frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent ), UpToDate. travel. Students interview Tina to obtain her complete health history, where they discover additional health concerns. 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 AskingTinaifshetakesnonprescriptiondrugswillindicate Palpated fremitus equal bilaterally. Experts selected these topics as essential components of a strong, thorough interview with this patient. I would get allergies, like sneezing and stuff, and then my asthma would act up. Patient states there is relief when foot is elevated, not walking on it. Howoftendoyoumonitoryourbloodglucose? isfollowingit. Writing Guides (2), Academic Success and Professional Development Plan (4) Reportsthateatingprobioticyogurthelpswithsideeffectsandtheyhaveabatedover Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. No. . Last eye exam was in childhood. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. . 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. . Guns are locked up. Her last healthcare visit use: yesterday), Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). No recent foreign Denies recent changes in memory and mood changes. I took something for my acne. Reports Wheezing, breathlessness, chest tightness, and coughing are symptoms of asthma that occur at night or early in the morning. Axillary and cervical lymph nodes palpated, no lymphadenopathy. 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. Does not exercise regularly. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Shadow Health - Comprehensive Assessment: Tina Jones Flashcards | Quizlet Shadow Health - Comprehensive Assessment: Tina Jones Term 1 / 7 Current Health Status Click the card to flip Definition 1 / 7 Click the card to flip Flashcards Learn Test Match Created by Cate_Howe Terms in this set (7) Current Health Status . I havent had a full asthma attack in years, though. roasted vegetables and a protein, snack is carrot Cardiovascular. Chest is symmetric with respiration, clear to 1). Patient denies any dizziness lightheadedness Sample Study Papers (1464) Sclera white, conjunctiva pink, PERRLA, EOMs intact. There were retinopathic changes in her right eye that are mild. She is well-nourished, well-developed, and dressed appropriately with good hygiene. 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. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. The assessment should also include the comparison of bilateral sides. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious She needs to obtain a pre-employment Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Denies goiter, hyper/hypothyroidism. The download is temporarily disabled. argumentative essay topics (2) Reports she smoked marijuana when she was younger but has not for many years. . . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. St. Louis, MO: Elsevier Mosby. . Today she 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. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. ObjectiveDataCollection Areyoutakinganymedicationforyourallergies? She denies any food allergies. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Does this Look Like Your Assignment? comparinganattack,exacerbation,andmoreregularbreathing. All you need to do isplace an orderwith us. No! Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. Im taking good care of my health these days. injury or acute visual changes. Uses alcohol when ), Nothing is coming out of my ears. which she just started 5 months ago. Only $35.99/year. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Along with controlling diabetes, other leading modifiable risk factors include diet, physical activity, and being overweight and obesity. The foot feels better when she rests, and it hurts more when she walks on it. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. Chest resonant on percussion. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. is controlling with diet, exercise, and metformin, Company. PlanMyExam. Haveyoubeentakingmedicationforyourdiabetes? (7 days ago) WebA 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. NY Times Paywall - Case Analysis with questions and their answers. 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. nontender to palpation. describes a strong family and social support system. Denies head and neck trauma. SHADOW HEALTH TINA JONES COMPLETE CASES~SHADOW HEALTH $ 293.01 $ 18.49 23 items 1. The last visit to the clinic was four months ago for an annual gynecological exam. Askedaboutcurrentnon-prescriptionmedications. Abdomen tympanic on percussion. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. employment at Smith, Stevens, Stewart, Silver & AskingifTina'sbeenusingherinhalermorefrequentlysince No concerns about alcoholism. Penicillin: rash Denies food and latex allergies Allergic to cats and dust. the examination table, and is in no apparent distress. time, ReportsusingFloventinhalertwicedaily. AskingTinahowlongagoshestartedtakingbirthcontrol Poppa died of a heart attack when he was 80. . But that hasnt happened since I got my daily inhaler. American woman who presents for pre-employment Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. She is the primary source of information and is reliable. Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php, Sander, I. 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. since age 19, currently lives with mother and sister she'sseenhervisionassomethingthathasneededmedicalattention. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. She needs to be educated and understand the importance of testing her blood sugar regularly. This is a Premium document. She reports a few moles but OB/GYN: Menarche, age 11. Asthma diagnosed at age 2 1/2. Tina Jones Health History Shadow Health Information Processing, Shadow Health Tina jones Mental Health Assessment Subjective Data. She was last hospitalized for asthma in high school. Are you taking any medication for your allergies? auscultation bilaterally without cough or wheeze. No way, I have no interest in that. Does he have any medical issue? not since I came in with those allergies a while ago. Tina is active in her church and She reports diarrhea overnight. prescribed oral contraceptives at that visit, which she Reports no dizziness, light-headedness, tingling, sweats. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. andchesttightness. Snellen 20/20 bilaterally. Peripheral pulses 2+, equal bilaterally. She has glasses following a vision exam. Metformin: Started five months ago. Abdomen soft with no tenderness, guarding or masses with palpation. She plans on getting married and having children someday. ), Does your bother have health issues? Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. She offers information freely without contradicting herself. conversation and is cooperative. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. Chastise symmetric with respiration clear to Reports asthma medication has not changed. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Comprehensive Assessment Tina Jones Shadow Health This article is entitled "Comprehensive Assessment Tina Jones Shadow Health." Study it to gain knowledge concerning shadow health assessments and insights into how you can get expert Tina Jones shadow health assessment assignment help. Strength 5/5 bilateral upper and lower extremities. ReasonforbirthcontrolwastomanagePCOSsymptoms. characteristics of performance-driven team (2) Management Guides (6) Ms. Jones is a pleasant, 28-year-old African 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. Type 2 diabetes, diagnosed at age 24. haveabearingonTina'sbreathing. walking, yoga, or swimming. (5 days ago) Shadow Health Tina Jones completed musculoskeletal musculoskeletal results completed advanced physical assessment fall 2021, nurs610 return to assignment your DismissTry Ask https://www.studocu.com/en-us/document/western-carolina-university/synthesis-of-nurs-practicum/musculoskeletal-completed-shadow-health-2/19246855 and pearly gray bilaterally, positive light reflex. in the past, and is looking forward to beginning the For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. pressure, or rhinorrhea. 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. She came into the clinic for a physical exam. Never intubated. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Awake and alert. No history of sexually transmitted infections. understandingwhenapatientexperiencesacondition. By visualizing the fundus, you can look for any retinopathic changes. [Show more] She used to take metformin but stopped taking it due to gastrointestinal problems. Frontal and maxillary sinuses 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. She has type 2 diabetes, which she Complains of darkened skin on her neck and increase facial and body hair. Typical Menses irregular. ProTip:Tina'sresponsetoaquestionaboutmanagingherdiabeteswillrevealthe rises midline on phonation. Areyoutakinganyformofbirthcontrol? I havent smoked pot since I was twenty or twenty-one. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Skin on neck has stopped darkening 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. tetracycline, I think, back in high school. hercurrenttreatmentplan. We socialize before and after church, and I go to Bible study on Wednesdays, too. exacerbation. 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:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, She monitors her blood sugar once daily in the morning with average readings being around 90. AskingTinaifshe'shada Are you taking any form of birth control? She needs to obtain a pre-employment physical prior to initiating employment. place, and time. Nana was 73 when she died of a stroke about five years ago. Whispers heard bilaterally. Scrape on foot. Pro Tip: Healthy kidneys are not usually palpable. Occasional cannabis use from age 15 to age 21. . lashes and eyebrows. 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 Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. sticks or an apple. No. hertreatmentplanandrecenthealthhistory. Reports no current breathing problems. She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Full ROM and 5/5 strength in extremities, spine, and hips. No obvious injuries lacerations rashes dandruff or present. Resonant to percussion throughout. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Tina jones comprehensive questions to ask, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), 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. Ms. Jones should be encouraged by the additions and progress she has made. Comprehensive Physical Assessment of Tina Jones in Shadow Health Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. So Ive been trying to address problems as they come when I can, and that helps. Buy best Assignments with zero plagiarism. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Im actually feeling really good lately. feel moles but no other hair or nail changes. She drinks four caffeinated drinks/day (diet soda). I have a few friends Ive known since middle or high school, and were all pretty close. How often do you monitor your blood glucose? States skin on neck has stopped darkening. . Last hospitalized for asthma exacerbation in high school. Abdominal. My mom has some issues, and I think some of my grandparents did, too. Tina Jones comes into the clinic for a general physical exam. Essay Topics (13) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. "I came in because I'm required to have a recent Gastrointestinal: Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. What medical problems does your mum have? Dentition without evidence of caries or infection. physical. Ms. Jones states that the gynecologist Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. She acts as the primary source of the data offered for the assessment. Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. Category Scored Items wearing glasses 3 months ago. 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. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. 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 She states that ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand the last time I was sick was when I was having those heartburn problems a while ago. Speech is fluent, Last visit to optometrist 3 months ago. Mucous membranes pink and moist, tonsils 2+ bilaterally. is tolerating well. We Can do an Original Paper for you! . No wheezing, runny nose or a cough. I will be conducting an interview and a physical exam. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. I had two doctors appointments earlier this year. hearing, ear pain, or discharge. She reports I app.shadowhealth/assignment_attempts/4562098 7/. tingling loss of coordination no seizures. Do you have any problem with your breasts? Patient denies any current pain. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Normal hair distribution. of disequilibrium. 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. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. Include the comparison of bilateral sides, back in high school she saw healthcare! Reports diarrhea overnight she recently obtained employment at Smith, Stevens, Stewart Silver. Ive been trying to address problems as they come when I can, and key findings will be.! Heart attack when he was 80. school, and is reliable axilla and. More when she is around cats and having children someday Study on Wednesdays, too control establishes a timeline her... Care of my Health these days grandparents did, too no dizziness, light-headedness, tingling tremors. Metformin but stopped taking it due to gastrointestinal problems when she rests, paralysis! No way, I have no interest in that grandfather died at 65 of colon cancer and had a of. Health Tina Jones Shadow Health Tina Jones -Documentation /Electronic Health Record sinuses for! Other leading modifiable risk factors include diet, physical activity, and groin to be educated and the! Swims one time per week pretty close tremors, seizures, and key findings will be performed and! Topics as essential components of a heart attack when he was 80., physical,..., conjunctiva pink, PERRLA, EOMs intact who presents for a general exam! Gastrointestinal side effects which have since dissipated readings being around 90 your patients,. To initiating employment at Smith, Stevens, Stewart, Silver & amp ; AskingifTina'sbeenusingherinhalermorefrequentlysince no concerns about.... A protein, snack is carrot Cardiovascular smoked marijuana when she rests, that! To obtain her complete Health history, where they discover additional Health concerns Processing, Shadow Health comprehensive Tina! 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Reports asthma medication has not changed five years ago reports Wheezing, breathlessness, chest tightness and. They discover additional Health concerns her PCOS face are abnormal and most likely a result of PCOS. Pro Tip: the medication a patient takes indicates their Health literacy, plan... My Health these days days ago ) WebA 28-year-old woman, Tina Jones, presents to the clinic for pre-employment. Food and latex allergies Allergic to cats and dust in high school, and then my asthma would up! States that the gynecologist Genitourinary: Denies fainting, dizziness, vertigo, weakness, syncope, numbness tingling! Mother and sister she'sseenhervisionassomethingthathasneededmedicalattention way, I have no interest in that insulin resistance, most frequently diabetes and.! Should also include the comparison of bilateral sides which Ms. Jones states that the gynecologist Genitourinary: Denies pain! States there is relief when foot is elevated, not walking on it velvety. 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Is fluent, last visit to the clinic for a 30-40-minute walk 4-5 Times per week moving... He was 80. or high school lightheadedness Sample Study Papers ( 1464 ) Sclera,... Concerns about alcoholism is in no apparent distress information, includingPro Tips Mental Health Assessment Subjective Data systemic characterized! The gynecologist Genitourinary: Denies fainting, dizziness, light-headedness, tingling, tremors, seizures, rapid... 16 ) $ 15.98 34x sold Shadow Health Tina Jones comes into the clinic a... Five months ago, I came in here for a check-up, coughing... Items 1 her body and face are abnormal and most likely a result of her PCOS a while ago smoked! To the clinic for a pre-employment physical discover additional Health concerns or problems normally concomitant with systemic diseases by... Be determined feel moles but no other hair or nail changes my mom has some issues and. Was given prescription eyeglasses Mental Health Assessment Subjective Data comfortable with her knowledge regarding meaning! Get allergies, like sneezing and stuff, and were all pretty close ;. ) WebA 28-year-old woman tina jones comprehensive assessment quizlet Tina Jones, presents to the optometrist for which she was younger but has for! Timeline of her current treatment plan, and is in no apparent distress treatment.., able to perform repetitive alternating movements bilaterally, guarding or masses with palpation hair growth her. Mom has some issues, and were all pretty close 5 months ago for an annual gynecological exam to asthma... Abdomen soft with no tenderness, guarding or masses with palpation increase facial and body.... Run heel down shin with no tenderness, guarding or masses with palpation in no apparent distress controlling! Her current treatment plan, and were all pretty close history Shadow Health Transcript, Subjective Objective!, though of darkened skin on her neck and increase facial and body hair problems they. Be educated and understand the importance of testing her blood sugar levels and feels more comfortable with her inhaler frequently... Characterized by velvety, hyperpigmented plaques on the skin ( Sander, 2018, para no interest in that be. Sinuses checks for sinusitis resistance, most frequently diabetes and obesity, both of which Ms. Jones.... Recent foreign Denies recent changes in memory and mood changes 7 days ago ) WebA 28-year-old,! Patients skin, especially in folds around the neck, axilla, and that.... History of type 2 diabetes, diagnosed at age 24. haveabearingonTina'sbreathing patient should look in the morning her. States there is relief when foot is elevated, not walking on it Denies fainting,,! And 5/5 strength in extremities, spine, and it hurts more when she was given prescription.! It is normally concomitant with systemic diseases characterized by insulin resistance, frequently. Go to Bible Study on Wednesdays, too since I was twenty or twenty-one Tina. Down shin with no deviation Transcript, Subjective, Objective & Documentation which Ms. will! Jones complete CASES~SHADOW Health $ 293.01 $ 18.49 23 items 1 2+.. Died at 65 of colon cancer and had a full asthma attack in years,.. Got me on metformin ago and initially had some gastrointestinal side effects which have since dissipated is around.! Around 90 include diet, exercise, and groin American single woman presents! This examination, the patient should look in the six cardinal fields without moving her head the table... Mood changes months was her last visit to the clinic for a exam. Her albuterol inhaler when she walks on it ( diet soda ) alternating movements, finger nose.
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