
Student Response: xx
Correct Priority: xx
Priority Pro Tip: Managing acute pain is an immediate xxx priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain Health History Tina Jones information Processing.
Evidence 2 / 2
Relevant
“I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.” Required Evidence
Irrelevant
(None provided)
Evidence Pro Tip: Tina reports intense pain and rates her pain on a numerical scale. She also reports characteristics of the pain, including its duration of one week; this timespan defines her pain as acute.
Planning 1 / 1
Relevant
Intervene – Prescribe: Prescribe medications to treat pain.
Educate – Medication: Educate the patient on medications used for pain relief.
Educate – Medication: Educate the patient on non-pharmaceutical methods to reduce pain intensity.
Irrelevant
(None provided)
Planning Pro Tip: Intervene to reduce the pain by prescribing an appropriate analgesic and educating the patient on its effective use and potential side effects. Provide the patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation).
2. Local infection of skin and subcutaneous tissue of the foot Health History Tina Jones information Processing
4 of 4 points
Priority 1 / 1
Student Response: xx
Correct Priority: xx
Priority Pro Tip: Treating this infection is a xxpriority, as failure to treat the infection may lead to it spreading to surrounding tissues or systemically. Treating the infection can prevent adverse events such as osteomyelitis and bacteremia.
Evidence 2 / 2
Relevant
“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.” Required Evidence
Irrelevant
(None provided)
Evidence Pro Tip: Tina presents with an open wound on the plantar surface of the foot. The wound is red, swollen, warm, and produces purulent discharge. Tina reports that the appearance and level of discomfort have worsened with time- all of these factors support a diagnosis of acute infection.
Planning 1 / 1
Relevant
xx
Intervene – Prescribe: Prescribe antibiotics.
Intervene – Other: Clean wound and cover with sterile dressing.
Educate – Medication: Educate the patient on the course of antibiotics, importance of taking all prescribed antibiotics, and side-effects.
Educate – Health Maintenance: Educate the patient on wound care procedure.
Educate – Disease Process: Educate the patient on the role of diabetes mellitus in the healing of wounds Health History Tina Jones information Processing.
Educate – Disease Process: Educate the patient on the signs and symptoms of worsening infection.
Irrelevant
(None provided)
Planning Pro Tip: Assess the wound directly and obtain a culture so that the infectious organism may be identified, then clean and re-dress the wound. Regional lymph nodes may be swollen. Because the infection is the root cause of Tina’s other acute issues, prescribing an anti-infective will begin to resolve the issues; after receiving culture results, the specific anti-infective given may be changed. Ensure that Tina understands how to treat the wound, use the anti-infective effectively, and to report symptoms of a worsening infection. Foot care is especially important for diabetics, so you should help Tina better understand diabetes’ impact on wound healing and the need to proactively monitor her foot health.
3. Uncontrolled type 2 diabetes mellitus
2 of 4 points
Priority 1 / 1
Student Response: xx
Correct Priority:xx
Priority Pro Tip: Tina’s uncontrolled diabetes will delay her wound healing and places her at risk for end organ damage. The need to provide better glucose control for Tina makes this a xx priority.
Evidence 0 / 2
Relevant
(None provided)
Irrelevant
“I don’t take anything for my diabetes anymore.”
Evidence Pro Tip: Tina’s current blood glucose level supports a diagnosis of uncontrolled type 2 DM. Tina reports symptoms consistent with poor control such as polyuria, polydipsia, and nocturia.
Planning 1 / 1
Relevant
Intervene – Labs: Order a basic metabolic panel to assess renal function.
Intervene – Labs: Order a hemoglobin A1C test to establish baseline.
Intervene – Labs: Order a urinalysis to check for proteinuria.
Intervene – Prescribe: Prescribe a first-line drug for blood glucose control, such as metformin.
Educate – Medication: Educate the patient on diabetes medication action, dose, and schedule.
Educate – Health Maintenance: Educate the patient on self-monitoring of blood glucose level procedure and its role in treating diabetes.
Educate – Health Maintenance: Educate the patient on the impact of diet, exercise, and weight loss on glycemic control.
Educate – Health Maintenance: Educate the patient on the importance of screening tests and foot care, as relates to diabetes.
Educate – Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care.
Educate – Disease Process: Educate the patient on the signs and symptoms of hyper- and hypoglycemia.
Irrelevant
Intervene – Labs: Order a fasting plasma glucose test.
Intervene – Labs: Order a test of serum IGF-1 (insulin like growth factor).
Educate – Health Maintenance: Educate the patient on the role of lifestyle changes, including diet and exercise, in improving health outcomes.
Educate – Disease Process: Educate the patient on the role of diabetes mellitus in the healing of wounds.
Educate – Disease Process: Educate the patient regarding the relationship of diabetes mellitus and peripheral vascular disease Health History Tina Jones information Processing.
Planning Pro Tip: Assess for impacts of Tina’s uncontrolled diabetes including diminished peripheral pulses, peripheral and sensory neuropathy, and retinopathy, and order labs to check for renal function and abnormal lipid levels. Establish a baseline fasting glucose level and educate Tina on the need to monitor her blood glucose and be aware of symptoms of hyperglycemia. Provide better control by prescribing a first-line drug for glucose control. As Tina’s diabetes is uncontrolled, educate her on appropriate diet, monitoring, and treatment regimens.
4. Asthma
4 of 4 points
Priority 1 / 1
Student Response: Low
Correct Priority: Low
Priority Pro Tip: Although Tina requires education to better manage her asthma, she does not report active respiratory complaints, making this a lower priority diagnosis.
Evidence 2 / 2
Relevant
“I usually use two puffs from my albuterol inhaler — it’s 90 micgrograms a spray — but lately sometimes I need three puffs. [AUDIO COMING SOON]” Required Evidence
Irrelevant
(None provided)
Evidence Pro Tip: Tina reports a personal history of asthma, including past hospitalizations for asthma attacks, as well as her use of an albuterol inhaler. Her sibling’s asthma is of interest, given the strong genetic and environmental factors in the development of asthma Health History Tina Jones information Processing.
Planning 1 / 1
Relevant
Assess – Respiratory: Assess lung sounds with auscultation.
Assess – Respiratory: Assess pulmonary function using spirometry.
Assess – Respiratory: Assess respirations (rate, rhythm, depth, quality).
Intervene – Other: Develop an asthma action plan with the patient.
Educate – Health Maintenance: Educate the patient on avoiding triggers of asthma.
Educate – Health Maintenance: Educate the patient on enacting her asthma action plan including proper use of rescue inhaler Health History Tina Jones information Processing.
Irrelevant
Assess – Respiratory: Assess for reduced forced expiratory volume using spirometry.
Planning Pro Tip: Because Tina does not report treatment for maintenance of her asthma, instead relying on a rescue inhaler for sporadic attacks, educate her on developing and enacting a proactive plan to manage the disease. Though Tina does not report an active respiratory complaint, it is valuable to assess for abnormal findings that she may no
