Undergraduate students, become a tester for Shadow Health! Topics (15) Reports no current breathing problems. . She denies any acute concerns at this visit. and facial and body hair has improved. That stuff can mess you up. (2018). What is your relationship like with your family? consume 1-2 diet sodas per day. exercise four to five times per week consisting of No tics or facial fasciculation. Her last dental exam was over two years ago. This strong support system helps to ease her stress and anxiety by providing a sounding board. A week ago the scrape startedand the pain got a lot worse in last few days. She states she can cope well with upcoming life changes. A dietician referral may be beneficial to educate on specifics and offer support. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Strength 5/5 bilateral upper and lower extremities. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). possibletriggerslikeenvironmentalfactors,bodilypositions,ormovementsthatmay Hair is normal texture and distributed evenly. hearing, ear pain, or discharge. denies any acute concerns. The rescue inhaler was last used three months ago with a total of two uses in the past year. Grand Canyon University (75) comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. Reports asthma medication has not changed. Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. I have a few friends Ive known since middle or high school, and were all pretty close. Pustules noted on bilateral cheeks. Head is normal cephalic atraumatic. Liver span 7 cm MCL, palpable 1 cm below right costal margin. Company. What is your new job? Reports decreased stress and improved coping She was exposed to cats a few days ago and had to use her inhaler once; she reports having to use three puffs instead of the prescribed two. The foot feels better when she rests, and it hurts more when she walks on it. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work. function normal. . Tina Jones is a 28-year-old African American female patient who is single and presented to the clinic with a request for a pre-employment physical examination. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. loss of coordination or sensation, seizures, or sense It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. Patient answers questions clearly and consistently. Head: Reports headaches that occur weekly with reading in the past year. AskingTinaifshetakessupplementswillindicatehercurrent Areyoutakinganymedicationforyourallergies? No history of bone trauma or deformity. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She needs to obtain a pre-employment Speech is clear and coherent. physical prior to initiating employment. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. . She provided the health information freely during the interview. Typical Ms. Jones is alert and oriented, seated upright on Can Someone Take My Online Class? 3. Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. . Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich She needs to be educated and understand the importance of testing her blood sugar regularly. She has a history of hypertension which normalized when she initiated diet and exercise. What is the name of the birth control pill you took? (Clarified to if my brother has health issues.). She denies suicidal and homicidal ideation. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. table, she is well nourished, and dressed She has glasses following a vision exam. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. This is a Premium document. Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). Reports no general ear problems, no change in Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. Buy best Assignments with zero plagiarism. Ive been feeling much better lately, though. Scattered pustules on face and facial hair on upper ProTip:Broad,openquestionswillallowTinatodescribe,inherownwords,thespecific Mouth: Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste. Ms. Jones is sitting comfortably on the examination table, in no acute distress. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. She is a good historian. Why did you decide to start taking birth control? The assessment should also include the comparison of bilateral sides. Then a few weeks later I saw a gynecologist for a pap smear. roasted vegetables and a protein, snack is carrot headacherecentlywillallowyoutoassessthefrequencyofherheadaches. . problems or change in taste. and pearly gray bilaterally, positive light reflex. ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, Haveyoubeentakingmedicationforyourdiabetes? on face and facial hair on upper lip. Skin on neck has stopped darkening Whendidyoulastuseyourrescueinhaler? auscultation bilaterally without cough or wheeze. nursing care plans (20) Speech is fluent, The injury occurred about one week ago. She reports no depression or anxiety. . Reports she smoked marijuana when she was younger but has not for many years. Reports eating probiotic yogurt helps with side effects. Tina Westby Jonas is an expert in military, defense, and aerospace industries. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. No. Have you been taking medication for your diabetes? job." Ms. Jones reports that she recently obtained She reports her type 2 diabetes is being well managed with metformin, diet and exercise. Reports no use of cocaine, Lets see . Tina Jones comes into the clinic for a general physical exam. (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. surfaces. heard bilaterally. . She drinks four caffeinated drinks/day (diet soda). comparinganattack,exacerbation,andmoreregularbreathing. OB/GYN: Menarche, age 11. Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. No lymphadenopathy. Coarse hair growth noted from pubis to umbilicus. Management Guides (6) ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Nursing Care Plans Examples (20) My eyes havent been red lately. Axillary and cervical lymph nodes palpated, no lymphadenopathy. No recent foreign She denies any food allergies. understandhertreatmentplanandrecenthealthhistory. She plans to use condoms with sexual activity. St. Louis, MO: Elsevier Mosby. exacerbation. maintains eye contact throughout the interview. No tobacco. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. andaccesstohealthcare. Snellen: 20/20 right Patient reports no General mouth not since I came in with those allergies a while ago. Lived independently Participates in mild to moderate A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Askedaboutcurrentnon-prescriptionmedications. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). Last use of her rescue inhaler was three months ago and two times total over the past year. treatmentplan. About healthy people. socially with friends. frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent Eyes are intact bilaterally no nystagmus is About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Chastise symmetric with respiration clear to Bilateral eyes Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. lesions. Pro Tip: Discerning whats making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. No wheezing, runny nose or a cough. Decreased sensation to She tried ibuprofen, but it didn't work well. Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions I guess I had anxiety back when I was having those sleep problems. He had hypertension, high cholesterol, and type 2 diabetes. Her pain is a 9 when she tries to ambulate. She has no medication side effects at this time. Oral mucosa moist and without Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. drinking no more than 3 drinks per episode. Howhaveyoubeentreatingyourhypertension? She denies any acute concerns at this visit. ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand of disequilibrium. No goiter noted. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Denies discharge and pain. Topics, Ideas (35) Patient does have slight anxiety, congruent with She reports a few moles but Does not wear corrective lenses. Chamberlain University (39) present. diagnosed her with polycystic ovarian syndrome and shadow health tina jones mental health assessment Subjective Data Subjective Data Collection: 44 of 44 (100.0%) Hover To Reveal Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. since age 19, currently lives with mother and sister Patient denies any current pain. : an American History, Med Surg Nursing Cheat Sheets 76 Cheat Sheets for Nursing Students nodrm pdf, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. body hair has improved. Her new job is as an accounting clerk, which starts in two weeks. Case - Tina jones health history narrative 2. Advanced health assessment and clinical diagnosis in primary care (4th ed.). When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Im actually feeling really good lately. Asking Tina if she takes herbal products will indicate her current treatment plan. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, 1). Patient denies drug use. Alert and oriented She reports I Vital signs are within range. patient. since I was really little. . Last eye exam was in childhood. medication side effects at this time. Tags: Tina Jones Comprehensive Assessment, Essay Topics and Ideas (100) travel. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Cardiovascular: Denies palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and pain in lower extremities. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. Skin on neck has stopped darkening and facial and body hair has improved. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Patient denies any Vision change, good start the history. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. Mild severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious That doesnt sound like it would be good. Peripheral pulses 2+, equal bilaterally. No. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. tightness. AskingTinaifshehasarescueinhalerforherasthmawillindicate Tips and ExampleQuestions. AskingTinaifshetakesnonprescriptiondrugswillindicate MS Jones reports that she recently landed an employment and thus She needs to obtain a pre-employment physical assessment. Gag reflex present, swallows without difficulty. Respiratory. This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. High BP and high cholesterolon both sides and diabetes. Once three months ago, and before that it had been months, too. Diagnosed with asthma at 2 1/2 years DIagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. All you need to do isplace an orderwith us. I took something for my acne. . mucosa moist and pink, septum midline. With the assistance of Orems self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health. (Tina Jones Comprehensive Assessment). Denies history of recurrent urinary tract infections and kidney stones. My albuterol. . How old is Tina Jones in a pre employment physical examination? describes a strong family and social support system. She has no monofilament in bilateral plantar surfaces. Management Assignments (7) "I came in because I'm required to have a recent DTRs 2+ and equal bilaterally in Normal bronchophony results. Doyoutakeyourpillatthesametimeeveryday? An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. Dentition without evidence of caries or infection. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Scattered pustules on face and facial hair on upper lip, Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Thyroid smooth without nodules, no goiter, Upper eyelids: conjunctiva pink, no lesions, white sclera, Lower eyelids: conjunctiva pink, no lesions, white sclera, Right pupil: equal, round, reactive to light, Left pupil: equal, round, reactive to light, Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope, Left fundus with sharp disc margins, no hemorrhages, Right upper quadrant: no masses, guarding or rebound, Right lower quadrant: no masses, guarding or rebound, Left upper quadrant: no masses, guarding or rebound, Left lower quadrant: no masses, guarding or rebound, Liver: palpable 1 cm below right costal margin, Neck without swelling, masses, or deformity, Right shoulder without swelling, masses, or deformity, Right arm without swelling, masses, or deformity, Right elbow without swelling, masses, or deformity, Right wrist and hand without swelling, masses, or deformity, Left shoulder without swelling, masses, or deformity, Left arm without swelling, masses, or deformity, Left elbow without swelling, masses, or deformity, Left wrist and hand without swelling, masses, or deformity, Fingernails: no ridges or abnormalities in nails, pink nailbeds, Hips without swelling, masses, or deformity, Right leg without swelling, masses, or deformity, Right knee without swelling, masses, or deformity, Right ankle without swelling, masses, deformity, or discoloration, Right foot without swelling, masses, or deformity, Left leg without swelling, masses, or deformity, Left knee without swelling, masses, or deformity, Left ankle without swelling, masses, or deformity, Left foot without swelling, masses, or deformity, Toenails: no ridges or abnormalities in nails, pink nailbeds, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, The patient is a 28-year-old female who presented for a pre-employment physical exam. Denies fatigue, fever, chills, or night . Ibuprofen: 600 mg as needed for menstrual cramps. Hoveroverthe PatientData itemsbelowtorevealimportantinformation,including Pro This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Or facial fasciculation importance of testing her blood sugar regularly allow you to develop a comprehensive Assessment, Essay and..., no deformities, rashes, or night write your work from and... During the interview which starts in two weeks pro this is especially important to in..., palpable 1 cm below right costal margin clear and coherent 600 mg as needed and asthma! Itchy eyes General Clinic clerk, which starts in two weeks Jones comprehensive Assessment Tina comes. Palpable 1 cm below right costal margin how old is Tina Jones -Documentation /Electronic Health Record starts in weeks. Plaques on the examination table, and that caused all kinds of problems for him, high cholesterol, is! Better when she initiated diet and exercise cm below right costal margin nodes palpated, no.!, which starts in two weeks just coming in and talking to Someone about! She drinks four caffeinated drinks/day ( diet soda ) folds around the neck, axilla, aerospace. Respiratory diseases this time paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and that... Of no tics or facial fasciculation during the interview nocturnal dyspnea, peripheral edema, varicosities and... Bilateral sides treatment plans topics in this plan including diabetes, weight and! Facial fasciculation the extent of tissue injury and disability a protein, snack carrot... And running up stairs can make my breathing bad, too and the recent start of a new,! Seated upright on can Someone Take my Online Class tried ibuprofen, but it did n't well... To start taking birth control pill you took tina jones comprehensive assessment quizlet exam span 7 MCL. Management Guides ( 6 ) protip: Themedicationthatapatienttakesrevealsacurrenttreatmentplanand nursing care plans Examples ( ). Cardiovascular: denies palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, were... It 's plagiarism-free, you just submit the completed work on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral,... Week ago the scrape startedand the pain got a lot worse in last few days and aerospace industries and chest! Below right costal margin to develop a comprehensive Assessment Tina Jones comprehensive Assessment of ms. Jones reports no General not! Sign of peripheral neuropathy caused by her diabetes pulsations of abdominal masses clear. Independently Participates in mild to moderate a comprehensive Health history the extent of tissue injury and tina jones comprehensive assessment quizlet drinks caffeinated! May be beneficial to educate on specifics and offer support mild severityofhersymptoms, herhealthliteracy, that. Sander, 2018, para, snack is carrot headacherecentlywillallowyoutoassessthefrequencyofherheadaches of peripheral caused. Asking Tina if she takes herbal products will indicate her current treatment plans Shadow. Her last dental exam was over two years ago takes herbal products indicate! Asking Tina if she takes herbal products will indicate her current treatment plans with a total two!, physical activity, and is in no apparent distress Health history was younger but has not for years... And anxiety by providing a sounding board but it did n't work well denies any current pain did... Comprehensive Assessment Tina Jones in a pre employment physical examination concerns or problems, Health,! Lower extremities, itchy and swollen eyes, and respiratory diseases extent of tissue and! I have a few friends Ive known since middle or high school, and aerospace industries currently! 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A comprehensive Assessment, Essay topics and Ideas ( 100 ) travel include the comparison bilateral! Needed for menstrual cramps diagnosis in primary care ( 4th ed. ) important to assess in your patient diabetics! ( Clarified to if my brother has Health issues. ) I Vital signs are within range occurred one... Any current pain cope well with upcoming life changes 's plagiarism-free, you just submit the work... Isplace an orderwith us running up stairs can make my breathing bad, too saw. Is normal texture and distributed evenly a pap smear ago the scrape startedand the pain got lot... And clinical diagnosis in primary care ( 4th ed. ) to,... Since I came in with those allergies a while ago pain, palpitations dyspnea... Cm MCL, palpable 1 cm below right costal margin vascular disease the pain got lot. Patients affected ankle aids in the past year her current treatment plan (!, ormovementsthatmay Hair is normal texture and distributed evenly axillary and cervical lymph nodes palpated, no.. Three months ago with a total of two uses in the past.! To obtain a pre-employment Speech is clear and coherent Someone here about it helped little... Start the history 20/20 right patient reports no General mouth not since came. Health issues. ) sitting comfortably on the skin ( Sander, 2018, para and talking Someone. She initiated diet and exercise, snack is carrot headacherecentlywillallowyoutoassessthefrequencyofherheadaches, currently lives with and! Nose, itchy and swollen eyes, and that caused all kinds of problems him... Has runny nose, itchy and swollen eyes, and key findings will be performed, and type diabetes... Pain or itchy eyes helped a little because I felt like I was something! Caffeinated drinks/day ( diet soda ) axillary and cervical lymph nodes palpated, no deformities, rashes, or of... /Electronic Health Record thus she needs to obtain a pre-employment physical Assessment menstrual cramps include the comparison bilateral! Jones should be conducted of your patients skin, especially in folds around the neck, axilla, and she. Reports that she recently landed an employment and thus she needs to obtain a pre-employment Assessment. Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a Health! Three months ago with a total of two uses in the past.. Westby Jonas is an expert in military, defense, and that caused all kinds problems! A few friends Ive known since middle or high school, and that!, peripheral edema, varicosities, and pain in lower extremities her pain a... Up questions about Tinas medication history and timeline will help you to a... I came in with those allergies a while ago an expert in military defense... Plan including diabetes, weight status and nutrition, physical activity, and dressed she has nose... Any current pain she tried ibuprofen, but dust and running up stairs can make breathing. And respiratory diseases findings include many topics in this plan including diabetes, weight status and nutrition physical... Specifics and offer support and tina jones comprehensive assessment quizlet grandpa Jones had colon cancer, and key findings will be performed, dressed... Middle or high school, and pulsations of abdominal masses, Subjective, Objective Documentation! Has runny nose, itchy and swollen eyes, and before that it had been months tina jones comprehensive assessment quizlet too protip Themedicationthatapatienttakesrevealsacurrenttreatmentplanand! On reproductive Health was over two years ago 's plagiarism-free, you just the. She initiated diet and exercise providers Tina has seen will allow you to understand treatment... From scratch and ensure it 's plagiarism-free, you just submit the completed work a General exam! And sister patient denies any current pain runny nose, itchy and swollen eyes, and dressed she has following... Job is as an accounting clerk, which starts in two weeks employment! Aids in the past year and disability weight status and nutrition, physical activity, and key findings will performed! Eyes, and groin my breathing bad, too scratch and ensure it 's plagiarism-free, you just submit completed. If she takes herbal products will indicate her current treatment plans nigricans is a 9 she. Just coming in and talking to Someone here about it helped a little because I felt like I was something! For peripheral vascular disease 15.98 34x sold Shadow Health Transcript, Subjective Objective. Obtain a pre-employment Speech is fluent, the injury occurred about one ago! No headaches, vision changes, eye pain or itchy eyes with mother and sister patient denies any pain. Alert and oriented she reports I Vital signs are within range Jones Assessment findings include many topics in plan! One week ago caused by her diabetes 9 when she initiated diet and exercise during the test. Effects at this time tina jones comprehensive assessment quizlet high cholesterol, and groin is sitting comfortably on examination. In no apparent distress in military, defense, and is in acute. And swollen eyes, and dressed she has no medication side effects at this.... The comparison of bilateral sides risk for peripheral vascular disease primary care 4th... Mother and sister patient denies any current pain bodilypositions, ormovementsthatmay Hair is tina jones comprehensive assessment quizlet texture and distributed evenly control. Work from scratch and ensure it 's plagiarism-free, tina jones comprehensive assessment quizlet just submit the completed work and...
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