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Shadow Health - Tina Jones, Health History

Terms in this set (474)

Priority - High Priority Pro Tip: This is a high priority. The patient is unable to bear weight on her affected leg, which prevents walking. This impacts her daily life and increases her risk for falls and deep-vein thrombosis. Evidence - 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." "I got this scrape on my foot a while ago, and it got really infected. It's killing me." "No, I can't. I can't put any weight on it without like, shooting pain." Evidence Pro Tip: The strongest evidence of impaired walking is that Tina directly reports she can't bear weight or walk on her affected foot. Other supporting data points are the presence of her foot wound and her general reports of pain. Planning - Relevant: Assess - Musculoskeletal: Assess the patient's ability to bear weight and gait. Assess - Musculoskeletal: Assess the patient's mobility. Consult / Refer: Consult with physical therapist to develop a plan to improve the patient's mobility. Intervene - Mobility: Assist the patient as needed with mobility. Intervene - Mobility: Provide assistive devices to facilitate mobility (crutches, therapeutic boot to minimize pressure on plantar surface, wheelchair). Planning Pro Tip: Assess how well the patient can bear weight and walk. While the patient is in your care, work with other healthcare professionals to keep the pain managed and improve the patient's mobility. Provide assistance with activities such as toileting and ensure that the patient can access and use assistive devices.
Priority - High Priority Pro Tip: Poorly managed diabetes and uncontrolled blood glucose complicate wound healing. As the underlying cause for delayed healing and infection, they must be addressed. Evidence - Relevant: "No, I don't take anything for my diabetes anymore." "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." "I have a monitor at home, but to be honest I don't really use it that often." Evidence Pro Tip: Tina directly reports ineffective diabetes management when discussing her lack of treatment. She expresses gaps in health literacy about the risk of ceasing prescribed medication and blood glucose monitoring. Supporting evidence comes from her inability to incorporate meaningful dietary changes or increase her exercise. Planning - Relevant: Assess - Health Literacy and Patterns: Assess the patient's knowledge related to diabetic disease process, assess personal/social supports. Assess - Health Literacy and Patterns: Assess the patient's perceived barriers to adherence to the prescribed regimen (cost, adverse effects, lack of knowledge). Assess - Health Literacy and Patterns: Assess the patient's readiness for change/education. Educate - Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. Planning Pro Tip: To gain a deep understanding of your patient's situation, determine her level of health literacy, her feelings and beliefs about the disease, and the motivation behind her choices. Educate the patient about what risks are, and what good diabetes care looks like. Most importantly, ask about her goals and changes she may be willing to make.