Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. She denies any acute concerns at this visit. Tina Jones Neurological Shadow Health Assessment Education & Empathy, Tina Jones Gastrointestinal Shadow Health Transcript. Pro Tip: Discerning whats making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. She reports a few moles but no other hair or nail changes. Awake and alert. Abdomen soft with no tenderness, guarding or masses with palpation. DTRs 2+ and equal bilaterally in States recent 10 pound weight loss AskingTinaifshetakesherbalproductswillindicateher Nana was 73 when she died of a stroke about five years ago. or night sweats. She denies suicidal and homicidal ideation. sleep problems, only lasted for a couple weeks, What is your relationship like with your family? Snellen: 20/20 right ProTip:Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Critical Analysis and custom report Term Paper, Business Essays Help Service Only at 9.99$. Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium. about 8 or 9 hours a night. 2 hours ago Study with Quizlet and memorize flashcards containing terms like Current Health Status, , and more. Tina is active in her church and Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. She was last hospitalized for asthma in high school. Type 2 diabetes, diagnosed at age 24. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. possibletriggerslikeenvironmentalfactors,bodilypositions,ormovementsthatmay No obvious injuries lacerations rashes dandruff or Sclera white, conjunctiva pink, PERRLA, EOMs intact. Mood is pleasant. Report document A.T. She tried ibuprofen, but it didn't work well. High BP and high cholesterolon both sides and diabetes. nontender to palpation. He had hypertension, high cholesterol, and type 2 diabetes. employment at Smith, Stevens, Stewart, Silver & Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. Tips and ExampleQuestions. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. An individualized plan of care taking into . Denies history of traumatic brain injury and meningitis. Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. How old is Tina Jones in a pre employment physical examination? Case - Tina jones heent shadow health complete 3. 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. Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. AskingTinaifshetakessupplementswillindicatehercurrent Patient denies any dizziness lightheadedness Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. patient self treated by attending church, and talking comparinganattack,exacerbation,andmoreregularbreathing. healthcareaccess. Im sleeping a lot better now, which is a relief. ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. 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. Bowel sounds are normoactive in all four quadrants. Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). hertreatmentplanandrecenthealthhistory. Ibuprofen: 600 mg as needed for menstrual cramps. Nasal Journal for Specialists in Pediatric Nursing. She is the primary source of the history. PERRLA bilaterally. Im usually asleep by 11:30, and I wake up at 8, so. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. NY Times Paywall - Case Analysis with questions and their answers. Guns are locked up. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. 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. she feels healthy, is taking better care of herself than Ms. Jones states that the gynecologist Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job. She is very active in her Baptist church, faith is important to her, and church community is a large part of her social network. Fingernails pink without clubbing, ridges or abnormalities. ), UpToDate. AskingTinaifshetakesmedicationforheartburnwillindicate She appears well-nourished and dresses appropriately. Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. She came into the clinic for a physical exam. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. 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. ProTip:AskingTinawhenshelastsawaneyedoctorwillindicatethedegreetowhich Diagnosed with PCOS four months ago. She works 32 hours/week as a supervisor at a printing and shipping company and is in her last semester of a bachelor's of accounting program. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Hover over thePatient Dataitems below to reveal important information, includingPro Tips. 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. AskingTinaifshehasbeentaking Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). That is great. Another abnormal finding was the discoloration on her neck. Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: andaccesstohealthcare. Experts selected these topics as essential components of a strong, thorough interview with this patient. Now that Im on the pill Im getting my period every month. lip, acanthosis nigricans on posterior neck. without contradiction. Skin on neck has stopped darkening and facial and I came in because Im required to have a recent physical exam for the health insurance at my new job. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. When did you last use your rescue inhaler? Upper and lower extremities symmetric without lesions or swelling. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Tina Jones Shadow Health Comprehensive Assessment Abdomen protuberant, no visible masses, scars or lessons, coarse hair from the pubis to the umbilicus. Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014). She denies any acute concerns at this visit. alternating movements bilaterally. Vision 20/20 bilateral with corrective lenses. ), Shes pretty healthy. She provided the health information freely during the interview. 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. Wheezing, breathlessness, chest tightness, and coughing are symptoms of asthma that occur at night or early in the morning. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, lesions. retinopathic changes on right. Have you been taking medication for your diabetes? indicatehertreatmentplanandthedegreetowhichsheisfollowingit. Oriented to person, place, and time. She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Thorough examinations will yield better patient data. 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 Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. Ms. Jones states her acne has improved due to oral contraceptive use. Eyes are intact bilaterally no nystagmus is Last eye exam was in childhood. problemscanelicitaresponseaboutrecenttroubles. 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 What is the name of your diabetes medication? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Undergraduate students, become a tester for Shadow Health! Asking Tina if she takes supplements will indicate her current treatment plan. Reports no current headache and no history of head Patience hair is well-groomed with even Drospirenone and ethinyl estradiol: one pill every day. isfollowingit. reports no change in sense of smell sneezing for No current complaints or recent illness. methamphetamines, and heroin. Click here for more informationClick here for more information, BP: 142/82; HR: 68; RR: 16; O2: 98%; Temperature: 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. . I havent had a full asthma attack in years, though. Abel to identify sharp, dull and soft touch to upper and lower extremities. 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