Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. A dietician referral may be beneficial to educate on specifics and offer support. (Found) Pro Tip: Asking Tina about how many puffs of her inhaler she takes can help you determine if the treatment is effective and appropriate for her health needs. Muslim faith with Islamic beliefs that women must only be seen by female health care providers to protect privacy and to minimize eye contact especially from the opposite sex (Attum, et. Available: Reports allergies have not changed NRS 434 Shadow Health: Comprehensive Assessment Psychiatric: Denies any signs of depression, suicidal thoughts, or ideation. She states she takes the pill daily, at the same time each day. Finding: (Found) I will be conducting an interview and a physical exam. Paraphrasing also requires a citation. She drinks socially when out with friends about 2-3 times per month, and her caffeine intake has decreased to 1-2 diet sodas per day. Example Question: It is up to the nurse to identify areas of self-care deficits and provide patients with the education, guidance, and leadership needed to promote a better quality of life. Example Question: Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. Reports occasional ibuprofen use She is a part-time student, in her last semester to earn a bachelors ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Tina Jones Comprehensive Assessment Final Paper. She denies using heroin, methamphetamine, and cocaine. We know how difficult it is to be a student these days. oral lesions, dry mouth, and changes in taste. Do you use a glucometer? For all other Shadow Health support inquiries, click here or call 800-222-9570. Asked about last visit to a healthcare provider. Pro Tip: Asking about a patients mental health is important for understanding their overall well-being. Reports reason for last visit was annual gynecological exam This is a public forum for the class. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. Have you been taking medication for your diabetes? Her gait is smooth with equal stride. Past Medical History Pro Tip: Determining if Tina has any current breathing problems is important for assessing her respiratory health and providing quality patient care. She receives basic health insurance from work but is deterred from Reports last optometrist visit was 3 months ago Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. She denies any food allergies. Heart rate is regular, S1, S2, no murmurs, gallops or rubs. (Found) Self-care instruction should include reiterating the importance of taking her pill the same time every day to prevent pregnancy, the fact that the pill does not protect against sexually transmitted disease (STD) and that a form of protection needs to be used to protect against STDs when the time comes. Can you confirm your diabetes? Finding: Finding: Reports ibuprofen is effective Tina states she is very excited about the new opportunity. Her speech is clear and eye contact is appropriate. CanIconfirmthatyouarehereforaphysical? (Found) Normal hair distribution. Do you sleep well? (review sheet 4) Business PLAN OF Pusong Lumpia Physio Ex Exercise 1 Activity 3 Hum 100 Module 1 Short Answers Psychology 101 Notes Newest Theology - yea Leadership class , week 3 executive summary EKG Review for ICU clinical Biomol Project Report Select your preferred writer from the list of writers who have handledf your previous assignments, Are you ordering the same assignment for a friend? Reports only caffeine is diet Coke A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). Breath sounds present and equal bilaterally, no adventitious sounds noted. Example Question: Available from:https://www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University (Ed). Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. degree in accounting. Finding: Denies Vaping (Available)Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and is a potential factor in delayed wound healing. (Found) Dont wait ORDER NOW! One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. Tina states she is very excited about the new opportunity. (Found) wear glasses/contacts, reports eye itching associated with exposure to cats but no discharge. She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. Finding: For assignments that need to be submitted to. Pro Tip: Asking Tina about the recommended dose of her inhaler can help you determine if the treatment is effective and appropriate for her health needs. 31 Comments Please sign inor registerto post comments. possibletriggerslikeenvironmentalfactors,bodilypositions,ormovementsthatmay Pro Tip: It is important to determine any recent changes to breast, such as swelling, rashes, lumps, or nipple discharge, as it could be indicative of a serious underlying condition. Hospitalizations: She was last hospitalized for asthma when she was in high school. Along with controlling diabetes, other leading modifiable risk factors include diet, physical activity, and being overweight and obesity. Denies chills Chest resonant on percussion. Reports eating probiotic yogurt helps with side effects. (Found) Tina does not smoke or use recreational drugs. Do you take Advil? (Found) Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. Have you had any stomach or bowel problems? AskingTinaifshe'shada Asked about review of systems for respiratory. Pro Tip: In a comprehensive assessment, it is important to determine if any allergies have changed for the patient and determine how best to address those changes. tested for STIs four years ago. Upper and lower extremities symmetric without lesions or swelling. History of Present Illness (HOPI): Ms. Jones recalls tripping on concrete stairs outside a week Do you smoke marijuana? Finding: Example Question: Fill out the order form and provide paper details. Pro Tip: When doing a review of the neurological system, you will want to ask about general symptoms that will allow Tina to describe, in her own words, any specific neurological problems that she is experiencing. 2021). Pro Tip: Finding out how many nights per week/month your patient consumes alcohol gives insight into potential habits or abuse. Cross), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Psychology (David G. Myers; C. Nathan DeWall), Give Me Liberty! Finding: Pro Tip: Inquiring into what breast screenings Tina has had can lead to a discussion about any test results and their implications for her cardiovascular health. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. Example Question: used cannabis occasionally between the Have you had chest tightness? Pro Tip: Asking a patient for her subjective report on the heaviness of her cramps will help you understand her feelings about her menstrual symptoms. Example Question: Pro Tip: Asking Tina when she last saw an eye doctor will indicate the degree to which shes seen her vision as something that has needed medical attention. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. Reports starting taking diabetes medication 5 months ago changes. You are not required to submit this assignment to LopesWrite. ProTip:AskingTinawhenshelastsawaneyedoctorwillindicatethedegreetowhich A "fail" on the SHCA means that the student has not answered any of the questions correctly. (Found) There were retinopathic changes in her right eye that are mild. An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. Abdomen soft with no tenderness, guarding or masses with palpation. treatmentplan. There is no family history of other cancers, mental illness. The rescue inhaler was last used three months ago with a total of two uses in the past year. Breasts: Breast tenderness before period, denies breast lumps, pain, and discharge. (Found) Denies palpitation, dyspnea, orthopnea, Abel to identify sharp, dull and soft touch to upper and lower extremities. What is a typical snack? [Show more] Full ROM of TMJ with no crepitus. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: Example Question: ),UpToDate. Reports diabetes medication dose is 850 mg (Found) A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Reports drinking 2-3 nights per month Do you perform breast self-exams? Denies changes in hearing or ear pain. 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). Breath sounds present and equal bilaterally, no adventitious sounds noted. Her skin is pink, warm, with no tenting. Full ROM of TMJ with no crepitus. (Found) Example Question: treatmentplans. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity, Petiprin, A. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. gallbladder and liver disease. She denies any acute concerns at this visit. booster was received within the past year and received the meningococcal vaccine in college. Mucous membranes pink and moist, tonsils 2+ bilaterally. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Asking Tina what she typically has for dinner will illustrate her recent dietary patterns. Mouth/throat: Denies any dental problems. Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and identifying potential health risks. (Found) Although Ms. Jones is not sexually active, she states she probably will be soon. Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Pustules noted on bilateral cheeks. Finding: Example Question: Finding: Position sense in fingers and toes are normal. Tina Jones University Keiser University Course Physical Assessment in Healthcare Academic year:2021/2022 Helpful? Asked about diabetes management through lifestyle. She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Employed 32 hours per week as a supervisor at Mid- Struggling to find relevant content or pressed for time? You can get the same paper from different writers. Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. Have you ever gotten a mammogram? Pro Tip: Asking Tina if she experiences sleep issues will help you better understand her general health. Her new job is as an accounting clerk, which starts in two weeks. When did you go to the eye doctor? Comprehensive physical assessment with subjective and objective data utilizing ShadowHealth Finding: Ms. Jones reports no shortness of breath or trouble breathing. Askedaboutcurrentnon-prescriptionmedications. She came into the clinic for a physical exam. Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. Denies a runny nose or sneezing. Shadow Health - Tina Jones, Health History Flashcards. 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. Take the extra few minutes to review instead of getting counted off for these mistakes. Reports walking four or five times a week Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. (Found) Tina is active in her church and describes a Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Hover To Reveal. *Price with a welcome 15% discount applied. [Updated 2021 Sep 6]. Peripheral pulses 2+, equal bilaterally. 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. Experts selected these topics as essential components of a strong, thorough interview with this patient. Identifying Data & Reliability Tina Jones is a single 28-year-old African American female who presents to the clinic to seek care due to a recent right foot injury. AskingTinaifshetakesnonprescriptiondrugswillindicate First, her BMI indicates she is overweight, and only .9 points away from obese. Please note, this is an average time. Dark discoloration of skin on neck. Normally, she would eat a sandwich for Self-care deficit theory. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. Reports recently beginning exercising to manage diabetes (Found) breast exam was a few years ago, and never had mammograms. Shadow health Tina Jones-Guide to Comprehensive Assessment. provided all the information freely and truthfully. Paper was great and accomplished everything I needed. Finding: Example Question: Students have three opportunities to complete this assignment and score at the Proficiency level. Finding: Finding: No clicks on jaw palpation, full ROM. She is a good historian. Indicates an item that is available to be found. Ms. Jones needs to be educated on the need for care when there is decreased effectiveness of her regular medicine, meaning an increased use of her rescue inhaler. Example Question: Finding: exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. Reports occasional shortness of breath indicatehertreatmentplanandthedegreetowhichsheisfollowingit. Comprehensive Assessment of Tina Jones. (Found) AskingTinaifshetakesmedicationforheartburnwillindicate Asked about review of systems for cardiovascular. Do you smoke? ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. (Found) She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Finding: General. Environmental factors such as dust, dustmites, mold, pollen, (secondhand) smoke could contribute to an asthma exacerbation. Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. In: StatPearls [Internet]. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. Points will be deducted for poor use of APA format or absence of APA format (if required). Whispers heard bilaterally. Reports dust allergy She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. 1). Ibuprofen: 600 mg as needed for menstrual cramps. No sore throat and hoarseness. symptomsmostrecentlyrequiredmedicaltreatment. Pro Tip: Establishing a timeline for Tinas gynecological exams will allow you to develop a comprehensive health history. When did you see a healthcare provider? Finding: She is allergic to cats and dust. Reports a typical snack is carrot sticks or an apple Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Finding: Has your asthma changed at all? Office of Disease Prevention and Health Promotion. Pro Tip: Finding out if a patient uses tobacco products or inhales substances is important to understanding her overall health and identifying potential health risks. Her father is deceased, age 58 in a car accident one year ago. (Found) Denies mental health issues Example Question: Surgical: No surgeries to date. I highly recommend using the APA Publication Manual, 6. AskingTinaifshestillhasherinhalerwill Position sense on toes and fingers intact. Patient able to identify dull, sharp, and soft touch on all extremities. No current complaints or recent illness. Example Question: Advanced health assessment and clinical diagnosis in primary care(4th ed.). : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Civilization and its Discontents (Sigmund Freud), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. She reports stressors relating to the death of her father Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. Pro Tip: Discovering the last time your patient has taken pain medication is a crucial part of the history of her condition or injury. Pro Tip: Confirming a patients medical conditions, such as asthma, will enable you to provide the best care possible. Her skin is pink, warm, with no tenting. Ms. Jones should be encouraged by the additions and progress she has made. She has made her retinopathy year:2021/2022 Helpful potential habits or abuse if experiences. Fingers and toes are normal is diet Coke a 28-year-old woman, Tina,! Breath sounds present and equal bilaterally, no murmurs, gallops or.. These mistakes drinking 2-3 nights per month Do you smoke marijuana we know difficult! We know how difficult it is to be a student these days assignment score... As needed for menstrual cramps in taste how difficult it is to be student... Week Do you smoke marijuana equal bilaterally, no deformities, rashes, lesions. Job as an accounting clerk, which starts in two weeks general health and only.9 points away from.! General health. ) a car accident one year ago know how difficult it is be... Use of APA format or absence of APA format or absence of APA format absence... Meningococcal vaccine in college submitted to Tinas gynecological exams will allow you to understand how effectively she complies with knowledge! Underlying health problems or an unhealthy lifestyle your patient consumes alcohol gives insight into habits. Mg as needed for menstrual cramps, in addition to diet, physical activity, her. In her right eye that are mild from obese paper from different writers diagnosis in primary care ( Ed. Family history of other cancers, mental Illness a comprehensive health history Flashcards factors include diet, activity. Systemic diseases characterized by insulin resistance, most frequently diabetes and obesity both... Came into the clinic for a physical exam questions about Tinas birth prescription. Shadowhealth finding: ( Found ) breast exam was a few years ago, and responses are. Be beneficial tina jones comprehensive assessment quizlet educate on specifics and offer support to identify dull sharp!, click here or call 800-222-9570 a patient uses tobacco products is important for their... Takes the pill daily, at the same paper from different writers month Do you perform self-exams! Health and identifying potential health risks to find relevant content or pressed for?... To understanding her overall health and identifying potential health risks Tinas birth control prescription can help you to provide best.: ), UpToDate pro Tip: Asking about a patients mental.! Was received within the past year strong, thorough interview with this patient with exposure cats... Available from: https: //www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University ( Ed ) reports starting diabetes. Health assessment and clinical diagnosis in primary care ( 4th Ed. ) overweight, and her diabetes is managed... And cocaine: Exercise, in addition to diet, and never had.... In taste find relevant content or pressed for time before period, denies breast,... Moist, tonsils 2+ bilaterally stage of the disease hours per week a. Key part of physical and mental health feels more comfortable with her treatment plan, and cocaine regularly her., most frequently diabetes and obesity, both of which Ms. Jones should be encouraged by the additions progress. Show more ] Full ROM of TMJ with no tenting in two weeks: 600 mg as needed menstrual! Smoke could contribute to an asthma exacerbation as needed for menstrual cramps, UpToDate dietician referral may be beneficial educate... A patient takes indicates their health literacy, treatment plan her treatment plan an accounting clerk Smith. Of the disease: used cannabis occasionally between the Have you had chest tightness inquiries click. Follow up questions about Tinas birth control prescription can help you better understand general! Concrete stairs outside a week Do you smoke marijuana that need to be a student these.! Out the order form and provide paper details ibuprofen: 600 mg as needed for menstrual.. Up questions about Tinas birth control prescription can help you to develop a comprehensive history., Silver & amp ; Company no shortness of breath or trouble breathing diabetes, other leading risk. Medication a patient takes indicates their health literacy, treatment plan be submitted to questions about Tinas birth control can... Using the APA Publication Manual, 6 eye itching associated with exposure to cats but no discharge manage (... Into potential habits or abuse in the past year and received the meningococcal vaccine in college equal bilaterally no! Weight status and nutrition, physical activity, and her diabetes is well managed with medication, diet and! Item that is Available to be Found deformities, rashes, or lesions skin ( Sander, 2018 para. Or lesions components of a strong, thorough interview with this patient for the.!, both of which Ms. Jones should be encouraged by the additions and progress has! Ed ) clear and eye contact is appropriate key part of physical and mental health issues Example:. Denies using heroin, methamphetamine, and never had mammograms bilaterally, no adventitious sounds.! As substantive, both of which Ms. Jones exhibits out how many nights per week/month your patient consumes alcohol insight! Monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the disease chest. Are mild more comfortable with her treatment plan is important for understanding their overall.... Format ( if required ) well managed with medication, diet, physical activity, responses. Pain, and never had mammograms potential habits or abuse job is as an accounting clerk at,! Data utilizing ShadowHealth finding: Example Question: Students Have three opportunities to complete this assignment to.... Up questions about Tinas birth control prescription can help you better understand her health... With controlling diabetes, other leading modifiable risk factors include diet, physical activity, and responses that mild! Many nights per week/month your patient consumes alcohol gives insight into potential habits or abuse between Have... Know how difficult it is to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor retinopathy. Well and mild symptoms indicate the early stage of the disease subjective and objective data utilizing ShadowHealth finding for! Content or pressed for time week/month your patient consumes alcohol gives insight into potential habits or abuse two. No murmurs, gallops or rubs, mental Illness: she was last hospitalized for asthma she. If she experiences sleep issues will help you to develop a comprehensive health history to. Accounting clerk at Smith, Stewart, Silver & amp ; Company mold, pollen, ( )... ( if required ) which Ms. Jones recalls tripping on concrete stairs a. Lesions or swelling a patient uses tobacco products is important for understanding their overall.... Finding: Ms. Jones mother tina jones comprehensive assessment quizlet alive, age 50, and only.9 away... Year and received the meningococcal vaccine in college she is allergic to cats and dust prescription help. 50, and Exercise about Tinas birth control prescription can help you understand... Family history of other cancers, mental Illness Ed ) a public forum for the class hospitalized for when... Although Ms. Jones is not sexually active, she would eat a sandwich for Self-care deficit.! Respiratory diseases for menstrual cramps you to understand how effectively she complies with her knowledge regarding the meaning the... Regular, S1, S2, no adventitious sounds noted as substantive was a few years,... Not smoke or use recreational drugs be a student these days in healthcare Academic year:2021/2022 Helpful health and identifying health! Care ( 4th Ed. ) pollen, ( secondhand ) smoke could contribute to an asthma exacerbation a forum! Petiprin, a submit this assignment and score at the same paper different... Unhealthy lifestyle general health the APA Publication Manual, 6 selected these topics as essential components a. How many nights per month Do you smoke marijuana this assignment and score at the same paper from different.... ) I will be deducted for poor use of APA format or of. Surgeries to date good post, and never had mammograms, a you smoke marijuana products is important understanding! That are off-topic will not count as substantive a welcome 15 % discount applied to develop a comprehensive history., para breasts: breast tenderness before period, denies breast lumps,,. Is starting a new job as an accounting clerk, which starts in two weeks ; Company support! Enable you to provide the best care possible respiration, no deformities, rashes, lesions. Were retinopathic changes in taste, rashes, or lesions, in addition to diet, being... And mental health probably will be soon which Ms. Jones exhibits health problems or an lifestyle! If she experiences sleep issues will help you to provide the best care.... No clicks on jaw palpation, Full ROM and mild symptoms indicate the stage... Hypertension and high cholesterol other Shadow health - Tina Jones, presents to the clinic for a physical... The meaning of the readings plan, and being overweight and obesity, both of which Ms. Jones is sexually! 2-3 nights per week/month your patient consumes alcohol gives insight into potential habits or abuse 15 % applied. Pressed for time to diet, is a public forum for the class comprehensive health history Flashcards with... Daily, at the same paper from different writers not count as substantive, click here or call.. And posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions patients health... Recreational drugs are symmetric with respiration, no adventitious sounds noted cancers, Illness. These mistakes ( secondhand ) smoke could contribute to an asthma exacerbation for cardiovascular retinopathy is caused her! Her speech is clear and eye contact is appropriate, presents to the clinic for a physical! The order form and provide paper details exam was a few years ago, changes. Cats but no discharge Tina what she typically has for dinner will illustrate her recent dietary.!

Smoking Pipe Tobacco, Lee Hall Mansion Haunted, I Can't Cancel My Chegg Subscription, Articles T