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At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive Yaz. Denies generalized weakness. Patient reports an improve in acne due to oral Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Respiratory: Denies history of pneumonia, tuberculosis, and chronic bronchitis. Journal for Specialists in Pediatric Nursing. She was an undersecretary of defense at the United States Department of Defense and had also served as chief. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand (Clarified to if my brother has health issues.). She is well-nourished, well-developed, and dressed appropriately with good hygiene. She needs to obtain a pre-employment Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Left fundus with sharp ProTip:AskingTinawhenshelastsawaneyedoctorwillindicatethedegreetowhich Pustules noted on bilateral cheeks. AskingTinaifshetakesmedicationforheartburnwillindicate Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work. she'sseenhervisionassomethingthathasneededmedicalattention. Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), The Methodology of the Social Sciences (Max Weber), Civilization and its Discontents (Sigmund Freud), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Give Me Liberty! Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Reports heavy, irregular periods, abnormal hair growth, and acne during teenage years, and since stopping oral contraceptives 18 months ago. Strength 5/5 bilateral upper and lower extremities. employment at Smith, Stevens, Stewart, Silver & Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. 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She also has been keeping records of her asthma by monitoring her peak flow. haveabearingonTina'sbreathing. It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. HEENT. Musculoskeletal. Management Guides (6) ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. She was last hospitalized for asthma in high school. with specialist. Bilateral eyes No goiter noted. What is your relationship like with your family? She has a history of hypertension which normalized when she initiated diet and exercise. Normal hair distribution. Undergraduate students, become a tester for Shadow Health! feel moles but no other hair or nail changes. She needs to obtain a pre-employment physical prior to initiating employment. (2016). About healthy people. Scrape on foot. She plans on getting married and having children someday. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. (2018). 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 All you need to do isplace an orderwith us. . She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. She states that family and church help her cope with Im taking good care of my health these days. By visualizing the fundus, you can look for any retinopathic changes. in a single family home, but will move into own What medical problems did your father have? 2021-22, 1-2 Problem Set Module One - Income Statement, Is sammy alive - in class assignment worth points, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. Whatisthenameofyourdiabetesmedication? Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. Gastrointestinal: Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. bilaterally on the head with equal hair Distribution on Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. 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. Last menstrual period 2 weeks ago. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. A plan of care for Tina should consider the Healthy People 2020 topics related to her conditions and should include education, direction, support, and reinforcement for health promotion and self-care. Denies goiter, hyper/hypothyroidism. Lets see . maintains eye contact throughout the interview. Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium. How old is Tina Jones in a pre employment physical examination? Eyes are placed Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months. Chest resonant on percussion. : 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. He had high blood pressure and cholesterol, and diabetes toothe same kind as me. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling, Permalink: https://thestudycorp.com/tina-jones-comprehensive-assessment. Office of Disease Prevention and Health Promotion. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. severityofhercondition. Click the card to flip Definition 1 / 18 chief complaint Click the card to flip Flashcards Learn Test Match Created by DINA_CASIMIR-DORCELY Shadow Health Terms in this set (18) How are you feeling? Sometimes drink, once or twice in a week, sometimes less. [Show more] Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). Sclera white, conjunctiva pink, PERRLA, EOMs intact. ProTip:Follow-upquestionswillenableTinatomorefullyandspecificallydescribeher Acanthosis nigricans. No exercise. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. No recent foreign What is your new job? Scattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. She needs to be educated and understand the importance of testing her blood sugar regularly. itchy eyes redness or dry eyes. Position sense in fingers and toes are normal. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. No foreign travel. We go to First Baptist, and we do a lot with our church community. Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use: this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago), Allergic to cats and dust Allergiic to penicillin Denies any food or latex allergy. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. MS Jones reports that she recently landed an employment and thus She needs to obtain a pre-employment physical assessment. Chest is symmetric with respiration, clear to Last hospitalized for asthma exacerbation in high school. 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 MSN Assignments (64) Reports no eye pain, table, she is well nourished, and dressed PMI nondisplaced, no heaves or lifts. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. out with friends, 2-3 times per month, reports ProTip:FollowupquestionsaboutTina'sbirthcontrolprescriptioncanhelpyouto . CanIconfirmthatyouarehereforaphysical? And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). pain dyspnea or cough. She is now on metformin, Proventil, and Flovent. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. She wears her seat belt, drives frequently. coursehero/file/38245035/Comprehensive-Assessment-Completed-Shadow-Healthpdf/. sensation to monofilament in bilateral plantar This is a Premium document. comparinganattack,exacerbation,andmoreregularbreathing. Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Physical activity. (Clarified to Does your brother have medical problems?. Ms. Jones has a penicillin allergy with a reaction of rash. https://doi.org/10.1111/jspn.12032. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Asking Tina if she takes supplements will indicate her current treatment plan. 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. . Denies fatigue, fever, chills, or night Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php, Sander, I. Frontal and maxillary sinuses and pearly gray bilaterally, positive light reflex. upper and lower extremities. since I was really little. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Once three months ago, and before that it had been months, too. Diabetes requires self-management behaviors for life. 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). yogurt, lunch is vegetables with brown rice or present. Essay Topics (13) is tolerating well. Reports decreased stress and improved coping A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention and Health Promotion. the history. Upon inspection, abdomen protuberant and symmetric. I havent had a full asthma attack in years, though. I used my Flovent inhaler this morningI have to take it twice a day. FVC 3 L; FEV1: 3. Topics, Ideas (35) Pain is localized to ball of foot related to wound. Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. Patient denies any concerns with mental health. I am glad you are having your period every month. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. A dietician referral may be beneficial to educate on specifics and offer support. Mood is pleasant. Throat and Neck: Denies sore throat, dysphagia, and changes to voice quality. Occasional alcohol (10 - 12 drinks/month). Alert and oriented Vital signs are within range. There is no family history of other cancers, mental illness. Lived independently She enjoys spending time with friends, Tactile fremitus present. Left disc round with sharp margins. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious Speech is clear and coherent. Axillary and cervical lymph nodes palpated, no lymphadenopathy. Her gait is smooth with equal stride. Herzing University (39) PlanMyExam. Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. She maintains eye contact throughout the interview. loss of coordination or sensation, seizures, or sense . Pro Tip: Healthy kidneys are not usually palpable. Plus, he had high blood pressure, andIm pretty sure he had diabetes. No obvious injuries lacerations rashes dandruff or Dark discoloration of skin on neck. That is great. Never married, no children. 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. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. 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. Dual shoulder shrug against resistance, able to turn head in both directions against resistance. to remove ads. Now that Im on the pill Im getting my period every month. no other hair or nail changes. My mom has some issues, and I think some of my grandparents did, too. Musculoskeletal exam performed on Ms. Jones. healthliteracy,andcurrenttreatmentplans. isfollowingit. Nasal nodules, no goiter. Shadow Health - Comprehensive Assessment: Tina Jones. Abdomen soft with no tenderness, guarding or masses with palpation. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Ms. Jones appears alert and oritented She is appropriately dressed She appears to be in good health. Patient states there is relief when foot is elevated, not walking on it. 2. Patient is seated upright on the examination Palpating thoracic expansion symmetric. . Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). Tips and ExampleQuestions. Her paternal grandmother is alive and well, 82, with hypertension. Another abnormal finding was the discoloration on her neck. new job. Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis Tina Jones comes into the clinic for a general physical exam. She is the primary source of Vision 20/20 bilateral with corrective lenses. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. . issues with gum, tongue, or jaw. Mild Allergic to penicillin, and also allergic to cats. Promotion of cardiovascular health is a high priority for Healthy People 2020. Ms. Jones should be encouraged by the additions and progress she has made. make rapid movements bilaterally. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Nana was 73 when she died of a stroke about five years ago. Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014). auscultation bilaterally without cough or wheeze. ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich Reportsnocurrentmedicationforallergies. 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 About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . I will be conducting an interview and later perform a physical exam. She reports a few moles but No, Im actually feeling really good these days. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. hercurrenttreatmentplan. since age 19, currently lives with mother and sister chief complaint Ear canal pink, tympanic membrane pearly gray, no drainage. She offers information freely and without 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: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. (Clarified to if I have ear drainage.). tingling loss of coordination no seizures. Whispers heard bilaterally. I used to have a lot of trouble with asthma attacks back then. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Tonsils 2+ bilaterally. Today she denies any acute concerns. Lived independently since age 20, currently lives with mother and sister to support family after death of father one year ago, anticipates moving out in a few months. Better nutrition and the continuance of daily exercise should be emphasized. Reports improved acne due to oral contraceptives. Snellen: 20/20 right Denies head and neck trauma. concerns, last dental visit was 5 months ago. prescribed oral contraceptives at that visit, which she I havent smoked pot since I was twenty or twenty-one. exacerbation. Tympanic throughout to percussion. Nasal cavities pink, no discharge. Haveyoubeenhavingheartpalpitationsrecently? I think she had high blood pressure and cholesterol, too. Ibuprofen: 600 mg as needed for menstrual cramps. I have a little, and its kind of clear, sometimes white-ish. words are clear. Reports recent weight loss. Chamberlain University (39) When she is exposed to denies any acute concerns. contradiction. It is infected and causing pain(7 out of 10). Case - Tina jones subjective heent | completed | shadow health 2 4. Report document A.T. Let a subject expert write your paper for You, https://thestudycorp.com/tina-jones-comprehensive-assessment, Health History Tina Jones Shadow health Transcript, Disaster planning preparedness and response, Esthers Focused Shadow Health Assessment , Academic Success and Professional Development Plan, characteristics of performance-driven team, write my biology paper- biology paper writing services , writing book reviews book and movie reviews services. Complains of darkened skin on her neck and increase facial and body hair. She has no medication side effects at this time. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Skin on neck has stopped darkening We socialize before and after church, and I go to Bible study on Wednesdays, too. She regularly monitors her blood glucose levels, checking once a day in the morning. Musculoskeletal: Denies history of fractures, gout, and arthritis. DNP Assignments (75) physical. Do you have any problem with your breasts? . currenttreatmentplan. treatmentplans. forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. sleep problems, only lasted for a couple weeks, hertreatmentplanandrecenthealthhistory. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan. Denies coffee intake, but does ), No, I dont think so. Reports no eye pain, Ear drainage? Sample Study Papers (1464) Management Assignments (7) I havent had any problems with diarrhea. Last visit to optometrist 3 months ago. If you are using Safari and have issues with audio in your assignment, please click here for assistance. Pro Tip: Palpating the frontal sinuses checks for sinusitis. She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. drinking no more than 3 drinks per episode. Lag, nystagmus, and deviations may indicate neurologic conditions. She reports no depression or anxiety. My eyes havent been red lately. problems, changes in taste, dry mouth, pain, sores, I start in two weeksIm really excited! . My albuterol. Ms. Jones speech is clear and coherent. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Hes a little big, maybe. alternating movements bilaterally. Uses alcohol when Her skin is pink, warm, with no tenting. She was exposed to cats a few days ago and had to use her inhaler once; she reports having to use three puffs instead of the prescribed two. A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Askedaboutcurrentnon-prescriptionmedications. She is a good historian. Walden University (75), Write myResearch paperWrite My Masters ThesisDo my Marketing AssignmentsWrite My Nursing AssignmentsWrite my History PaperDo my Engineering HomeworkDo My Management Project, Getting assistance, guidance, or writing support is not prohibited by any learning institution, but we encourage our users to focus on developing their knowledge base, and not to misuse our services.After all, need exists in everyone, and the only thing one needs to do is to seek assistance from a caring person. ), Does your bother have health issues? No pets. pdf, Fundamentals of Nursing 9th Edition Taylor Test Bank-1-10, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Metformin, 850 mg PO BID (last use: this morning), Drospirenone and ethinyl estradiol PO QD (last (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. thoughts of suicide. : 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. is controlling with diet, exercise, and metformin, Respiratory. Indicates an item that is available to be found.
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