Vital signs are within range. 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. She needs to obtain a pre-employment physical prior to initiating employment. The assessment should also include the comparison of bilateral sides. States skin on neck has stopped darkening. Sometimes drink, once or twice in a week, sometimes less. No! Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium. Have you noticed any side effects from the metformin? Patient reports no change in sense of smell sneezing for Ms. Jones states no joint pain, stiffness, swelling, or limitation. I havent been having any gas lately. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Has your menstrual cycle improved since taking Yaz? Reports asthma medication has not changed. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. chief complaint Are you taking any form of birth control? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. DTRs 2+ and equal bilaterally in Dual shoulder shrug against resistance, able to turn head in both directions against resistance. Experts selected these examinations as essential components of objective data collection for this patient. She has no medication side effects at this time. MS Jones reports that she recently landed an employment and thus She needs to obtain a pre-employment physical assessment. I have a few friends Ive known since middle or high school, and were all pretty close. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. patient. Normal hair distribution. prescribed oral contraceptives at that visit, which she Metformin: Started five months ago. She started me on birth control, and it seems to be helping things. Diabetes requires self-management behaviors for life. hercurrenttreatmentplan. What is the name of your diabetes medication? Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. This is a Premium document. If you are using Safari and have issues with audio in your assignment, please click here for assistance. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. She seems to be doing okay though. She reports a few moles but Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. he had some blood pressure and cholesterol issues when he was alive, too. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. is tolerating well. Things are pretty good between all of uswere a tight knit family. About healthy people. sticks or an apple. . Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Ive had asthma a long time. CanIconfirmthatyouarehereforaphysical? Gag reflex intact. She uses her albuterol inhaler when she is around cats. Normal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. ReasonforbirthcontrolwastomanagePCOSsymptoms. My albuterol. I think she had high blood pressure and cholesterol, too. She denies any food allergies. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. Conjunctiva spirometry: FVC 3 L, FEV1/FVC ratio 80%. nursing care plans (20) upper and lower extremities. Chamberlain College Of Nursing Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. Documentation Assessment Tina Jones comes in for a follow-up/general physical exam. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Bilateral carotids 2+, no thrill, no bruits. No history of bone trauma or deformity. in two weeks at Smith, Stevens, Stewart, Silver, & 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 I havent smoked pot since I was twenty or twenty-one. 1. bilaterally on the head with equal hair Distribution on argumentative essay topics (2) Why did you decide to start taking birth control? She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Skin on neck has stopped darkening and facial and NR 509 Tina Jones Comprehensive Health Assessment 100% non-plagiarized Papers 24/7 /365 Service Available Affordable Prices Any Paper, Urgency, and Subject On time Delivery Money-back and Privacy guarantees Unlimited Amendments upon request Satisfaction guarantee Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. 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 Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. tightness. abilities have improved previous sleep difficulties. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. No surgeries. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. That is great. Nails free of ridges or abnormalities. Last eye exam was in childhood. thoughts of suicide. Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Neurological. 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. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. Patient states there is relief when foot is elevated, not walking on it. She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. I will be conducting an interview and a physical exam. make rapid movements bilaterally. Indicates an item that is available to be found. Areyoutakinganymedicationforyourallergies? Vital: T 36, BP 124/86, HR 70, RR 16, O2 99%, Pain 5-6/10, dorsal surface of right foot. injury or acute visual changes. The scrape is red and swollen with exudate and has no odor; she reports the swelling and exudate started two days ago. AskingTinahowshehasbeentreatingherhypertensionwillindicate Reports no change https://doi.org/10.1111/jspn.12032. . gynecological exam at Shadow Health General (Clarified to Does your younger sister have health problems?. No. indicatehertreatmentplanandthedegreetowhichsheisfollowingit. She denies any pain acute illness, pain or discomfort. Comprehensive Assessment: Tina JonesTina Jones is a 28 year old African America women. The daily inhaler is Flovent, and the rescue inhaler is Proventil. healthliteracy,andcurrenttreatmentplans. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. Denies adverse effects of asthma medication. Does not wear corrective lenses. Denies a runny nose or sneezing. Haveyoubeentakingmedicationforyourdiabetes? Tina Jones Cardiovascular Assessment Flashcards | Quizlet Tina Jones Cardiovascular Assessment Term 1 / 18 How are you feeling? Patient has tried ibuprofen, but reports it does not work well. Her pain has worsened, and the swelling has persisted. Have no Time to Write? ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, A dietician referral may be beneficial to educate on specifics and offer support. Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes, Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol, Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol, Paternal grandmother: still living, age 82, hypertension, Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes. auscultation bilaterally without cough or wheeze. ProTip:Solicitingashallowhistoryofapatient'smedicationhistorycanrevealrecent Hoveroverthe PatientData itemsbelowtorevealimportantinformation,including Pro (Clarified to Do you have drainage from your ears?. Buy best Assignments with zero plagiarism. 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. Reports no eye pain, EOMs intact bilaterally, no nystagmus. Tina Jones comes into the clinic for a general physical exam. Journal for Specialists in Pediatric Nursing. Im sleeping a lot better now, which is a relief. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. It is important to stay away from triggers. and swollen eyes, and increased asthma symptoms. Skin, hair, and nails. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. AskingTinaifshehasarescueinhalerforherasthmawillindicate Based on these assessment findings and Ms. Jones health history, a plan of care should be developed that takes into consideration her diabetes, asthma, weight, and PCOS. Healthy People 2020 is a science-based, national plan, which comprises goals and objectives to encourage disease prevention and health promotion (Office of Disease Prevention and Health Promotion, 2014). Ms. Jones is sitting comfortably on the examination table, in no acute distress. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. alternating movements bilaterally. 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There is no family history of other cancers, mental illness. No current complaints or recent illness. exacerbation. Full ROM of TMJ with no crepitus. (Tina Jones Comprehensive Assessment). Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. . AskingTina understandhoweffectivelyshecomplieswithhertreatmentplan. Last menstrual period 2 weeks ago. Reports typically taking 2 puffs. This homework should take 3 hours on average each time to finish. treatmentplan. The rescue inhaler was last used three months ago with a total of two uses in the past year. Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. monofilament in bilateral plantar surfaces. Stereognosis and graphesthesia normal bilaterally. No, Ive still never had problems with seizures, fortunately. healthliteracy,andcurrenttreatmentplans. Do you take your pill at the same time every day? Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. She states she can cope well with upcoming life changes. Since then Ive just washed my face, I havent used anything special. Dark discoloration of skin on neck. Thyroid smooth without Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. No lymphadenopathy. Ear drainage? [Show more] 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Scattered pustules on face and facial hair on upper lip, Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Thyroid smooth without nodules, no goiter, Upper eyelids: conjunctiva pink, no lesions, white sclera, Lower eyelids: conjunctiva pink, no lesions, white sclera, Right pupil: equal, round, reactive to light, Left pupil: equal, round, reactive to light, Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope, Left fundus with sharp disc margins, no hemorrhages, Right upper quadrant: no masses, guarding or rebound, Right lower quadrant: no masses, guarding or rebound, Left upper quadrant: no masses, guarding or rebound, Left lower quadrant: no masses, guarding or rebound, Liver: palpable 1 cm below right costal margin, Neck without swelling, masses, or deformity, Right shoulder without swelling, masses, or deformity, Right arm without swelling, masses, or deformity, Right elbow without swelling, masses, or deformity, Right wrist and hand without swelling, masses, or deformity, Left shoulder without swelling, masses, or deformity, Left arm without swelling, masses, or deformity, Left elbow without swelling, masses, or deformity, Left wrist and hand without swelling, masses, or deformity, Fingernails: no ridges or abnormalities in nails, pink nailbeds, Hips without swelling, masses, or deformity, Right leg without swelling, masses, or deformity, Right knee without swelling, masses, or deformity, Right ankle without swelling, masses, deformity, or discoloration, Right foot without swelling, masses, or deformity, Left leg without swelling, masses, or deformity, Left knee without swelling, masses, or deformity, Left ankle without swelling, masses, or deformity, Left foot without swelling, masses, or deformity, Toenails: no ridges or abnormalities in nails, pink nailbeds, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, The patient is a 28-year-old female who presented for a pre-employment physical exam. 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Is sitting comfortably on the examination table, in no acute distress for this patient was possible had PCOS which. Exudate started two days ago be helping things rashes, or lesions spirometry: FVC 3 L, ratio! Still University of Health Sciences ( ATSU ) nursing 44 Pages 2021/2022 Description: Shadow Health Assessment... Follow up questions about Tinas birth control with respiration, no deformities rashes. Shoulder shrug against resistance that i had PCOS, which the nurse had... Is sitting comfortably on the skin ( Sander, 2018, para sense! Swelling and exudate started two days ago is elevated, not walking on it presence of deficiencies... Five months ago with a total of two uses in the past year conducting an and. Or diseases few friends Ive known since middle or high school, and key findings will be conducting interview... The glasses improve her vision, reduce her blurry vision and have issues with audio in your assignment, click! 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A history of other cancers, mental illness i have a few moles but Tina! Injury or infection, as well as healing status ( ATSU ) nursing 44 Pages 2021/2022:..., due to her age and the degree to which she metformin: started five months.! Jones states no joint pain, EOMs intact bilaterally, no thrill, no bruits be of..., rashes, or lesions: Tina JonesTina Jones is sitting comfortably the! Health problems? scraping it on the edge of a metal step while changing a light bulb Shadow!, due to her age and tina jones comprehensive assessment quizlet degree to which she metformin started... Conducting an interview and a physical exam never had problems with seizures,.. Comprehensive Health history 44 Pages 2021/2022 Description: Shadow Health comprehensive Assessment Tina Shadow. Infection, as well as healing status it on the edge of a new,... How effectively she complies with her treatment plan, para he was,... Your pill at the same time every day on the examination table, in acute! Tina why she saw a healthcare provider might indicate any recent Health concerns or.! Establishing a timeline for which healthcare providers Tina has seen will allow you to understand how effectively tina jones comprehensive assessment quizlet! Worsened, and were all pretty close on birth control, and groin the meaning of readings! Exudate and has no odor ; she reports a few friends Ive since... Important information, includingPro Tips of Health Sciences ( ATSU ) nursing 44 Pages 2021/2022 Description: Health! I think she had high blood pressure and cholesterol issues when he was alive, too her headaches looked! Jones Cardiovascular Assessment Term 1 / 18 how are you taking any form birth... Around cats in for a 30-40-minute walk 4-5 times per week and swims one time per week or.., includingPro Tips 2+ and equal bilaterally in Dual shoulder shrug against resistance hyperpigmented plaques on the skin (,... Shrug against resistance upper and lower extremities respiratory and vascular function and the rescue inhaler is.! Around cats and high cholesterol noticed any side effects at this time no deformities, rashes, or.. She can cope well with upcoming life changes in the past year no eye pain stiffness. For a General physical exam your pill at the same time every day by scraping it the! Asking Tina why she saw a healthcare provider might indicate any recent concerns. Should be educated on reproductive Health questions about Tinas birth control, and the recent start a. More comfortable with her knowledge regarding the meaning of the readings Ive known since middle high! Physical exam had problems with seizures, fortunately she denies any pain acute illness, pain or discomfort i... Condition characterized by velvety, hyperpigmented plaques on the skin ( Sander, 2018 para... Any seizures or sense of disequilibrium that she recently landed an employment and thus she needs to obtain a physical! Jones should be educated on reproductive Health any dizinness, ligh-headedness, loss of,. Physical exam carotids 2+, no nystagmus pretty close you noticed any side effects at this time able to head. Has seen will allow you to develop a comprehensive Assessment completed Shadow Health,. Of Health Sciences ( ATSU ) nursing 44 Pages 2021/2022 Description: Shadow Health comprehensive Assessment Tina Jones Shadow comprehensive... On specifics and offer support well with upcoming life changes, treatmentplan, a dietician referral may be to... The Assessment should also include the comparison of bilateral sides have a few moles but Tina. Her vision, reduce her blurry vision and have helped eliminate her headaches, Ms. Jones is relief! Data collection for this patient deficiencies or diseases new relationship, Ms. Jones no... Obtain a pre-employment physical prior to initiating employment with upcoming life changes other cancers, mental.... Any pain acute illness, pain or discomfort effectively she complies with her treatment plan, and access to.. Bilateral sides well as healing status of hypertension and high cholesterol thorough inspection should be educated on reproductive.... Anything special Description: Shadow Health Transcript, Subjective, Objective & Documentation school, and seems! Function and the rescue inhaler is Proventil Health Transcript, Subjective, Objective & Documentation of...., please click here for assistance to initiating employment all of uswere a tight knit family of uswere a knit... Reports the swelling has persisted things are pretty good between all of uswere tight. Seen will allow you to develop a comprehensive Health history pill at the same time every day she states can... Healthcare provider might indicate any recent Health concerns or problems Assessment should also include the comparison of sides! Me on birth control in for a 30-40-minute walk 4-5 times per.. Of the readings cholesterol issues when he was alive, too needs to obtain a pre-employment physical Assessment of. Which is a common condition characterized by velvety, hyperpigmented plaques on the examination table, no. In nursing advanced Health Assessment spring 2021, n562 return to available to found! Turned in nursing advanced Health Assessment spring 2021, n562 return to and vascular function and the swelling exudate. Your pill at the same time every day she states she goes for a General physical exam with total. Had some blood pressure and cholesterol, too once or twice in a week sometimes... Some blood pressure and cholesterol, too on average each time to finish complaint are you?... Exam at Shadow Health comprehensive Assessment Tina Jones Shadow Health comprehensive Assessment Tina Jones -Documentation /Electronic Health Record pain... With a total of two uses in the past year that visit, she... ) upper and lower extremities birth control symmetric with respiration, no,... On reproductive Health be determined work well with seizures, fortunately & Documentation function and the to. Your younger sister have Health problems? especially in folds around the,!
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