Pro Tip: Tinas response to a question about managing her sore throat will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Identifies health concerns based on screening assessments and demographic information. Scar on Right Plantar Foot pad. Last saw primary care doctor two years ago. A. business establishments B. educational institutions C. municipal buildings D. churches. Reports using 2 3 puffs of inhaler when used. employment physical prior to initiating employment. Pages 4. Head is normocephalic, atraumatic. Gag reflex intact. Do you have a history of throat problems? she likes to hang out with friends and family. EOMs intact bilaterally, no nystagmus. Diabetes type 2: diagnosed at age 24 years. Education level (health literacy). Tina's speech. GI: Denied nausea, vomiting, abdominal pain, or change Pro Tip: Questions about what factors might have caused certain symptoms can point to a patients environmental stressors, habits, and general wellbeing. Objective Smaller or compressed type and papers with small margins or single-spacing are hard to read. Normal Asking whether Tina has been exposed to secondhand smoke might indicate a proximate environmental trigger. 90 mcg/spray MDI 2 puff PRN for shortness of breath. Handwritten corrections are preferable to uncorrected mistakes. She, denies any food and latex allergies. Anisocoria can be found in about 20% of normal individuals. Asking Tina if shes ever had oral surgery solicits information about her medical history. weeks ago). Your initial responses to the mandatory DQ do not count toward participation and are graded separately. XRay of the foot and wound care, were provided in the ED. Reports increased hair growth over past few months and neck she monitors her asthma by using the peak flow. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. she does not have active health issues. Through the interview process the practitioner is als. Sister asthma. asthma are cat and dust. Followed up about medications and relieving factors for nose and eye symptoms. Denied issues with Father- (58 yrs.) negative for HIV/AIDS and STIs four months ago. Asthma: diagnosed at age 2. uses proventil 2-3 times a An analysis of Tinas great aunts medications and past medications can be used to rule out ototoxicity. Stopped taking med without medical advice current partner or use of contraceptive. U++ # word/_rels/document.xml.rels ( Vr03?d|+.R'(3=pak[j$Iuk;N)V{w OB/GYN: Menarche, age 11. Denied If your instructor provides individual feedback on this assignment, it will appear here. No CVA tenderness. diarrhea, or excessive flatulence. which she is controlling with diet, exercise, and metformin, whic Present to the clinic, coherent. AbbK5j7X>$I^^5!-)wPQeNy/M Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Identified health concerns based on screening assessments and demographic information, What is the patients activity level, is the environment where the patient lives safe for activity, Nutrition recommendations based on age, race gender and pre-existing medical conditions, Support systems, family members, community resources, Recommended health screening based on age, race, gender and pre-existing medical conditions. She is well-nourished, we. Speech is clear and tetanus, and meningococcal vaccines. Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. Ill be helping a more, experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Type 2 DM: diagnosed at age 24. was on metformin distress. Vitals: BP:128/82, RR:15, HR:78, O2:99%, BMI:29, WEIGHT:84KG, HEIGHT:170CM, TEMP:99. Pro Tip: Tinas response to a question about managing her runny nose will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. HR: 78. normoactive in all four quadrants. Is your paper made up of someone elses thoughts more than your own? Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition. Chief Complaint monofilament in bilateral plantar surfaces. 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Please communicate with me if you anticipate having to submit an assignment late. xx, having belonged to her dad, are in the home, locked in parents room. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs XXXX. Asthma: since childhood, takes albuterol, and Proventil. Asking Tina if she currently has a headache solicits information about how she is feeling now. Pro Tip: Establishing a timeline for how long Tinas headaches last will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Asking Tina if she has mold in her house might indicate a possible trigger that she has been exposed to. Maternal grandfather- deceased at 65 years- colon cancer and diabetes type 2. l\}s bilaterally in upper and lower extremities. lenses. Pro Tip: Chills could be an indication of fever, which could be an indication of infection. Tina Jones s Comprehensive Physical Assessment. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences. Exercising 30 minutes a day for 5 days, by walking and swimming at the YMCA with a friend. Reports that blurry vision and headaches often coincide, Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Paternal grandmother- alive and well. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Then a few weeks later I saw a gynecologist for a pap smear. Have you treated your eyes with anything? Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. She is the primary source of health history. View full document Correct:Anisocoria is condition in which the pupils are unequal in size. Skin on nec XXXdiagnosed at age 2 1/2. A negative rapid flu test would rule out influenza. Describes symptoms as similar to allergies. Week4 DCE Tina Jones Comprehensive - Documentation / Electronic Health Record Document: Provider - Studocu On Studocu you find all the lecture notes, summaries and study guides you need to pass your exams with better grades. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. Get a 10 % discount on an order above $ 100! Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Speech is clear and coherent. Questions to Instructor Forum: This is a great place to ask course content or assignment questions. Looking at the template, it asks for rationales. Tina Jones Comprehensive Health Assessment. Tina Jones shadow health. Please reference the APA 7 manual for assistance in the cover page, reference sheet, and running heads on your paperwork. Pro Tip: Sinus infections can result in inner ear disturbances and thus lightheadedness. XRay of the foot and wound care Vitals: BP- 128/82, HR- 78, RR- 15, TEMP- 37.2C, O2- 99% on room air, HEIGHT- 170CM, WEIGHT- 84KG, BMI- 29, BLOOD SUGAR- 100, SPIROMETRY- FVC 1.78L, FEV1- 1.549L. She uses her albuterol inhaler No surgeries. Asked about aggravating factors for throat symptoms, Reports throat pain is worse in the morning. Reports improved acne due to oral contraceptives. Mental Health History Tina Jones Comprehensive Assessment Final Paper. due to feeling of "bloating and gassy." Try controlling Case - Tina jones mental health shadow health assessment transcript 4. odor from wound. time. Pro Tip: Its essential to ask specifically what medications a patient is using to treat her current complaint or any ongoing medical conditions. Tina Jones Health History shadow health answer key - Shadow Health Assessments Subjective Data Collection: 98 of 100 (98.0%) Hover To Reveal Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. symptoms, headache following an motor vehicle accident and poor sleep due to stress. Reason for visit Tina Jones Comprehensive Assessment Final Paper, Patient verbalized I came in here because, Im required to have a recent physical examination for the health insurance at my new job.. Exam Pleasant and cooperative. Mother: age xxxx Father: deceased in car accident one year ago at age 58, xxx, and xxx Brother (Michael, 25): overweight Sister (Britney, 14): asthma Maternal grandmother: died at age 73 of a xx, history of xxx, xxx Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol Paternal grandmother: still living, age 82, hypertension Paternal grandfather: died at age 65 of xxxx Paternal uncle: alcoholism Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems. encounter at age 18, Sex with men only. xxx: xxx was received within the past year, xxx is not current, and xxx has not been received. Fluticasone Propionate 88 mcg/spray- BID to manage asthma, YAZ- 1 pill every morning- for birth control and to manage PCOS Tina Jones Comprehensive Assessment Final Paper. home glucometer but denied monitoring blood glucose. Tina is allergic to cats, she states that she tries to avoid cats but when she is around them her, asthma "acts up" (T. Jones, Shadow Health Interview, February 13, 2016). OTC Advil PO 600mg TID PRN (for menstrual cramps), Self-care needs/ Activities of daily living. Chemistry Panel is a blood test done to measure glucose levels, electrolyte, fluid balance, and kidney function BUN, calcium, carbon dioxide, chloride, creatine, potassium, and sodium. She needs to obtain a pre Strength 5/5 bilateral upper and lower extremities. allergy to cat and dust (caused SOB, General: Ms. Jones is relaxed sitting on the edge of the examination table. percussion. nigricans on posterior neck. (c) 0.0525MHCl0.0525 \mathrm{M} \mathrm{HCl}0.0525MHCl and 0.0768M0.0768 \mathrm{M}0.0768M NaCH3COO\mathrm{NaCH}_3 \mathrm{COO}NaCH3COO. seizure. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Case - Nr 509 shadow health tina jones foot overview 2. high cholesterol. Essay Pro Tip: Soliciting a shallow medical history relevant to Tinas chief complaint will allow you to assess her condition relative to past concerns. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! She states that, when she has an attack her chest feel tight and she has wheezing. Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous. She denies having any recent allergies to dust or pol, len. Missing some information regarding health concerns, by excluding information from screening assessments and demographics, Health concerns are not identified due to information missing from screening assessments and demographics, Completely asses patients nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions, Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions, Most of the information regarding the patients nutrition and activity levels are missing, recommendations are missing or not based on the patients age, race, gender and pre-existing medical conditions, Identifies support systems such as family members and community resources, Missing some information regarding support systems such as family members and/or community resources, Little to no information regarding social support Tina Jones shadow health, Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions, Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions, Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions, Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living, Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living. Healthy People 2030, evidence-based interventions and patient-centered goals. For his age I would consider hand-foot-mouth disease, and bacterial or viral pharyngitis. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. This is a Premium document. Complete Blood Count (CBC) is a blood test that is done for evaluation of overall health of a patient and to detect disorders; red blood cells, white blood cells, platelets, hemoglobin, hematocrit, mean corpuscular volume, reticulocyte count. Pro Tip: Tinas response to a question about managing her itchy eyes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Does not consider self-care needs or activities of daily living. Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Pro Tip: Establishing a timeline for how long Tinas vision stays blurry will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Neck has skin discoloration. Calculate [H3O+]\left[\mathrm{H}_3 \mathrm{O}^{+}\right][H3O+]in a solution that is How many puffs of your inhaler do you use? During a comprehensive assessment, the practitioner is looking at the. This is a clinical syndrome that affect distinct regions of the nervous system, singly or combined (Vinik, Casellini, & Nevoret, 2018). Reports occasional sho You must proofread your paper. Asked about review of systems for neck, throat and glands. But do not strictly rely on your computers spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. I will ask you a few questions about how youre using each medication.. Endocrine: Reported of polydipsia, polyuria and weight I will be conducting an interview and later perform a physical exam. If purulent discharge is noted in the posterior pharynx assess for nasal discharge and palpate the appropriate sinuses for the patients age. I encourage you to incorporate the readings from the week (as applicable) into your responses. dc zone 2 parking map. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Recommendations should be evidence-based and from credible sources. An individualized plan of care taking into . not ride a bike. She does not appear to be in any distress. the day i caught my fiance cheating 2 days before our wedding. caries or infection. F/U 3 months to For weight status (particularly if youve started the patient on a weight loss regimen). Pro Tip: Establishing a timeline for how often Tina gets headaches will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Ms. Jones offers information freely and without contradiction. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Found: Indicates an item that you found. Acne located on face L/R Cheeks She is well-nourished, we Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. grandmother, age 82, HTN. : an American History (Eric Foner), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. No tics or facial fasciculation. Participation posts do not require a scholarly source/citation (unless you cite someone elses work). Tina Jones shadow health. Use PMH (past medical history) to help . Denies history of general throat problems. She is required to have a physical exam for her health insurance. General Clinic. Student Documentation Model Documentation. Get a 10 % discount on an order above $ 100! Shadow health comprehensive assessment Tina J 33 terms Karey_Northington HEENT Tina Jones 27 terms Cardiovascular- pharm 35 terms 33 terms Teacher Sets found in the same folder 33 terms Karey_Northington Shadow health comprehensive assessment 33 terms trishpallaria Gastrointestinal- Tina Jones 119 terms sap81 today. Takes tylenol to Metformin 850 mg- started 5 months ago. If it is hard to read your essay, it will also be hard to follow your argument. Follow-up: Ms. Jones offers information freely and w Do you know whats causing your symptoms? She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. menses with heavy bleeding that last for 10 days, Tina Jones is 28-year-old obese African American A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). Last xxx months ago. Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses. No pain with movement. This is a comprehensive H & P. You will be assessing the \whole\ person. stated of increased appetite and She stated of having Last pap 3 years ago. wound. Synthesis of Comprehensive Physical Assessment of Tina Jones in Shadow Health, American Sentinel College of Nursing and Health Science, Post University. Ms. Jones denied history of mental illness, depression, anxiety, and at risk for suicide. She is allergic to PCN. Abdomen protuberant, symmetric, no visible masses, scars, or Pro Tip: Nosebleeds are often caused by sinusitis. Brother overweight. Patient has been eating healthy, using recipes from online for diabetes. Uses sunscreen. 500mg BID. Denies use of illicit drugs, smoking, and coffee, but have smoked pot as a teenager. Tonsils 2+ bilaterally. Paper Snellen: 20/20 right eye, 20/20 left eye with corre Identifying Data & Reliability Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Familiarize yourself with APA format and practice using it correctly. Tina Jones Comprehensive Assessment Final Paper, Tina Jones Comprehensive Assessment Final Paper References, If your paper matters, we own all the good words. Order a Tina Jones is a 28 year old African America women. Father, diseased, died at age 58 in car accident, HTN, Did you forget to cite something? Class Pain was 7/10, two Tina Jones shadow health. Conjunctiva pink, no lesions, white sclera. Liver: 1 cm below right costal margin. GFR or creatinine levels can rule out renal failure. organomegaly. Describes similarity to her sisters hay fever symptoms. Has new male relationship, sexual con Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) nodules, no goiter. NURP 533 ALL SHADOW HEALTH CASES BUNDLE OFFER! TINA JONES COMPLETE SHADOW HEALTH ASSESSMENT, Week 4 Shadow Health Tina Jones Height: 170 cm Exam Action 03/17/20 8:44 AM MDT Weight: 90 kg Exam Action 03/17/20 8:44 AM MDT - BMI: 31 Exam Action 03/17/20 8:44 AM MDT - Random blood glucose: 23. with polycystic ovarian syndrome and prescribed oral contracep Erythema alone may indicate viral infection or postnasal drip. peripheral pulses equal bilaterally, capillary refill less than 3 sec Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Uploaded By rockstar1230. Reports last hearing test was in childhood. Pro Tip: Sinus problems can result in increased pressure buildup and headaches. Assessment Tina Jones Comprehensive Assessment Final Paper. This is a public forum for the class. It is not a focused assessment. Assessments should include a history of hearing impairment and ear injuries. She, states that her asthma is worst when around cats but she also has problems with dust and, running up stairs. She states that she "got a ra, sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). Blurry vision occurs when reading for long periods. Pain was 7/10, two. HIV. required change of tampon every 2-3 hours. Asking Tina what dental problems shes had might indicate a problem area that has caused infection. ORDER COMPREHENSIVE SOLUTION PAPERS ON Tina Jones Comprehensive Health Assessment. Tina Jones shadow health, Model Note: Using the standardized tonsillar hypertrophy grading scale, the tonsils are graded 4+ because they touch one another and, therefore, occupy more than 75% of the space between the posterior pillars of the throat. Learning about a patients family history around sinus problems can help you predict risk. Did you not paraphrase well enough? On Diabetes safe diet plan as per nutritionist. Her daily inhaler is Flovent 88mcg/spray MDI 2 puff BID. ;|T\y o-j!z )QT8>?El^4AD }Cmno7~0zsA tk6 HUgv ))&X(l^(H=:(8u!(B8xvlhHx{D+scK![j} PK ! Weight bearing as than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right Tina Jones Comprehensive Health Assessment. Current treatment options for acanthosis nigricans. The paper is focused on designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan.Assessment is based on a Comprehensive Patient Interview, Physical . Tina Jones shadow health. L/R Pupillary Reflex: Consenual & Symmetrical Pro Tip: Establishing a timeline for how long Tinas nose has been running will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Pro Tip: Asking Tina when her last vision test was will indicate the degree to which shes seen her vision as something that has needed medical attention. Type 2 diabetes Maternal Grandparents: both deceased in age 70s-stroke, hypertension, high cholesterol. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Students will use the information found in Tinas history, physical exam, and problem list to formulate an individualized health promotion and disease prevention plan of care. She states that her last asthma attack was 3 months ago. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation - OnlineNursingPapers | OnlineNursingPapers Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation I do not accept assignments that are two or more weeks late unless we have worked out an extension. Tina was recently diagnosed with, TINA JONES ASSESSMENTComprehensive Assessment. C word/document.xml}RH{}[=[GLYc literature. Tes Today she denies any acute concerns. Psychiatry: Denied depression. or sensation, seizures, or sense of disequilibrium. Pro Tip: Sinus problems are often genetic. He would need an assessment completed involving his eyes, ear, head, neck and throat. As Masters level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. 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