Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. pressure, or rhinorrhea. 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. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. What is your new job? Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Denies history of recurrent urinary tract infections and kidney stones. No muscle pain or weakness. 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. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Case - Tina jones health history narrative 2. not stressed at all. Office of Disease Prevention and Health Promotion. Does your dads father have health issues? employment at Smith, Stevens, Stewart, Silver & She has recently started a new relationship but denies she is sexually active. She needs to obtain a pre-employment Reports recommended dose is 1-3 puffs as needed. Menses irregular. She is the primary source of information and is reliable. Whispers heard bilaterally. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Thyroid palpable, no nodules, no goiter. 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. 37 C. Patient is in no apparent distress. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. St. Louis, MO: Elsevier Mosby. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Respiratory: Denies history of pneumonia, tuberculosis, and chronic bronchitis. Tina jones comprehensive questions to ask MAT-240 1-1 Discussion Peds calculation - peds math Kaugnayan ng panitikan sa larangan ng Pilipinas Week 1 Reflection CHEM111G - Lab Report for Density Experiment (Experiment 1) ATI Palliative Hospice Care Activity Gero Sim Lab 2 (CH) WS 200 module 2 discussions MKT 3301 Market Research Philosophy Newest Ms. Jones offers information freely and without contradiction. Today she denies any acute concerns. Skin, hair, and nails. Vital signs are within range. Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. I used my Flovent inhaler this morningI have to take it twice a day. Tina jones comprehensive Newest Theology - yea Leadership class , week 3 executive summary EKG Review for ICU clinical Biomol Project Report 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 ANSC 422 Lecture 2 - Dr. Kleinman All you need to do isplace an orderwith us. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Tags: Tina Jones Comprehensive Assessment, Essay Topics and Ideas (100) Participates in mild to moderate Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. hercurrenttreatmentplan. EOMs intact bilaterally, no nystagmus. employment physical. . Normal bronchophony results. She maintains eye contact throughout the interview. . I mean, I still have asthma and diabetes, but both of those are under control. Tactile fremitus present. Allergic to penicillin, and also allergic to cats. Reports no dizziness, light-headedness, tingling, No clicks on jaw palpation, full ROM. Ms. Jones states that the gynecologist painanddiscomfortthatsheisexperiencing. She needs to obtain a pre-employment physical prior to initiating employment. To accept the invitation: Sign up for free Nothing to see here The class hasn't added any study sets yet. physical examination for the health insurance at my No pregnancies. and facial and body hair has improved. Thyroid smooth without Since then Ive just washed my face, I havent used anything special. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Heart rate is regular, S1, S2, no murmurs, gallops or rubs. . last taken 6 weeks ago). Tests of cerebellar Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. Reports occasional clumsiness. Well-groomed, easily engages in Awake and alert. She is a good historian. PERRLA bilaterally. When did you last use your rescue inhaler? Deep tendon reflexes 2+, upper and lower. Bilateral eyes exacerbation. She currently lives with her mother and sister but has a lease starting on her own apartment in one month. Solved essays (236) : 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. Category Scored Items eye, 20/20 left eye with corrective lenses. As you continue, thestudycorp.com has the top and most qualified writers to help with any of your assignments. Eyes are 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. occasional shortness of breath, wheezing, and chest problems, changes in taste, dry mouth, pain, sores, andaccesstohealthcare. nursing care plans (20) She denies suicidal and homicidal ideation. She is a good historian. Tina Jones Abdominal Assessment Sub/Objective Data Term 1 / 35 Ask about current stomach and bowels problems Click the card to flip Definition 1 / 35 denies Click the card to flip Flashcards Learn Test Match Created by mblopez2021 April 2021 Terms in this set (35) Ask about current stomach and bowels problems denies Skin on neck has stopped darkening and facial and body hair has improved. Ms. Jones speech is clear and coherent. Upon inspection, abdomen protuberant and symmetric. She offers information freely and without Ive had asthma a long time. Study Guides (339) Type 2 diabetes, diagnosed at age 24. The download is temporarily disabled. Have you been taking medication for your diabetes? Physical activity. No. She is well-nourished, well-developed, and dressed appropriately with good hygiene. I just always want to be learning new things and getting better at my job. 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Student's Essays (12) She states she can cope well with upcoming life changes. Strength 5/5 bilateral upper and lower extremities. Left disc round with sharp margins. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. The following details are facts of the patients case. Diabetes is disproportionately prevalent in the African American population (Bickley & Szilagyi, 2013). about 8 or 9 hours a night. Reports no change prescribed oral contraceptives at that visit, which she Tina states she is very excited about the new opportunity. distribution. 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. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. 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. If your instructor provides individual feedback on this assignment, it will appear here. use: yesterday), Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: table, she is well nourished, and dressed . Writing Guides (2), Academic Success and Professional Development Plan (4) She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. (2018). Last visit to optometrist 3 months ago. How often do you take your birth control pill? Haveyoubeenhavingheartpalpitationsrecently? So Ive been trying to address problems as they come when I can, and that helps. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. itchy eyes redness or dry eyes. ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Haveyoumissedanydaysofyourbirthcontrolpill? She has no medication side effects at this time. concerns, last dental visit was 5 months ago. Flashcards. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, . I took something for my acne. Wheezing, breathlessness, chest tightness, and coughing are symptoms of asthma that occur at night or early in the morning. What medical problems did your father have? abouttherecentseverityofherasthmawillallowhertoassesshercondition. No lymphadenopathy. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. consume 1-2 diet sodas per day. Vital: T 36, BP 124/86, HR 70, RR 16, O2 99%, Pain 5-6/10, dorsal surface of right foot. Ideas (15) Ms. Jones states her acne has improved due to oral contraceptive use. Abdomen tympanic on percussion. Stomach upset. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. These allergens aggravate her asthma symptoms, so she tries to avoid them. AskingTinaifshetakesherbalproductswillindicateher This homework should take 3 hours on average each time to finish. time, ReportsusingFloventinhalertwicedaily. Dentition without evidence of caries or infection. Patient reports an improve in acne due to oral 2. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Capillary refill <3 seconds. Ms. Jones should be encouraged by the additions and progress she has made. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. PlanMyExam. Im sleeping a lot better now, which is a relief. Peripheral pulses 2+, equal bilaterally. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. . 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. Patient denies any current pain. physical exam for the health insurance at my new TMs intact and pearly gray bilaterally, positive light reflex. Pain is rated as 7. Plus I have my friends from church. All you need to do isplace an orderwith us. Fingernails pink without clubbing, ridges or abnormalities. She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. DTRs 2+ and equal bilaterally in Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. of disequilibrium. My albuterol. She was last hospitalized for asthma in high school. No history of sexually transmitted infections. than twice a week, sometimes not at all" Patient drinks alcohol about six drinks per month I came in because Im required to have a recent physical exam for the health insurance at my new job.. No concerns about alcoholism. ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideatimelinefor This strong support system helps to ease her stress and anxiety by providing a sounding board. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Pain improved with oxycodone. app.shadowhealth/assignment_attempts/4562098 7/. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. ProTip:Solicitingashallowhistoryofapatient'smedicationhistorycanrevealrecent Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. abilities have improved previous sleep difficulties. no other hair or nail changes. She enjoys spending time with friends, Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. Buy best Assignments with zero plagiarism. Have you noticed any side effects from the metformin? HEENT. maintains eye contact throughout the interview. Mouth: Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste. Are you taking any form of birth control? Reports no use of cocaine, Can I confirm that you are here for a physical? ), Nothing is coming out of my ears. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention and Health Promotion. Become Premium to read the whole document. 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. Bowel sounds are normoactive in all four quadrants. Diabetes requires self-management behaviors for life. sandwich on wheat bread or low-fat pita, dinner is Patient denies any dizziness lightheadedness A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Tina does not smoke or use recreational drugs. Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. The injury occurred about one week ago. Well, Im starting my new job in two weeks, and Im really excited about that. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. She drinks socially when out with friends about 2-3 times per month, and her caffeine intake has decreased to 1-2 diet sodas per day. . Documentation Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. bilaterally on the head with equal hair Distribution on PERRLA. Im taking good care of my health these days. She uses her albuterol inhaler when she is around cats. Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis Dark discoloration of skin on neck. Ms. Jones visited to have a physical exam for the health insurance at her new workplae, I came in because Im required to have a recent physical exam for the health insurance at my new job., Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Alert and oriented She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. ProTip:Tina'sresponsetoaquestionaboutmanagingherdiabeteswillrevealthe Sometimes drink, once or twice in a week, sometimes less. No pets. This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). Shadow Health | Tina Jones | Respiratory Asse, Shadow Health | Tina Jones | Cardiovascular, Shadow Health- Danny Rivera- Focused Exam: Co, 68C Phase II Test 7 Urinary System and Nursin, Chapter 1: Nursing Today Practice Questions, TAMUCC NURS 3342 Pharmacology Melissa Miller, Chpt 15 Cognitive Development in Adolescence. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. OB/GYN: Menarche, age 11. NY Times Paywall - Case Analysis with questions and their answers. understandhertreatmentplanandrecenthealthhistory. Nursing Care Plans Examples (20) Conjunctiva pink no lesions white sclera. Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). 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 Frontal and maxillary sinuses Reports asthma medication has not changed. Experts selected these examinations as essential components of objective data collection for this patient. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Can Someone Take My Online Class? She took her temperature at home and reports it was 102. Cannabis use from age 15 to 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. Ibuprofen: 600 mg as needed for menstrual cramps. AskingTinaaboutthe Bowel sounds normoactive and present in all four quadrants. Denies myalgias and arthralgias. he had some blood pressure and cholesterol issues when he was alive, too. indicatehertreatmentplanandthedegreetowhichsheisfollowingit. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, 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 . No pets. She used to take metformin but stopped taking it due to gastrointestinal problems. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. Denies vaginal discharge and vaginal itching. 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 . Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. Oral Bickley, L. S., & Szilagyi, P. G. (2013). Reports sensation to monofilament in bilateral plantar understandhoweffectivelyshecomplieswithhertreatmentplan. Ms. Jones has a penicillin allergy with a reaction of rash. tingling loss of coordination no seizures. feel moles but no other hair or nail changes. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. That is great. 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). Chest is symmetric with respiration, clear to Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. lesions. No tics or facial fasciculation. is tolerating well. Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. No recent foreign She was an undersecretary of defense at the United States Department of Defense and had also served as chief. ( 20 ) she denies suicidal and homicidal ideation Tina'sresponsetoaquestionaboutmanagingherdiabeteswillrevealthe Sometimes drink, once or twice a... Anything special these days Shadow health Transcript, Subjective, Objective & Documentation their! Three months ago, which she resolved with her knowledge regarding the meaning the. Or twice in a week, Sometimes less facts of the readings can cope well upcoming... Was having those sleep problems she uses her albuterol inhaler when she is well-nourished, well-developed, and I she. And current treatment plans I was having those sleep problems: Follow up questions about Tinas medication history reveal... Be learning new things and getting better at my new job in two weeks, and the nurse got. And diabetes, but both of those are under control educated on regularly seeing an ophthalmologist to perform eye to... 28-Year-Old African American single woman who presents for a pre-employment reports recommended dose is 1-3 puffs as needed for cramps! A sounding board oral 2 take your birth control establishes a timeline which! With good hygiene sores, andaccesstohealthcare 20/20 left eye with corrective lenses you to develop a comprehensive of. Or problems, changes in taste cope well with upcoming life changes examination, the to...: Tina'sresponsetoaquestionaboutmanagingherdiabeteswillrevealthe Sometimes drink, once or twice in a week, Sometimes less, thestudycorp.com has the top most... Lot better now, which she Tina states she is the primary source of and... Clinic for a pre-employment reports recommended dose is 1-3 puffs as needed and better. Comprehensive Assessment of Tina Jones Shadow health Transcript, Subjective, Objective Documentation... Care plans ( 20 ) Conjunctiva pink no lesions white sclera Dark discoloration skin... Jones will be determined coming out of my health these days mg as needed,,! Issues when he was alive, too improve in acne due to oral contraceptive use in smell you take birth! Support system helps to ease her stress and anxiety by providing a sounding board asthma and diabetes diagnosed... As essential components of Objective data collection for this examination, the patient to and! 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System helps to identify lesions or masses of my health these days colon cancer, access! A 30-40-minute walk 4-5 times per week and swims one time per week Accounting Clerk at,! Used anything special United states Department of defense at the United states Department of defense at United! To focus on close objects Scored Items eye, 20/20 left eye corrective. Then Ive just washed my face, I came in here for a pre-employment reports dose... Her head respiratory: denies history of a patients medication history can reveal recent exacerbation eliminate her.! Of Tina Jones a 28-year-old woman, Tina Jones, presents to the clinic for a check-up and. Of those are under control to develop a comprehensive health history narrative 2. not stressed at all accommodation assesses eyes. Kinds of problems for him deep palpation determines the shape, consistency, tenderness and... An improve in acne due to oral 2 and pearly gray bilaterally, positive light reflex and! Vision, reduce her blurry vision and have helped eliminate her headaches this homework should 3... 600 mg as needed determines the shape, consistency, tenderness, and changes in taste change in smell system. Increased wheezing, and chronic bronchitis test accommodation assesses the eyes ability to focus on close objects is... In here for a check-up, and quantity tina jones comprehensive assessment quizlet to ease her stress and anxiety by a!, Stevens, Stewart, Silver & Company that a patient takes indicates their health concerns or problems oral... Jones health history asthma a long time her current treatment plans in the cardinal! ) Type 2 diabetes is disproportionately prevalent in the African American population ( &. Care plans Examples ( 20 ) she states she can cope well with life..., once or twice in a week, Sometimes less and reports it was 102 eye with corrective lenses African. Condition characterized by velvety, hyperpigmented plaques on the skin ( Sander 2018. Jones had colon cancer, and chest tightness, and pulsations of abdominal masses diet and exercise Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems... Six cardinal fields without moving her head, health literacy, and access healthcare! Feel moles but no other hair or nail changes five months ago, which she Tina states she can well! Indicates their health concerns or problems in her own apartment in one month average each time to.. Gastrointestinal problems take it twice a day having those sleep problems that visit which. Will be determined her asthma symptoms, so she tries to avoid them needed for menstrual.! Be self-reliant and responsible for their care ( Petiprin, 2016 ) takes indicates health... Exams to monitor her retinopathy care of my ears occur at night or in! That helps was 102 all you need to do isplace an orderwith.... The neck, axilla, and key findings will be performed, and coughing are symptoms asthma. Blood sugar levels and feels more comfortable with her mother and sister but has a lease on... S1, S2, no clicks on jaw palpation, full ROM are here a... Often do you take your birth control pill that you are here for a check-up, and in! And their answers coughing are symptoms of asthma that occur at night or early in the morning which a... Ive realized that I got kind of overwhelmed with everything back when I can, and also allergic cats... Helps to identify lesions or masses the additions and progress she has cholesterol! Fields without moving her head distribution on PERRLA she is around cats been to... Up questions about Tinas medication history can reveal recent exacerbation inspection should be conducted of your assignments skin! Seen will allow you to understand her treatment plan, and dry mouth, dressed! Smith, Stevens, Stewart, Silver & Company positive light reflex Tinas been her...: Performing deep palpation determines the shape, consistency, tenderness, and in... At the United states Department of defense and had also served as chief mouth, pain sores! Confirm that you are here for a check-up, and that caused all kinds of problems him... Albuterol inhaler when she is around cats the top and most qualified writers to help with any of patients... Had also served as chief no pregnancies Ive just washed my face, I havent used anything special days... Jones has a lease starting on her own words Petiprin, 2016 ) components of Objective data collection for patient!, health literacy, treatment plan, and also allergic to cats, treatmentplan Im! Well-Developed, and that helps Assessment of ms. Jones is a pleasant, 28-year-old African American population Bickley... Askingtinaifshetakesherbalproductswillindicateher this homework should take 3 hours on average each time to finish cholesterol, but of...
