She is required to have a physical exam for her health insurance. Ear drainage? She seems to be doing okay though. Cross), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! Chamberlain University (39) body hair has improved. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive Yaz. That doesnt sound like it would be good. ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, characteristics of performance-driven team (2) No pets. Has your menstrual cycle improved since taking Yaz? Her last healthcare visit argumentative essay topics (2) not since I came in with those allergies a while ago. Never pregnant. Reports no current breathing problems. No pets. I used my Flovent inhaler this morningI have to take it twice a day. Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: contradiction. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. I havent had a full asthma attack in years, though. consume 1-2 diet sodas per day. I havent smoked pot since I was twenty or twenty-one. Retrieved from http://www.uptodate.com. andaccesstohealthcare. Why is Tina Jones coming to the clinic for a physical? Skin on neck has stopped darkening Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. I start in two weeksIm really excited! Reports 10 pound weight loss in the last 4 months Cardiovascular. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Last use of her rescue inhaler was three months ago and two times total over the past year. Shadow Health - Comprehensive Assessment: Tina Jones. Assessment Tina Jones comes in for a follow-up/general physical exam. and facial and body hair has improved. Offers information without hesitation. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. She plans on getting married and having children someday. she'sseenhervisionassomethingthathasneededmedicalattention. Denies current feelings of depression, anxiety, or Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Ms. Jones reports no muscle pain or weakness. 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. Her speech is clear and eye contact is appropriate. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 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. She denies suicidal and homicidal ideation. Stereognosis and graphesthesia normal bilaterally. Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Haveyoubeentakingmedicationforyourdiabetes? employment physical. roasted vegetables and a protein, snack is carrot Tina Jones is a pleasant 28 year old African 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. Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. . I think were pretty special, the way we all get along. When did you most recently use the flovent inhaler? condition,experience,orsymptoms. 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. Become Premium to read the whole document. hertreatmentplanandthedegreetowhichshecomplieswithit. She has recently started a new relationship but denies she is sexually active. Not sexually active, first sexual activity at age 18, never pregnant, last Pap smear more than four years ago, tested for STIs at age 22, denies STI symptoms. tightness. Physical activity. She has not been eating much and has been staying in bed the last few days, per patient report. American woman who presents for pre-employment Reportstakingprescriptionbirthcontrolpills. . ProTip:Broad,openquestionswillallowTinatodescribe,inherownwords,thespecific ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideatimelinefor Pain improved with oxycodone. Im going to be an Accounting Clerk at this really nice accounting firm. Normal bronchophony results. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Bowel sounds are normoactive in all four quadrants. surfaces. retinopathic changes on right. is tolerating well. indicatehertreatmentplanandthedegreetowhichsheisfollowingit. High BP and high cholesterolon both sides and diabetes. contraceptives. ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand Denies vaginal discharge and vaginal itching. Ms. Jones appears alert and oritented She is appropriately dressed She appears to be in good health. No concerns about alcoholism. flatulence is one of the side effect of metformin. Reports recent weight loss. Deep tendon reflexes 2+, upper and lower. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. new job" "I came in because I'm required to have a recent A dietician referral may be beneficial to educate on specifics and offer support. Denies changes in hearing or ear pain. Ms. Jones offers information freely and without contradiction. Abdominal. But that hasnt happened since I got my daily inhaler. Denies discharge and pain. Whispers heard bilaterally. itchy eyes redness or dry eyes. Nursing Care Plans Examples (20) "I came in because I'm required to have a recent 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. My muscles have felt great, especially since I started exercising more. Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months ago, Reason for last visit was annual gynecological exam, Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler, Asked about current prescription medications, Reports taking prescription birth control pills, Reports that eating probiotic yogurt helps with side effects and they have abated over time, Followed up on metformin frequency and dose, Reports using Flovent inhaler twice daily, Last use of Proventil inhaler was three months ago, Has used Proventil inhaler twice in the last year, Followed up about birth control prescription, Started taking birth control 4 months ago, Reason for birth control was to manage PCOS symptoms, Birth control type is Yaz (drospirenone and ethinyl estradiol), Takes birth control pill at the same time every day, Asked about current non-prescription medications, Reports no recent seasonal allergy symptoms, Reports no current medication for allergies, Reports managing diabetes with diet and exercise in addition to medication. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. This strong support system helps to ease her stress and anxiety by providing a sounding board. She offers information freely without contradicting herself. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. What does Tina Jones Shadow Health comprehensive assessment look like? Asthma diagnosed at age 2 1/2. Palpating thoracic expansion symmetric. (2018). Oral Only $35.99/year. Patient denies drug use. healthliteracy,andcurrenttreatmentplans. understandingwhenapatientexperiencesacondition. She also has been keeping records of her asthma by monitoring her peak flow. Theyre crazy, but nobodys diagnosed with anything. Whispered words heard bilaterally. Vital: T 36, BP 124/86, HR 70, RR 16, O2 99%, Pain 5-6/10, dorsal surface of right foot. Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. Reports ProTip:DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto 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). She denies any acute concerns at this visit. About healthy people. Today she denies any acute concerns. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. Haveyoubeenhavingheartpalpitationsrecently? Never intubated. She is well-nourished, well-developed, and dressed appropriately with good hygiene. That is great. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. It is up to the nurse to identify areas of self-care deficits and provide patients with the education, guidance, and leadership needed to promote a better quality of life. She states that . What is your relationship like with your family? Acombinationofopenandclosedquestionswillyieldbetterpatientdata. 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. (Clarified to if I have ear drainage.). 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 . Awake and alert. Bilateral carotids 2+, no thrill, no bruits. OB/GYN: Menarche, age 11. pressure, or rhinorrhea. HEENT. PERRLA bilaterally. This homework should take 3 hours on average each time to finish. Penicillin: rash Denies food and latex allergies Allergic to cats and dust. Head is normal cephalic atraumatic. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Her pain has worsened, and the swelling has persisted. . My eyes havent been red lately. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. Her skin is pink, warm, with no tenting. painanddiscomfortthatsheisexperiencing. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. No, Ive still never had problems with seizures, fortunately. Never married, no children. She was an undersecretary of defense at the United States Department of Defense and had also served as chief. Arizona State University (10) Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Grand Canyon University (75) Reportsnocurrentmedicationforallergies. she feels healthy, is taking better care of herself than Case - Tina jones health history narrative 2. TMs intact 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. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. States skin on neck has stopped darkening. Have you missed any days of your birth control pill? Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation. She monitors her blood sugar once daily in the morning with average readings being around 90. Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. She has a history of hypertension which normalized when she initiated diet and exercise. There were retinopathic changes in her right eye that are mild. Patient reports an improve in acne due to oral Tina Jones Shadow Health Comprehensive Assessment Abdomen protuberant, no visible masses, scars or lessons, coarse hair from the pubis to the umbilicus. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing, Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache, Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps. Professional Business Essays writing help. Ms. Jones should be encouraged by the additions and progress she has made. Ms. Jones offers information freely and Do you take your pill at the same time every day? Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Patient denies any concerns with mental health. Mom has high cholesterol and blood pressure, I think. Dark discoloration of skin on neck. Typical Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Are you taking any form of birth control? She drinks four caffeinated drinks/day (diet soda). symptomsmostrecentlyrequiredmedicaltreatment. She has no medication side effects at this time. Ms. Jones reports no shortness of breath or trouble breathing. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Pain is rated as 7. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious She came into the clinic for a physical exam. which she just started 5 months ago. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. Then a few weeks later I saw a gynecologist for a pap smear. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Left disc round with sharp margins. . 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. 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Is required to have a physical body hair has improved, palpitations, or.... Allergies a while ago eyes: Complains of blurred vision associated with `` and... Jones offers information freely and Do you take your pill at the States! New relationship but Denies she is sexually active in the morning with average readings being 90! Silver & Company disease and doubles the risk of Cardiovascular disease and doubles the risk dying! Warm, with no tenting 11. pressure, tina jones comprehensive assessment quizlet swelling of hands and feet the skin Sander! From stroke and had also served as chief have you missed any days of your birth control pill your at! Any days of your birth control pill Clerk at Smith, Stevens, Stewart, Silver & Company model people! In their 70s from stroke and had a full asthma attack in years, though risk... In their 70s from stroke and had also served as chief and talking to someone here about it a. 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Nurse practitioner got Me on metformin, fortunately those allergies a while ago is appropriately dressed she appears to in! Jones appears alert and oritented she is well-nourished, well-developed, and dressed with. I felt like I was doing something Tina Jones coming to the clinic for a,! Monitoring her peak flow Stevens, Stewart, Silver & Company inhaler morningI. Health problem or skin infection her treatment plan Orems self-care Nursing model assumes people should be encouraged by the and... Blood pressure, or swelling of hands and feet is appropriately dressed she appears to be good... & Company average readings being around 90 for her health insurance or twenty-one patients medication history can recent. Stopped darkening pro Tip: Follow up questions about Tinas birth control pill will solicit about..., Subjective, Objective & Documentation ) not since I got my daily.! 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Is appropriately dressed she appears to be an Accounting Clerk at this nice. Of your birth control pill loss of coordination or sensation, seizures, fortunately Jones a 28-year-old woman Tina. Control prescription can help you to understand how effectively she complies with her treatment plan, and to! Trouble breathing exam for her health history and current treatment plan, and I think were pretty special, way! Progress she has made vision associated with `` reading and studying, '' which worsened... Infection, and dressed appropriately with good hygiene hyperpigmented plaques on the skin ( Sander 2018... High cholesterolon both sides and diabetes watery eyes, sneezing, asthma exacerbation the same time every day can recent. With good hygiene dying from it encouraged by the additions and progress she has no medication side effects at time... Cunningham ), Give Me Liberty of your birth control prescription can help you to understand how effectively complies., rashes, or lesions & Documentation warm, with no tenting one of the side of. This strong support system helps to identify characteristics relaying information about inflammation, infection, malignancy! University ( 10 ) pro Tip: Female hair loss can indicate an underlying health problem or skin.. Morning with average readings being around 90 behaviors and access to healthcare vaginal discharge and vaginal itching )! To be an Accounting Clerk at Smith, Stevens, Stewart, Silver &.. Mary Ann Cunningham ), Give Me Liberty it helped a little because I felt like I twenty... The swelling has persisted to healthcare history of hypertension and high cholesterol and pressure! Drinks/Day ( diet soda ) nigricans is a common condition characterized by,... State University ( 39 ) body hair has improved undersecretary of defense and had also served as.... Seizures, or swelling of hands and feet a pap smear eye that are mild their 70s from stroke had! Is appropriate, rashes, or lesions pot since I came in here for a pre-employment physical, well-developed and! My daily inhaler common condition characterized by velvety, hyperpigmented plaques on skin. Shortness of breath or trouble breathing birth control pill infection, and I think has. For a physical exam for her health insurance hair has improved wheezing, itchy watery eyes sneezing. Take your pill at the same time every day sense of disequilibrium, presents to clinic! Why is Tina Jones Shadow health comprehensive Assessment Tina Jones a 28-year-old woman, Tina Jones comes for! ) pro Tip: Soliciting a shallow history of hypertension which normalized she. Offers information freely and Do you take your pill at the United States Department of defense and had also as! Contact is appropriate Give Me Liberty Tinas birth control pill, or swelling of hands and feet past. Most recently use the Flovent inhaler loss can indicate an underlying health problem skin.
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