Coldspa pain example

Student example

General status, vital signs and pain: Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions

Findings

Current Status

1. Allergies: Food, medication, environmental

No Known Drug Allergies or food allergies; is allergic to cats—gets a stuffy nose when in close proximity.

2. Present health concerns

Vocalizes concern about hypercholesterolemia. Denies other health concerns.

Past History

3. Recent weight gains or losses?

NA

4. Previous high fevers, cause, and treatment?

Denies any recent fevers.

5. History of abnormal pulse?

none

6. History of abnormal respiratory rate or character?

Denies history of respiratory illness.

7. Usual blood pressure, who checked it last, and when?

Usual blood pressure is described by patient as normal. Checked last month at doctor’s office, reading: 100/76.

8. History of pain and treatment?

Complains of arthritis in hands.

Family History

9. Hypertension? Paternal grandfather has history of hypertension.

10. M metabolic/growth problems?

Denies family history of metabolic or growth problems.

Pain (Everyone has had pain at some time or other-if your patient is healthy and currently pain-free, you may need to use a past instance of pain.)

11. P Pain (using COLDSPA) Character: how does it feel—what sort of pain is it?

Aching sensation

Commented [D1]: Note that examples may not be exactly like your assignment-this form is used in several classes and differs from class to class.

Commented [D2]: -1 pt. NA not appropriate for this class. Could have used “Denies”

Commented [D3]: -1 pt. “Denies” would have been OK— “none” not appropriate for this class.

Commented [D4]: This is OK because it is using the patient’s own words—no point off for this. It goes on to describe what the patient considers “normal”.

Commented [D5]: The form asks for history, which this assessment partner has—we need how long and what treatment here. -1 pt.

12. Onset:

About 10 years ago

13. Location:

Base of both thumbs and in her fingers.

14. Duration:

Mild constant underlying pain

15. Severity (scale of 1 – 10):

1 - 2

16. Pattern—what makes it better or worse:

NSAID’s help temporarily, specifically Advil. She takes a dose 2 – 3 times per week as directed on the bottle. (She reports taking either 3 or 4 200 mg. tablets in a dose, depending on how uncomfortable she is.)

17. Associated factors— does it cause you to have other symptoms too?

Weather affect it, cold weather make it worse.

18. How does pain impact the other areas of life?

2.What are your concerns about the pain’s effect on

a. general activity? Denies effect

b. mood/emotions? Makes pt feel old

c. concentration? Denies effects

d. physical ability? She doesn’t exercise on days when she it is worse.

e. work? Denies effects

f. relations with other people? Initially denies effects, though admits that she is more irritable and impatient with others.

g. sleep? Denies effects

h. appetite? Denies effects

Commented [D6]: Could have been more specific— “constant” does describ