Hello. How are you today? I will talk with you and check your body today.

Table of Contents

Hi.

What brings you here today?

I’m here to talk about my last visit regarding my joint pain and how tired I’ve been.

I understand.

Thank you.

How long have you had joint pain?

The joint pain started about 3 months ago.

Where do you feel the joint pain?

Primarily in my hands and wrists, but I also experience pain all over my body.

Can you describe your pain?

I feel stiff and achy all over, with a dull, throbbing pain in my hands and wrists.

What makes your pain worse?

Activities like holding my coffee cup or typing aggravate the pain.

What helps relieve your pain?

Hot showers and diclofenac medication provide some relief.

On a scale of 1 to 10, how would you rate your pain?

Since starting diclofenac, maybe a 2 out of 10.

How long have you felt fatigued?

For about 3 months.

Is your fatigue constant?

Yes, it’s always there.

Does anything make your fatigue worse?

It tends to worsen as the day goes on.

What contributes to your fatigue?

I’m not sure, possibly stress.

I’m sorry to hear that.

Thank you.

Can you still manage your daily activities?

Yes, but it takes longer due to fatigue.

What might be causing your fatigue?

I’m not sure, maybe hormones or stress.

Do you have any allergies?

Yes, to codeine.

Any food allergies?

No.

How often do you experience pain?

It’s constant, especially in the morning.

Any other health issues?

Besides joint pain and fatigue, nothing diagnosed.

Have you experienced any mental health concerns?

Nothing diagnosed, but I’ve been feeling down and anxious lately.

I’m sorry to hear that.

Thank you.

Have you been hospitalized before?

Only for childbirth.

Have you had any surgeries?

No.

Are you taking any medications?

Yes, diclofenac and previously ibuprofen, and I have an IUD.

What’s the dosage of diclofenac?

50 mg.

Why were you prescribed diclofenac?

For joint pain.

How much ibuprofen did you take?

400 mg, 2 or 3 times a day.

Which IUD do you have?

Levonorgestrel.

Do you take your medications as directed?

Yes, always.

When did you last take your medication?

This morning, the diclofenac.

Do you smoke?

No, never.

Do you drink alcohol?

Yes, occasionally.

What’s your typical diet?

I try to eat healthy with lots of fruits, veggies, and lean proteins.

How much water do you drink daily?

About 6 to 8 glasses.

Do you consume caffeine?

Yes, a few cups of coffee daily.

It’s important not to overdo it with caffeine.

Got it.

Do you exercise?

I walk the dog a few times a week, but not much else.

Regular exercise is important for overall health.

I understand.

How many hours of sleep do you get?

About 5 or 6 hours.

What do you do for work?

I run an art gallery called Bricolage with my husband, and I’m also an artist.

What’s your education level?

I have degrees in studio art and art history.

Are you satisfied with your income?

The gallery is profitable now, but running a small business is challenging.

Feeling stressed?

Yes, it’s been tough.

NURS-6051N Week 11: Assignment POLICY/REGULATION FACT SHEET EXAMPLE