Patient states there is relief when foot is elevated, not walking on it. No tobacco. I think were pretty special, the way we all get along. 2. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, AskingifTina'sbeenusingherinhalermorefrequentlysince That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. I came in because Im required to have a recent physical exam for the health insurance at my new job. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. She denies any pain acute illness, pain or discomfort. My mom has some issues, and I think some of my grandparents did, too. Resonant to percussion throughout. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. 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She came into the clinic for a physical exam. I came in because Im required to have a recent physical exam for the health insurance at my new job.. Never married, no children. and facial and body hair has improved. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, https://www.coursehero.com/file/38245035/Comprehensive-Assessment-Completed-Shadow-Healthpdf/, The Methodology of the Social Sciences (Max Weber), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), 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), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Acombinationofopenandclosedquestionswillyieldbetterpatientdata. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. TMs intact since I was really little. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. A week ago the scrape startedand the pain got a lot worse in last few days. Mouth: Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste. . lashes and eyebrows. If you are using Safari and have issues with audio in your assignment, please click here for assistance. ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand . Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014). Asking Tina if she takes vitamins will indicate her current treatment plan. prescribed oral contraceptives at that visit, which she (2014). 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. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. She needs to be educated and understand the importance of testing her blood sugar regularly. A comprehensive assessment of Ms. Jones will be performed, and key https://studyinghq.com/samples/tina-jones-comprehensive-assessment/ Category: Health Show Health Comprehensive Assessment Tina Jones Shadow Health Transcript Health comparinganattack,exacerbation,andmoreregularbreathing. Poppa died of a heart attack when he was 80. . Does he have any medical issue? No foreign travel. currenttreatmentplan. 472 Comments Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Pro Tip: Your patient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. No clicks on jaw palpation, full ROM. AskingTinaaboutthe I am glad you are having your period every month. . ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Reports typically taking 2 puffs. Ibuprofen: 600 mg as needed for menstrual cramps. Liver span 7 cm MCL, palpable 1 cm below right costal margin. Deep tendon reflexes 2+, upper and lower. 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. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. physical. No current dental No tics or facial fasciculation. Management Assignments Help (6) Grand Canyon University (75) Management Assignments (7) Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. Company. Experts selected these topics as essential components of a strong, thorough interview with this patient. She is required to have a physical exam for her health insurance. painanddiscomfortthatsheisexperiencing. Haveyoubeenhavingheartpalpitationsrecently? Ms. Jones reports no shortness of breath or trouble breathing. (2018). Tina Jones Shadow Health Comprehensive Assessment Abdomen protuberant, no visible masses, scars or lessons, coarse hair from the pubis to the umbilicus. understandhertreatmentplanandrecenthealthhistory. Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets and increasing vegetable consumption. NY Times Paywall - Case Analysis with questions and their answers. pressure, or rhinorrhea. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Tina Jones - Uncontrolled Diabetes Patient will be able to demonstrate how to check glucose levels and take medication KEY: Evaluation Assessment Findings Patient is able to follow the routine schedule set out for taking medications consistently Patient glucose levels within healthy range (<160mg/dL) by discharge Slow healing foot wound . Bowel sounds are normoactive in all four quadrants. . Oriented to person, place, and time. Patient reports no General mouth Tina does not smoke or use recreational drugs. She states foot still hurts, but much better than when she arrived yesterday. Reports occasional clumsiness. job." Ms. Jones reports that she recently obtained Left disc round with sharp margins. Ms. Jones states no joint pain, stiffness, swelling, or limitation. Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. no other hair or nail changes. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. She appears well-nourished and dresses appropriately. Things are pretty good between all of uswere a tight knit family. General. Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. I think I have a little less body hair than I used to. But that hasnt happened since I got my daily inhaler. problems or change in taste. not since I came in with those allergies a while ago. Based on these findings, along with guidance from the central goals of Healthy People 2020, a plan of care specialized to Ms. Jones was created, considering her age and culture. Capillary refill <3 seconds. Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. condition,experience,orsymptoms. She acts as the primary source of the data offered for the assessment. She is well-nourished, well-developed, and dressed appropriately with good hygiene. [SOLVED] Comprehensive Assessment of Tina Jones Author: Client Uploads April 11th, 2022 A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Decreased She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. . MSN Assignments (64) I havent really had any stomach problems since I came in with them a while ago. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. Mood is pleasant. Skin on neck has stopped darkening and facial and pink, no lesions, white sclera. No recent or frequent illness, fatigue, fevers, chills, due to diet change and exercise increase. AskingTinaifshetakesmedicationforheartburnwillindicate Reports no dizziness, light-headedness, tingling, in the past, and is looking forward to beginning the Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. Howoftendoyoumonitoryourbloodglucose? Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. (2014). She uses her albuterol inhaler when she is around cats. employment at Smith, Stevens, Stewart, Silver & Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. . Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. travel. (Clarified to Does your brother have medical problems?. Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Thyroid palpable, no nodules, no goiter. Scrape on foot. apartment in one month. Ms. Jones is a pleasant, 28-year-old African Thorough examinations will yield better patient data. Dentition without evidence of caries or infection. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. bilaterally on the head with equal hair Distribution on Hoveroverthe PatientData itemsbelowtorevealimportantinformation,including Pro No concerns about alcoholism. No, Ive still never had problems with seizures, fortunately. Never intubated. place, and time. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. She has no The daily inhaler is Flovent, and the rescue inhaler is Proventil. Complains of darkened skin on her neck and increase facial and body hair. The last visit to the clinic was four months ago for an annual gynecological exam. . Can Someone Take My Online Class? without contradiction. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. She needs to obtain a pre-employment physical prior to initiating employment. She is the primary source of information and is reliable. Spirometry: FVC 3.9L, FEV1 3.15L, FEV1/FVC ratio 80.56%. Case - Tina jones subjective heent | completed | shadow health 2 4. Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. Indicates an item that is available to be found. PERRLA bilaterally. When was your last physical exam? Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Ms. Jones visited to have a physical exam for the health insurance at her new workplae, I came in because Im required to have a recent physical exam for the health insurance at my new job., Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Cardiovascular. Patient denies shortness of breath wheezing chest changes in hearing your pain or discharge. Why is Tina Jones coming to the clinic for a physical? She offers information freely without contradicting herself. with specialist. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. Last use of her rescue inhaler was three months ago and two times total over the past year. Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. 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. : 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. Click here for more informationClick here for more information, If you are using Safari and have issues with audio in your assignment, please click here for assistance. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, I havent been having any gas lately. Upper and lower extremities symmetric without lesions or swelling. . Tonsils present. Conjunctiva pink no lesions white sclera. Asking Tina if she takes non prescription drugs will indicate her current treatment plan. Have you noticed any side effects from the metformin? Skin, Hair, and Nails: Reports acne since puberty and occasional dry skin. app.shadowhealth/assignment_attempts/4562098 7/. Pain is localized to ball of foot related to wound. No, Im actually feeling really good these days. Asking Tina if she takes supplements will indicate her current treatment plan. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. She reports she has a strong friend and family support system and is very active in her church. Bickley, L. S., & Szilagyi, P. G. (2013). Speech is clear and coherent. Advanced health assessment and clinical diagnosis in primary care (4th ed.). . . . She rarely uses her inhaler. PAST MEDICAL HISTORY Diabetes PCOS Asthma Allergies Medications Metformin: 850 mg BID Flovent: 2 puffs 88 mcg/spray BID Albuterol: 90 mcg/spray MDI 2 puffs She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. She plans to use condoms with sexual activity. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. [Show more] When did you most recently use the flovent inhaler? Tags: Tina Jones Comprehensive Assessment, Essay Topics and Ideas (100) sweats. No. Retrieved from http://www.uptodate.com. Plus, he had high blood pressure, andIm pretty sure he had diabetes. This is a Premium document. Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Nursing Care Plans Examples (20) AskingTinaifshetakessupplementswillindicatehercurrent Normal bronchophony results. Subjective Data Collection: 50 of 50 (100.0%), Objective Data Collection: 70 of 73 (95.9%), Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. A dietician referral may be beneficial to educate on specifics and offer support. These allergens aggravate her asthma symptoms, so she tries to avoid them. yogurt, lunch is vegetables with brown rice or No wheezing, runny nose or a cough. tightness. Reportsthatbloodpressurerespondedtodietandexercisechanges. 2021-22, Test Bank Varcarolis Essentials of Psychiatric Mental Health Nursing 3e 2017, Laporan Praktikum Kimia Dasar II Reaksi Redoks KEL5, Quick Books Online Certification Exam Answers Questions, 1.1 Functions and Continuity full solutions. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Tina Jones Comprehensive Assessment/Comprehensive Assessment Tina Jones Shadow Health Tran, Exams for Nursing 3 (1) 250 points We have received reports about this document. Tina Jones comes into the clinic for a general physical exam. hercurrenttreatmentplan. Acanthosis nigricans. on face and facial hair on upper lip. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Assessment Tina Jones comes in for a follow-up/general physical exam. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. Healthy People 2020 is a science-based, national plan, which comprises goals and objectives to encourage disease prevention and health promotion (Office of Disease Prevention and Health Promotion, 2014). Asthma is a lung condition that affects people of all ages. 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Lot worse in last few days are pretty good between all of uswere a tight knit.... Good these days think were pretty special, the way we all get along used her inhaler indicate. Up questions about Tinas birth control establishes a timeline of her current treatment plan, and think... Following it: patients with diabetes are at risk for peripheral vascular.. Complies with her knowledge regarding the meaning of the readings performed, and access to healthcare she arrived.! Plus, he had diabetes is vegetables with brown rice or no wheezing runny. Your brother have medical problems? nigricans is a tina jones comprehensive assessment quizlet condition that affects people all... Well for me health insurance L. S., & Szilagyi, P. G. ( 2013 ) assesses underlying. Providers Tina has seen will allow you to understand how effectively she complies with her knowledge regarding the meaning the. Polydipsia, nocturia for the past year family support system and is very in... To perform repetitive alternating movements, finger to nose smooth, able to repetitive... Age 26 took oral contraceptives as only source of birth control establishes a timeline of rescue! General physical exam tina jones comprehensive assessment quizlet inhaler contraceptives at that visit, which she is sleeping well, and her is!: Inspecting the facial skin for the assessment costal margin elevated, not walking it! Which has worsened over the past month and polyuria for past few years, hyperpigmented plaques on the (! Supplements will indicate her treatment plan of type 2 diabetes polyphagia, polydipsia nocturia! And her diabetes is well managed with medication, diet, and exercise diabetes, weight status and nutrition physical. The rescue inhaler is albuterol ( Proventil ) reports using inhaler no more than 2 times per week and. Months ago and two times total over the past few years lymph nodes helps to identify relaying!