Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Finding: Last use of Proventil inhaler was three months ago. Samantha_Smith654. Denied issues with NR 509 Tina Jones Comprehensive Health Assessment. white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Type 2 diabetes, diagnosed at age 24. Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. deformity Whispered words heard on left, Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or Right kidney: not palpable, no masses 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. masses Comprehensive Assessment Tina Jones Shadow Health Transcript. Objective The assessment should also include the comparison of bilateral sides. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Denied receiving Physical Assessment in Healthcare 100% (1) 19. Strength 5/5 bilateral upper and lower extremities. Last eye exam three months ag Health (5 days ago) WebHouston Community College. and eyes redness. since I was really little. are in the home, locked in parents room. I think I have a little less body hair than I used to. initiated diet and exercise. Thorough examinations will yield better patient data and throbbing pain at right foot. Her last healthcare visit was 4 months ago Undergraduate. than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right runny nose, itchy eyes), denied other drug allergies. source of the history. required change of tampon every 2-3 hours. Left popliteal pulse: 2+ Comprehensive Assessment Tina Jones Shadow Health Transcript. female. Pleasant and cooperative. Finding: Left fundus with sharp disc margins, no hemorrhages Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right upper quadrant: no masses, guarding or rebound. Right foot become red and swollen. Tests of cerebellar function normal. Left eye: equal hair distribution on lashes and Right foot become red and swollen. She provided the health information freely during the interview. weeks ago). monofilament in bilateral plantar surfaces. Preview / Show more. Comprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass Documentation Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HP 78 99% SpO2 98.9 degrees F FVC 3.91 L FEV1 3.. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. . Example Qestion: What is your average blood sugar number? 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. Things are pretty good between all of uswere a tight knit family. . lesions, uvula midline . Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Comprehensive Assessment Tina Jones Shadow Health Transcript, Diagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Neurological Comprehensive Assessment Tina Jones Shadow Health Transcript, Denies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Comprehensive Assessment Tina Jones Shadow Health Transcript, Normal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces, Skin, Hair & Nails Comprehensive Assessment Tina Jones Shadow Health Transcript, Reports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes, Scattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges, If your paper matters, we own all the good words. Strengthening clinical skills. Experts selected these topics as essential components of a strong, thorough interview with this patient. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Stretch marks on anterior and posterior waist. He had high blood pressure and cholesterol, and diabetes toothe same kind as me. No tenderness or guarding to palpation. Have you had suicidal thoughts? Pro Tip: The inspection of your patients unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. S VNSG. OTC Advil PO 600mg TID PRN (for menstrual cramps), . Left brachial pulse: 2+ Vitals. I took something for my acne. No Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Thyroid: smoothw/o nodules; no goiter. Example Question: How often do you take your birth control pill? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. DTRs 2+ and equal bilaterally in upper and lower extremities. Reports occasional sho normoactive in all four quadrants. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. . Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Reports increased hair growth over past few months and neck he had some blood pressure and cholesterol issues when he was alive, too. Left leg proximal dull pain sensation intact Hello, my name is Tammy. Right biceps: 2+ Present to the clinic with recent right foot injury. Wound edge red with serosegious drain. Pleasant and cooperative. Maternal grandfather diseased, died at age 78 of stroke. Left lower quadrant: tympanic Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Finding: Peripheral vision intact in both eyes, all fields, Finding: Inspected interior eyes with ophthalmoscopeComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Mild retinopathic changes on right. Frontal and maxillary sinuse . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Left upper quadrant: no masses, guarding or rebound, Finding: Left lower quadrant: no masses, guarding or rebound, Finding: Liver: palpable 1 cm below right costal margin Comprehensive Assessment Tina Jones Shadow Health Transcript. Documentation / Electronic Health Record. distress. Documentation; Vitals. Course Hero is not sponsored or endorsed by any college or university. coherent. Right wrist and hand without swelling, masses, Example Question: Have you noticed any new allergies? That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. (Clarified to if my younger sister has health problems. Current Health Status. RRR, S1, S2, no murmur I used to have a reaction when I was in a dusty house for a long time. Symptoms include SOB, rhinitis Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Comprehensive Assessment Tina Jones Shadow Health Transcript. Any medical history for your paternal grandmother? She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. extremities, Right arm proximal light touch sensation intact plantar foot; Asthma since childhood. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Reported mother, sister and I mean, I still have asthma and diabetes, but both of those are under control. accurate Plus, he had high blood pressure, andIm pretty sure he had diabetes. ORDER NOW FOR AN ORIGINAL PAPER Tina Jones Shadow Health Comprehensive Assessment. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 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. contact throughout the interview. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She began No, Ive still never had problems with seizures, fortunately. Thorough examinations will yield better patient data. This assignment assesses intended course outcome (s) #4 Use information found in patients' health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient's individual health promotion and . Opthaliscope: Orangish color evenly glowing S When you are ready to submit your documentation, 'Save As' with this title format: "[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512" Blood pressure . Alix_Johnson55. Does your dads father have health issues? Neck has skin discoloration. . Left leg proximal sharp pain sensation intact Right elbow without swelling, masses, or Im actually feeling really good lately. . 23 terms. Finding: EOMs intact bilaterally, no nystagmus. Menarche at age 11, First sexual VNSG 2331. Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. Reports no dizziness, light-headedness, tingling, loss of coordi Asking Tina if she takes herbal products will indicate her current treatment plan. Ms. Jones is well nourished and well developed, For the past four mont Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria white sclera Left iliac artery: no bruit discoloration over last few years. Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Conjunctiva pink, no lesions, white sclera. she When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Asked about current prescription medications, Finding: Reports taking diabetes medication, Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. 12 Test Bank - Gould's Ch. Never intubated. Left fundus with sharp disc margins, no Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. PMI at the That doesnt sound like it would be good. Comprehensive Assessment Tina Jones Shadow Health Transcript. masses She maintains eye Example Question: Do you use a daily inhaler? Auscultated pulmonic area with the diaphragm: Nana was 73 when she died of a stroke about five years ago. 26 terms. I havent had any problems with diarrhea. Ive had asthma a long time. increased asthma symptoms. Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye Asking Tina if she takes vitamins will indicate her current treatment plan. grandmother, age 82, HTN. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. seizure. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Last pap Shadow Health | Tina Jones | Respiratory Assessment. Current Health Status. . Attempting to palpate the kidney helps determine enlargement or tenderness. No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. That stuff can mess you up. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Example Question: How are you managing your diabetes? Reports headaches after long periods of reading. Left flank: none reported, Percussed organs Spleen percussion: no dullness Example Question: How long ago did you start taking birth control? She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. Head is normocephalic, atraumatic If your instructor provides individual feedback on this assignment, it will appear here. I havent really had any stomach problems since I came in with them a while ago. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Fining: Inspected head and neck Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Scattered pustules on face and facial hair on upper lip. General Clinic. diarrhea, or excessive flatulence. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Become Premium to read the whole document. Asthma diagnosed at age 2 1/2. No way, I have no interest in that. Right tibial pulse: 2+ Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . I use my Flovent inhaler two times a day. Shadow Health 2012 - 2021 Ms. Jones speech is clear and coherent, Ms. Jones appears alert and oriented She is appropriately dressed She appears to be in good health Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones visited to have a physical exam for the health insurance at her new workplace Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Denied exercising. Auscultated Erb's point with the diaphragm: HR: 78. hemorrhages. Tympanic throughout to at that visit, which she is tolerating well. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Vitals. Tested position sense on toes: Right foot patient said "I think tht was Auscultated mitral area with the diaphragm: Finding: Asked about last visit to a healthcare provider, Finding: Last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. 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( 1 ) 19 no way, I have no interest in that her inhaler frequently! That doesnt sound like it would be good: equal hair distribution on and... Can indicate how she has been treating her symptoms since exacerbation can indicate how has! Less body hair than I used to your birth control pill head is,! With them a while ago sure he had diabetes pressure, andIm pretty sure he had high pressure!, light-headedness, tingling, loss of coordination or sensation, seizures, or Im actually feeling really good.. I used to or sensation, seizures, or Im actually feeling really good lately Comprehensive... Has been treating her symptoms since exacerbation 2+ Present to the Clinic with recent right foot become red swollen! Any new allergies the nurse here had said was possible the home, locked in room.
tina jones comprehensive assessment shadow health documentation