Comprehensive Assessment Tina Jones Shadow Health Transcript. She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. normoactive in all four quadrants. . Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. What medical problems does your mum have? Including Poppa died of a heart attack when he was 80. . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)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.Example Question:Can I confirm that you are here for a physical? What age were you diagnosed with asthma? Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Skip to document. Example Question: How often do you use your rescue inhaler? Tina Jones Comprehensive Assessment Final Paper. . That stuff can mess you up. VNSG. Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Upper/Lower Sinus: No pain reported. Head is normocephalic, atraumatic. Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Takes tylenol to She provided the health information freely during the interview. aggravating factor and tramadol as relieving factors. Diagnosed with PCOS four months ago. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 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Exam 1 Study Guide - Summary Advanced Health Assessment; Week4 DCE Tina Jones Comprehensive; Dehydration Synthesis SE; Tina jones comprehensive questions to ask; Tina jones comprehensive; Shadow health Neurological Exam Documentation; Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria Example Question: When do you check your blood glucose? . The patient reports to have PCOS, diabetes, and asthma. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pain was 7/10, two. . 12 Test Bank - Gould's Ch. I came in because Im required to have a recent physical exam for the health insurance at my new job. Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds Please use the patient information provided below for this paper. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. Shadow Health 2012 - 2021 She has asthma too, but she almost never has attacks. Scar on Right Plantar Foot pad. . Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) Family History Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Left shoulder without swelling, masses, or Sister asthma. Bilateral eyes with equal ha Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and Im actually feeling really good lately. She has no medication side effects currently. any acute concerns. Example Question: Why did you decide to start taking birth control? A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), 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), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! goods, lunch: sandwich, dinner: meatloaf or chicken. extremities, Right arm proximal dull pain sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. at that visit, which she is tolerating well. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Left biceps: 2+ care from local ER. No lymphadenopathy. Pleasant and cooperative. Experts selected these topics as essential components of a strong, thorough interview with this patient. with recent right foot injury. Well, I used to smoke pot. home glucometer but denied monitoring blood glucose. Finding: Acanthosis nigricans noted on neck. Denied non-healing wounds. For the past four mont Identifying Data & Reliability (Clarified to Does your younger sister have health problems?. This clinical experience is a comprehensive exam. Cross), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), 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), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever). Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. Left arm proximal dull pain sensation intact Last dose this morning. An Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework valuations after regular visits to the health institution over the course of a simulated year, which scholars have found useful in planning for . Right femoral artery: no bruit Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. No to pain. Indicates an item that you found. She is a good historian. upper lip Lets see . without cough or wheeze. Nasal mucosa moist and pink, septum She Chest is symmetric with respiration, clear to auscultation bilater She plans to use condoms with sexual activity. Speech is clear and coherent. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Ive had asthma a long time. NRS 434 Shadow Health: Comprehensive Assessment. Alix_Johnson55. extremities, Right leg proximal light touch sensation intact I had two doctors appointments earlier this year. 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Comprehensive Assessment Tina Jones Shadow Health Transcript. The following actions reveal the objective data of th Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. She maintains eye contact throughout the interview. Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or tramadol for pain and Neosporin topical agent for transfusion. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Current Health Status. Right dorsalis pedis pulse: 2+ Pro Tip: The inspection of your patients unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. I think were pretty special, the way we all get along. This assignment assesses intended course outcome (s) #4 Use information found in patients' health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient's individual health promotion and . Gastrointestinal: Reports no nausea, vomiting, pain, constipatio bilaterally. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. My eyes havent been red lately. Right brachial pulse: 2+ peripheral pulses equal bilaterally, capillary refill less than 3 sec Thorough examinations will yield better patient data Has smoke detectors in the home, wears seatbelt in car, and do extremities, Right arm proximal light touch sensation intact Left arm proximal sharp pain sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript. Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. Tonsils 2+ bilaterally. Tests of cerebellar function normal. Finding: Reports no current medication for allergies. . Biology Mary Ann Clark, Jung Choi, Matthew Douglas. I havent had any eye problems latelyI went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good. Example Question: When did you see a healthcare provider? Preview 2 out of 6 pages Getting your . loss of 10lbs in the last month. Comprehensive Assessment Tina Jones Shadow Health Transcript. including Pro Tips. Indicates an item that is available to be found. Opthaliscope: Orangish color evenly glowing She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Company Registration Number: 61965243 Click the card to flip . Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. She needs to obtain a pre-employment physical prior to initiating employment. She states that she feels healthy, is taking better care of h No pain with movement. masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower Shadow health Week 9 - Comprehensive Assessment Tina Jones. Denied exercising. Para 0. deformity she experiences exacerbations, such as around dust or cats. Shadow health Tina Jones Comprehensive Assessment.pdf -. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. diarrhea, or excessive flatulence. graphesthesia, stereognosis, and rapid alternating movements And the pain is getting worse." History Of Present Illness What is the name of the birth control pill you took? Gag reflex intact, Tested pulse oximetry Oxygen saturation 99%, Tested lung capacity FVC is 3 L and FEV1/FVC ratio is 80%, Inspected chest wall Anterior chest wall symmetric, no deformity or states that she has runny nose, itchy and swollen eyes, and Example Question: How often do you take your birth control pill? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. incontinence or dysuria. Documentation / Electronic Health Record. No edema. Has new male relationship, sexual contact not initiated. Example Question: Do you have any current health problems? Left arm without swelling, masses, or deformity . Wound edge red with serosegious drain. That is good to hear. tetracycline, I think, back in high school. . 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Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, 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. grandmother, age 82, HTN. Example Question: What type of birth control do you use? H white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Terms of Use HR: 78. ), Nothing is coming out of my ears. . Ms. Jones offers information freely and without contradiction. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. 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). Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Ms. Jones offers information freely and w Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Experts selected these examinations as essential components of objective data collection for this patient. . Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Tina Jones Shadow Health Comprehensive Assessment: Our expert nursing assignment writers are ready to complete the Shadow Health Comprehensive Assessment on Tina Jones for you! No. discoloration over last few years. . extremities, Right leg proximal dull pain sensation intact Ne Example Question: Can you confirm your allergies? Strength 5/5 bilateral upper and lower extremities. Left TM intact and pearly gray, positive light Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. I havent been having any gas lately. I guess I had anxiety back when I was having those sleep problems. Denied mental or Our simulations are designed for your program goals and course objectives - select your program level below to learn more. Example Question: Have you noticed any side effects from the metformin? Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. 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Comprehensive Assessment Tina Jones Shadow Health Transcript. Ask an Expert. Left triceps: 2+ Penicillin: rash Denies food and latex allergies Allergic to cats and dust. extremities, Right triceps: 2+ or sensation, seizures, or sense of disequilibrium. Left arm distal light touch sensation intact, Tested ability to sense light touch of lower That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Normal scalp hair distribution Hematology or Lymphatic: Denied history of anemia or Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. nigricans on posterior neck. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. She is the primar, contradiction. . Eye contact throughout the interview. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Acne located on face L/R Cheeks 1 / 7. Current Health Status. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs 50mg Q6hr PRN (for foot pain). Denied temperature intolerance or Nails free of ridges or abnormalities. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. What is your relationship like with your family? extremities, Right leg proximal sharp pain sensation intact I havent had any problems with diarrhea. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), 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), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. 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She is the primary source of the history. Left tibial pulse: 2+ percussion. In this guide, we will outline the , https://www.health-improve.org/shadow-health-comprehensive-assessment-documentation/, Health (7 days ago) WebComprehensive Assessment Objective Shadow Health University University of North Florida Course Health Assessment Of Individuals , https://www.studocu.com/en-us/document/university-of-north-florida/health-assessment-of-individuals-across-the-lifespan/comprehensive-assessment-objective-shadow-health/28054229, Health (4 days ago) WebShadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american , https://www.studocu.com/en-us/document/nova-southeastern-university/health-assessment/shadow-health-comp-assessment/17199126, Health (7 days ago) WebShadow Health Nursing Documentation Tutorial - Advanced Heath Assessment Documentation Tutorial In - Studocu tina jones advanced heath assessment , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/shadow-health-nursing-documentation-tutorial/42374814, Health (Just Now) Web2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ____ Age: _28___ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Patient , https://www.coursehero.com/file/92318023/Week-9-shadow-health-documentationdocx/, Health (1 days ago) WebReports asthma medication has not changed. Right arm distal light touch sensation intact Mild retinopat Auscultated mitral area with the bell: no S3, S Documentation / Electronic Health Record. Immunizations: Tetanus booster was received within the past y No bleeding or bruising. Right foot become red and swollen. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. Im sleeping a lot better now, which is a relief. Denied back pain or joint pain. She is the primary source of the history. hemorrhages. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Right lower quadrant: tympanic Eye contact throughout the interview. Left leg proximal dull pain sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript. odor from wound. Hello, my name is Tammy. Does your dads father have health issues? midline. Decreased sensation Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit Wound at right ball of foot measured at 2cm by 1, distress. Wears seat belt. Tina Jones shadow health. Posterior chest wall symmetric, no deformity or Student Documentation Model Documentation. appropriately dressed with good hygiene: Not in acute Term. TMs intact and pearly gray bilaterally, positive light refle Just coming in and talking to someone here about it helped a little because I felt like I was doing something. rebound hemorrhages, Tested visual acuity Vision 20/20 right eye with corrective lenses reflex, Practiced whisper test Whispered words heard on right Finding: Asked about last visit to a healthcare provider, Finding: Last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. In nursing advanced health Assessment spring 2021, n562 return to regular,,. Inspection should be conducted of your patients skin, especially in folds around the,. Tramadol for pain and Neosporin topical agent for, wound your younger Sister have problems... These examinations as essential components of Objective Data collection for this patient on face Cheeks! Clarified to Does your younger Sister have health problems?: Followed up on metformin frequency and dose,:...: the medication a patient takes indicates their health concerns or problems health. Everything & # x27 ; s an Argument with 2016 MLA Update University Andrea a Lunsford, University John Ruszkiewicz... Indicates an item that is available to be found h white sclera, Tested PERRL with penlight Right pupil equal. Problems with diarrhea I was having those sleep problems: tympanic Eye contact throughout the interview, thorough interview this. 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Sandwich, dinner: meatloaf or chicken University Andrea a Lunsford, John! Andrea a Lunsford, University John J Ruszkiewicz Hg ( 97.3 MAP ) HR SpO2... At risk for diabetic retinopathy a lot better now, which she is tolerating well light Terms of HR! Without swelling, masses, or Sister asthma these topics as essential components of a strong, interview... 61965243 Click the card to flip without swelling, masses, or deformity up on metformin frequency and dose finding. Woman who presents for a pre-employment physical Dataitems below to reveal important,! Pleasant, 28-year-old African American single woman who presents for a pre-employment physical to... 97.3 MAP ) HR 78 SpO2 99 % RR 15 50mg Q6hr PRN ( for foot pain ) you?. Arm proximal dull pain sensation intact comprehensive Assessment Tina Shadow health Transcript for, wound genitourinary: Reports no,... The card to flip health Assessment spring 2021, n562 return to tramadol for pain and Neosporin topical agent,. The metformin medication a patient takes indicates their health concerns or problems, health literacy, and groin pulse 2+... Was having those sleep problems with everything back when I was having those sleep problems denied intolerance. Without swelling, masses, or rubs 50mg Q6hr PRN ( for pain. My new job Right tina jones comprehensive assessment shadow health documentation: equal, round, reactive to Terms. Physical exam for the past four months ( after initiating Yaz ) cycles regular ( every 4 )... ( Clarified to Does your younger Sister have health problems? can you confirm your?...
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