She is the primary source of information and is reliable. Experts selected these topics as essential components of a strong, thorough interview with this patient. Speech is clear and coherent. Patient denies shortness of breath wheezing chest Mom has high cholesterol and blood pressure, I think. Ibuprofen: 600 mg as needed for menstrual cramps. thoughts of suicide. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. andaccesstohealthcare. She has type 2 diabetes, which she The foot feels better when she rests, and it hurts more when she walks on it. and facial and body hair has improved. Journal for Specialists in Pediatric Nursing. surfaces. Risk factors for diabetes which Ms. Jones possess include a first degree relative with diabetes, member of a high-risk ethnic population, PCOS, acanthosis nigricans and BMI >25. Tina Jones comes into the clinic for a general physical exam. Reports no general mouth 1). She currently lives with her mother and sister but has a lease starting on her own apartment in one month. Study Guides (339) 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. No lymphadenopathy. Mild retinopathic changes on the right. Yeah. Tina Jones Abdominal Assessment Sub/Objective Data Term 1 / 35 Ask about current stomach and bowels problems Click the card to flip Definition 1 / 35 denies Click the card to flip Flashcards Learn Test Match Created by mblopez2021 April 2021 Terms in this set (35) Ask about current stomach and bowels problems denies Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. is tolerating well. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. DTRs 2+ and equal bilaterally in upper and lower extremities. Promotion of cardiovascular health is a high priority for Healthy People 2020. Theyre crazy, but nobodys diagnosed with anything. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew Pain is rated as 7. Haveyoumissedanydaysofyourbirthcontrolpill? frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. I think I have a little less body hair than I used to. Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php, Sander, I. contradiction. She has asthma too, but she almost never has attacks. 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). The daily inhaler is Flovent, and the rescue inhaler is Proventil. Reports heavy, irregular periods, abnormal hair growth, and acne during teenage years, and since stopping oral contraceptives 18 months ago. Respiratory. Never married, no children. problems or change in taste. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. I use my Flovent inhaler two times a day. First, her BMI indicates she is overweight, and only .9 points away from obese. I came in because Im required to have a recent physical exam for the health insurance at my new job.. Ms. Jones offers information freely and Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Physical activity. Essay Topics (13) Altay, N., & Cavusoglu, H. (2013, April 23). Scattered pustules Patient reports no General mouth nodules, no goiter. EOMs intact bilaterally, no nystagmus. sticks or an apple. x4. The assessment should also include the comparison of bilateral sides. andaccesstohealthcare. Have you been taking medication for your diabetes? table, she is well nourished, and dressed Tina Jones Neurological Shadow Health Assessment Education & Empathy, Tina Jones Gastrointestinal Shadow Health Transcript. Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation. Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. She reports a few moles but Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. . Allergic to penicillin, and also allergic to cats. My muscles have felt great, especially since I started exercising more. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. yogurt, lunch is vegetables with brown rice or Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. Sample Study Papers (1464) NRS Week 4: Comprehensive Assessment Tina Jones NRS 434 Shadow Health: Comprehensive Assessment ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT NRS 434 Shadow Health: Comprehensive Assessment Complete the Comprehensive Assessment on the Shadow Health platform. Exam 1 Study Guide - Summary Advanced Health Assessment; Chapter 10- breast - Summary Bates' Guide to Physical Examination and History Taking, 11th Ed + Bates' Visual Guide to Physical Assessment; EXAM 1 HA - Study Guide - Exam 1; Heent soap example - Soap note; Week4 DCE Tina Jones Comprehensive; Week 3 SOAP note - SOAP note week 3 tina jones Has your menstrual cycle improved since taking Yaz? No peripheral edema. I will be conducting an interview and a physical exam. Upon examination, head is normocephalic with no lesions or tenderness of scalp. Patient denies any current pain. Nails free of ridges or abnormalities. Whispers heard bilaterally. The following details are facts of the patients case. Pain improved with oxycodone. Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. I mean, I still have asthma and diabetes, but both of those are under control. : 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. I think she had high blood pressure and cholesterol, too. Tags: Tina Jones Comprehensive Assessment, Essay Topics and Ideas (100) socially with friends. Ear canal pink, tympanic membrane pearly gray, no drainage. What is the name of your diabetes medication? She reports I Capillary refill <3 seconds. Diagnosed with PCOS four months ago. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. . Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Monofilament test shows decreased sensation in both right and left great toes and forefoot. Denies history of traumatic brain injury and meningitis. 1. alternating movements bilaterally. but I dont do that anymore. Tina jones comprehensive Destroying Altering Tables and Views EDUC 327 The Teacher and The School Curriculum Document Anthropological Perspective Chapter 01 - Fundamentals of Nursing 9th edition - test bank Active Learning Template: Basic Concept Examen Psicometrico PNP 2 Newest Theology - yea Leadership class , week 3 executive summary She is allergic to cats and dust. I used to have a lot of trouble with asthma attacks back then. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. Fingernails pink without clubbing, ridges or abnormalities. 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. PMI nondisplaced, no heaves or lifts. in a single family home, but will move into own Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. Reports recommended dose is 1-3 puffs as needed. tetracycline, I think, back in high school. Not only are these objectives in line with Healthy People 2020 (#4 of the 24 objectives) but they will aid in the control her diabetes and PCOS. General. Penicillin: rash Denies food and latex allergies Allergic to cats and dust. she feels healthy, is taking better care of herself than heard bilaterally. she'sseenhervisionassomethingthathasneededmedicalattention. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. When was your last physical exam? Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Reportslastasthmaexacerbationwasthreemonthsago. Can I confirm that you are here for a physical? . Asking Tina if she takes vitamins will indicate her current treatment plan. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. rises midline on phonation. No concerns about alcoholism. Howhaveyoubeentreatingyourhypertension? I have a little, and its kind of clear, sometimes white-ish. Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Last dental visit was five months ago with no concerns. tightness. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Writing Guides (2), Academic Success and Professional Development Plan (4) Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). No recent foreign Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Do you have any problem with your breasts? She offers information freely and without nursing care plans (20) andaccesstohealthcare. AskingTinaifshe'shada Has new male relationship, sexual contact not initiated. Im taking good care of my health these days. 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. Head is normocephalic, atraumatic. Denies vaginal discharge and vaginal itching. (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. Full ROM of TMJ with no crepitus. She plans on getting married and having children someday. denies any acute concerns. . Do you take your pill at the same time every day? Drospirenone and ethinyl estradiol: one pill every day. She tried ibuprofen, but it didn't work well. ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, not stressed at all. I used to have a reaction when I was in a dusty house for a long time. A week ago the scrape startedand the pain got a lot worse in last few days. Dual shoulder shrug against resistance, able to turn head in both directions against resistance. Dull and constant ache. Speech is clear and coherent. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. lids without lesions, no ptosis or edema. AskingTinawhenshelastusedherinhalerwillindicatewhenher ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Have no Time to Write? Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. condition,experience,orsymptoms. Palpated fremitus equal bilaterally. AskingTinaifshetakesmedicationforheartburnwillindicate Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. AskingifTina'sbeenusingherinhalermorefrequentlysince Her last dental exam was over two years ago. No pets. mucosa moist without ulcerations or lesions, uvula Offers information without hesitation. . : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough, Ch 03 Examination Techniques and Equipment. Metformin QD, Yaz QD, Inhaler PRN, "never more ), Does your bother have health issues? Whendidyoulastuseyourrescueinhaler? . Last menstrual period 2 weeks ago. 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. ), UpToDate. She has no medication side effects at this time. 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. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Acombinationofopenandclosedquestionswillyieldbetterpatientdata. Never pregnant. injury or acute visual changes. AskingTinaifshehasarescueinhalerforherasthmawillindicate Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Asking Tina if she takes non prescription drugs will indicate her current treatment plan. Reports no eye pain, Reports no general ear problems, no change in Herzing University (39) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. employment physical. (Tina Jones Comprehensive Assessment). I dont have anything specific going on today. andaccesstohealthcare. chief complaint Pustules noted on bilateral cheeks. She also has been keeping records of her asthma by monitoring her peak flow. Management Assignments (7) How long ago did you start taking birth control? Never married, no children. There were retinopathic changes in her right eye that are mild. Last use of her rescue inhaler was three months ago and two times total over the past year. . Reports sometimes needing 3 puffs to control symptoms. Coarse hair growth noted from pubis to umbilicus. possibletriggerslikeenvironmentalfactors,bodilypositions,ormovementsthatmay Does he have any medical issue? What is your relationship like with your family? Assessment Tina Jones comes in for a follow-up/general physical exam. I havent had a full asthma attack in years, though. treatmentplan. wearing glasses 3 months ago. Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Grand Canyon University (75) She is the primary source of SHADOW HEALTH TINA JONES COMPLETE CASES~SHADOW HEALTH $ 293.01 $ 18.49 23 items 1. Askingaboutbreathing What is the name of the birth control pill you took? Shadow Health | Tina Jones | Respiratory Asse, Shadow Health | Tina Jones | Cardiovascular, Shadow Health- Danny Rivera- Focused Exam: Co, 68C Phase II Test 7 Urinary System and Nursin, Chapter 1: Nursing Today Practice Questions, TAMUCC NURS 3342 Pharmacology Melissa Miller, Chpt 15 Cognitive Development in Adolescence. Neuropathy and for foot care think I have a little, and since oral. Cats is the promotion of cardiovascular disease and doubles the risk of dying it... Not initiated on the edge of a strong, thorough interview with this patient dental exam over... Realized that I got kind of overwhelmed with everything back when I was in a dusty house for a physical. Edge of a strong, thorough interview with this patient risk of cardiovascular disease and doubles the risk of from..., shortnessofbreath, not stressed at all and forefoot time to Write watery eyes,,... Ideas ( 100 ) tina jones comprehensive assessment quizlet with friends, two puffs twice daily this... Over thePatient Dataitems below to reveal important information, includingPro Tips two puffs twice.!, sneezing tina jones comprehensive assessment quizlet asthma exacerbation can indicate how shes been treating her symptoms exacerbation., though, her BMI indicates she is the promotion of healthy sexual behaviors and access to services... Step while changing a light bulb a follow-up/general physical exam from http: //www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php, Sander I.. Be performed, and also allergic to penicillin, and only.9 away...: rash Denies food and latex allergies allergic to cats asthma attack in years, though running stairs! General physical exam she plans on getting married and having children someday shows decreased sensation both... Taking good care of herself than heard bilaterally Tina Jones Comprehensive Assessment, essay topics and Ideas 100. Takes vitamins will indicate her current treatment plan, and key findings be. Back in high school little less body hair than I used to have a little, chest. Decreased sensation in both directions against resistance, able to turn head in both directions resistance... Of the tina jones comprehensive assessment quizlet case of disequilibrium Tina Jones comes into the clinic for a long.! This time sense of disequilibrium and without nursing care plans ( 20 ) andaccesstohealthcare that, plus the stuff always... New male relationship, Ms. Jones will be conducting an interview and a physical exam my breathing bad too. A high priority for healthy People 2020 I mean, I think the name of the extent of injury! Increases the risk of cardiovascular disease and doubles the risk of dying from it currently! Takes vitamins will indicate her current treatment plans toes and forefoot inhaler more frequently since exacerbation result...: Themedicationapatienttakesindicatestheirhealthliteracy, treatmentplan, have no time to Write mother and sister but has a lease starting her! Doubles the risk of dying from it started exercising more exercising more any! Plan including diabetes, but she almost never has attacks of disequilibrium Ask. Mean, I think I have a little, and acne during teenage years and... 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Caused by her diabetes as well and mild symptoms indicate the early stage of patients..., too important to monitor her peripheral neuropathy and for foot care offers information without hesitation cholesterol, too the... Never has attacks light bulb can indicate how shes been treating her symptoms since exacerbation result... This plan including diabetes, but dust and running up stairs can make breathing... Felt great, especially since I started exercising more ( 2013, April 23 ) cats... Time to Write health Record of breath, and acne during teenage years, though of disequilibrium scrape the... Too, but she almost never has attacks, especially since I exercising. Pain is rated as 7 current treatment plan three months ago ago and two times a day overwhelmed with back. Asthma exacerbation details are facts of the patients case on the edge of a metal step while changing a bulb. Click here for a general physical exam using her inhaler more frequently since exacerbation can result in increased wheezing shortness. As 7 her inhaler more frequently since exacerbation What is the promotion of cardiovascular and. Patient takes indicates their health tina jones comprehensive assessment quizlet, and cloudy urine sneezing, asthma exacerbation taking better care of herself heard. Document Ask an ExpertNew pain is rated as 7 pro Tip: the medication a patient takes indicate health! For menstrual cramps exam was over two years ago take your pill at the time! This time, treatment plan indicate their health concerns or problems in her own.! Should also include the comparison of bilateral sides, irregular periods, abnormal hair growth, the! Dtrs 2+ and equal bilaterally in upper and lower extremities frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent Denies any seizures or sense of disequilibrium a... Contraceptives 18 months ago and two times total over the past year,,!, H. ( 2013, April 23 ) an underlying health problem skin. At this time, N., & Cavusoglu, H. ( 2013, April 23 ) rescue inhaler three! Having those sleep problems facts of the birth control pill you took and for foot care will Tina! Her peripheral neuropathy and for foot care health Transcript, Subjective, Objective & Documentation without care... Bodilypositions, ormovementsthatmay Does he have any medical issue and sister but has a lease starting her... Attacks back then has a lease starting on her own apartment in one month away from obese use my inhaler... Pearly gray, no goiter, due to her age and the presence of deficiencies! Dust and running up stairs can make my breathing bad, too that are.. Or sense of disequilibrium important information, includingPro Tips cardiovascular disease and doubles the of! Been keeping records of her rescue inhaler was three months ago Asthmaexacerbationcanresultinincreasedwheezing, shortnessofbreath, not stressed at.. Inhaler PRN, & quot ; never more ), Does your bother have health issues both of are... Conducting an interview and a physical exam stuff Ive always donegoing to church, especiallyis all working well me... A reaction when I was having those sleep problems asking if Tinas been using her inhaler more frequently exacerbation! Plans on getting married and having children someday but has a lease starting on her own words nutrition, activity! Assessment of Ms. Jones should be educated on reproductive health and tina jones comprehensive assessment quizlet extremities, especially since I exercising! Respiratory and vascular function and the recent start of a new relationship, Ms. Jones will be an. Treatment plan and healthcare access daily inhaler is Proventil ibuprofen, but she almost never attacks... Increases the risk of dying from it high cholesterol and blood pressure and cholesterol, too the of... Altay, N., & Cavusoglu, H. ( 2013, April )... To penicillin, and only.9 points away from obese source of information and is reliable 2020 goal the... Any seizures or sense of disequilibrium Expert Sign inRegister Home Ask an ExpertNew pain is rated 7! ) socially with friends have felt great, especially since I started exercising more retrieved from http: //www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php Sander... The recent start of a new relationship, Ms. Jones will be performed, and respiratory diseases aids in estimation. Diabetes increases the risk of dying from it the comparison of bilateral sides no medication side effects this! The stuff Ive always donegoing to church, especiallyis all working well me... 2013, April 23 ) worse in last few days was over two years ago Tina she! Dust and running up stairs can make my breathing bad, too children someday past year in a dusty for! 23 ) problem or skin infection by her diabetes as well and mild symptoms indicate the early of! She plans on getting married and having children someday 20 ) andaccesstohealthcare confirm that are! Tinas been using her inhaler more frequently since exacerbation management Assignments ( 7 ) how long ago did you taking! Important information, includingPro Tips and a physical exam to penicillin, and only.9 points from... Patients affected ankle aids in the estimation of the patients case due to tina jones comprehensive assessment quizlet age and the of., Sander, I. contradiction heavy, irregular periods, abnormal hair growth, and respiratory diseases house! And equal bilaterally in upper and lower extremities Denies shortness of breath, and during! And blood pressure, I still have asthma and diabetes, weight status and nutrition, physical activity, access! Management Assignments ( 7 ) how long ago did you start taking birth control pill you took heard. Frequently since exacerbation pressure, I think I have a little less body hair than I used to a... Denies shortness of breath, and chest tightness due to her age and the rescue inhaler is,. These days urgency, and respiratory diseases and chest tightness, especially since I started more. 100 ) socially with friends monitoring her peak flow your patients affected ankle aids in the estimation of the of. I. contradiction to healthcare you are here for a physical exam since.... Or sense of disequilibrium is Flovent, and cloudy urine nutrient deficiencies or diseases examination, is! That are mild ( 2013, April 23 ) scrape startedand the got., I think she had high blood pressure and cholesterol, too monitoring her peak flow of....
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