Participation posts do not require a scholarly source/citation (unless you cite someone elses work). What exercise do you do? Pro Tip: Confirming a patients medical conditions, such as asthma, will enable you to provide the best care possible. her neck and increased facial and body hair. The universitys policy on late assignments is 10% penalty PER DAY LATE. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Finding: Asking Tina what exercise she does can help you to assess her current levels of health and nutrition. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand hertreatmentplanandrecenthealthhistory. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. wear glasses/contacts, reports eye itching associated with exposure to cats but no discharge. Pro Tip: In a comprehensive assessment, it is important to determine if any allergies have changed for the patient and determine how best to address those changes. Nose/sinuses: Rhinitis and congestion related to cat allergy. Asking how frequently Tina uses her inhaler can indicate how shes been treating her symptoms. Abnormalities may also point to underlying issues that should be addressed. Finding: How often do you use your inhaler? Asked about diabetes management through lifestyle. How long are your walks? Finding: Wears severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious Finding: Example Question: Example Question: Example Question: (Found) As Masters level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Cite all sources of information! abouttherecentseverityofherasthmawillallowhertoassesshercondition. Finding: Chest resonant on percussion. Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. No sore throat and hoarseness. I am happy to be flexible. Finding: How are you managing your diabetes? Take the extra few minutes to review instead of getting counted off for these mistakes. Finding: AskingTinahowshehasbeentreatingherhypertensionwillindicate andaccesstohealthcare. (Found) Sinus palpated with no tenderness noted. She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. All Rights Reserved. Pro Tip: It is important to determine the severity of Tinas asthma, as a worsening conditions indicates a need for further treatment. Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. due to gastrointestinal upset. A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. Example Question: Pro Tip: Broad questions about the cardiovascular system will enable the patient to express any symptoms, concerns, or conditions concerning that she may have. i got the paper a bit late but it is good quality will for sure come back and use this website. Finding: Do you smoke? Reports reason for birth control was to manage PCOS symptoms How many nights a month do you drink? ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, The last visit to the clinic was four months ago for an annual gynecological exam. 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. Denies using tobacco. Week4 DCE Tina Jones Comprehensive - Documentation / Electronic Health Record Document: Provider - Studocu On Studocu you find all the lecture notes, summaries and study guides you need to pass your exams with better grades. Reports recent weight loss. Fingernails pink without clubbing, ridges or abnormalities. ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideatimelinefor Why did you see a healthcare provider? Reports recent weight loss possibletriggerslikeenvironmentalfactors,bodilypositions,ormovementsthatmay Dark discoloration of skin on neck. Available: Retrieved from: https://www.mcssd.org/. Physical activity. support her in managing stress. Finding: Finding: Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. Finding: Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets and increasing vegetable consumption. Finding: Advanced Health Assessment 95% (444) In A. O. Ofori (Ed. If you have a question, there is a good chance one of your peers does as well. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Example Question: Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it. COMPREHENSIVE HISTORY (Subjective Data), Date & Time: 1/20/2023 at 8pm sister after the death of father one year ago. Example Question: Have you been coughing? Neurological. She reports no depression or anxiety. What reason did you decide to start taking birth control? With the assistance of Orems self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health. Asked about review of systems for cardiovascular. factsofthepatient'scase. treatmentplans. Verified answer physics String is wrapped around the outer rim of a solid uniform cylinder that axles through its center. Do you still have menstrual cramps? She needs to be educated and understand the importance of testing her blood sugar regularly. Dont wait ORDER NOW! 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. Finding: Dark discoloration of skin on neck. (Found) She denies having homicidal and suicidal thoughts. Reports last use of ibuprofen was six weeks ago Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). It is also good practice to identify the purpose of drug use, such as recreation or pain management. Reports reason for last visit was annual gynecological exam Speech is coherent and audible. Pro Tip: Determining any outcomes from Tinas last optometrist visit is important, as it may reveal treatments that you should follow-up on. Found: Medical: Type 2 diabetes, diagnosed at age 24. (Found) She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). Capillary refill <3 seconds. Using the patient information provided, choose a culture unfamiliar to you and describe what would be important to remember while you interview this patient. This strong support system helps to ease her stress and anxiety by providing a sounding board. Tina does not smoke or use recreational drugs. Did you get prescription eyeglasses? Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. 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. oral lesions, dry mouth, and changes in taste. 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). (Found) Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. Howhaveyoubeentreatingyourhypertension? Monofilament test shows decreased sensation in both right and left great toes and forefoot. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. She reports stressors relating to the death of her father Example Question: She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Past Medical History Finding: Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. Altay, N., & Cavusoglu, H. (2013, April 23). Based on Tinas physical examination, there were some key findings which were abnormal. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). (Found) WK7Assgn 1Payette A - Assignment for week 7, WK9Assgn 1 The patient is a 70 year old Caucasian female that presents with complaints, WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough, Focused Episodic SOAP Note for Sore Throat, Week 4 Skin Assignment Picture 2 (Stretch Marks), Business Environment Applications II: Process, Logistics, and Operations (D079), Bachelor of Secondary Education Major in Filipino (BSED 2000, FIL 201), Professional Nursing Concepts III (5-8-8) (HSNS 2118), Art History I OR ART102 Art History II (ART101), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Summary Reimagining Global Health - Chapter 5 & 6, Eden Wu.Focused Exam Respiratory Syncytial Virus Completed Shadow Health, Chapter 15 Anxiety and Obsessive-Compulsive Disorders, Lunchroom Fight II Student Materials - En fillable 0, Summary Give Me Liberty! pdf, SCS 200 Applied Social Sciences Module 1 Short Answers, Leadership class , week 3 executive summary, 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, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive Yaz. (Found) Last dental visit was five months ago with no concerns. The last visit to the clinic was four months ago for an annual gynecological exam. How many drinks do you have in a sitting? Finding: Pro Tip: Asking Tina if she experiences swelling will help you better understand her general health. Familiarize yourself with APA format and practice using it correctly. Denies adverse effects of asthma medication Followed up about birth control prescription. Reports diabetes medication is metformin Reports diabetes medication dose is 850 mg Full ROM and 5/5 strength in extremities, spine, and hips. Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Finding: Do you take any supplements? Bilateral carotids 2+, no thrill, no bruits. Finding: She has recently started a new relationship but denies she is sexually active. For nurses unfamiliar with the culture, it may be a good advice to inquire with the patient or any accompanying family their cultural norms and how they can be treated with respect and without judgement. Asked review of systems for genitourinary. Active problems: Acute foot pain and local infection of the tissue and subcutaneous tissue of Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Example Question: Reports a typical snack is carrot sticks or an apple Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol. Her new job is as an accounting clerk, which starts in two weeks. General. Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). Denies drinking coffee Students must score at the level of Proficiency in the Shadow Health Digital Clinical Experience. Whispers heard bilaterally. Her 24-hour diet Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). Finding: No peripheral edema. Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. Otterbein University NURS 6830 Advanced Health Assessment Dr Joy Shoemaker, Ruth Chavez, Deidre Arms, Chai Sribanditmongkol January 30, 2023 . Finding: Diabetes requires self-management behaviors for life. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Three months was her last visit to the optometrist for which she was given prescription eyeglasses. Assessment Tina Jones comes in for a follow-up/general physical exam. Reports penicillin allergy Spirometry: FVC 3.9L, FEV1 3.15L, FEV1/FVC ratio 80.56%. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Left disc round with sharp margins. Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. (Found) Ms. Jones has a penicillin allergy with a reaction of rash. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Respiratory. No wheezing, runny nose or a cough. Mucous membranes pink and moist, tonsils 2+ bilaterally. A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. How many times a day do you take metformin? Finding: Do you think your asthma is under control? Indicatesanitemthatisavailabletobefound. She is the primary source to her own health history. (Found) She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Oriented to person, place, and time. (Found) A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. When did you go to the eye doctor? the pain and swelling in her ankles have subsided, but the bottom of her foot is increasingly. You are admitting a 19-year old female college student to the hospital for fevers. The papers are not supposed to be submitted for academic credit. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, (Found) Surgical: No surgeries to date. Another abnormal finding was the discoloration on her neck. NRS 434 Shadow Health: Comprehensive Assessment Capillary refill <3 seconds.Comprehensive Assessment of Tina Jones. Cardiovascular. Her snacks consist of pretzels or French fries. Also for Muslims, the belief of illness is a test from God and it is a trial for removal of sin, therefore when ill they may call for spiritual intervention (Attum, et. Denies a runny nose or sneezing. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. 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). (Found) No current complaints or recent illness. Promotion of cardiovascular health is a high priority for Healthy People 2020. Do you use a glucometer? Ms. Jones states her acne has improved due to oral contraceptive use. She also has increased her physical activity. ProTip:Broad,openquestionswillallowTinatodescribe,inherownwords,thespecific NRS 434 Shadow Health: Comprehensive Assessment Reports weight loss of about 10 pounds Nasal cavities pink, no discharge. Have you had chest tightness? Respiratory: History of asthma and inhaler use, asthma symptoms triggered by cats, and dust Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Comprehensive Health History for Shadow Health History & Final Comprehensive Health If no support systems are available in your community, identify a national resource. Example Question: allergy. Example Question: We know how difficult it is to be a student these days. Finding: Finding: Employed 32 hours per week as a supervisor at Mid- Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. Example Question: Reportsthatbloodpressurerespondedtodietandexercisechanges. Pro Tip: Asking Tina if she experiences night sweats will help you better understand her general health. There is no family history of other cancers, mental illness. She regularly monitors her blood glucose levels, checking once a day in the morning. NRS 434 Shadow Health: Comprehensive Assessment (Found) Do you have an inhaler? Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Pro Tip: Broad questions about the genitourinary system will enable the patient to express any symptoms, concerns, or conditions that she may have. She denies any acute concerns at this visit. Example Question: Example Question: AskingTinaaboutthe Finding: Experts selected these topics as essential components of a strong, thorough interview with this patient. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. (Found) Reports belief that asthma is well-controlled B. Her last ProTip:Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe She receives basic health insurance from work but is deterred from Asking Tina how long her walks are can help you to assess her current levels of health and nutrition. NRS Week 4: Comprehensive Assessment Tina Jones NRS 434 Shadow Health: Comprehensive Assessment Within the Shadow Health platform, complete the Comprehensive Assessment. Pustules noted on bilateral cheeks. Normally, she would eat a sandwich for She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. Reports a typical dinner is vegetables with a protein and brown rice or quinoa Example Question: Ears: Denies difficulty hearing, tinnitus, vertigo, ear pain, infections, and discharge. Pro Tip: Asking if Tina is currently sexually active will help you determine is she is practicing safe sex and has any potential health risks. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Reports checking blood sugar once a day Example Question: This will be checked at least once every 24 hours. Another abnormal finding was the discoloration on her neck. Example Question: Fill in your requirements and let our experts deliver your work asap. Her skin is pink, warm, with no tenting. Pro Tip: Asking Tina about the recommended dose of her inhaler can help you determine if the treatment is effective and appropriate for her health needs. Denies vaping eye contact throughout the interview. Reports recently prescribed eyeglasses I came in because Im required to have a recent physical exam for the health insurance at my new job.. hertreatmentplanandthedegreetowhichshecomplieswithit. Do you smoke marijuana? Mouth/throat: Denies any dental problems. Reports dust allergy Does ibuprofen help your cramps? II. Reports last optometrist visit was 3 months ago Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014). (Found) Example Question: (Found) She appears well-nourished and dresses appropriately. An individualized plan of care taking into . She reports she has a strong friend and family support system and is very active in her church. Example Question: She visited a nearby emergency Denies sexual activity A. Followedupaboutbirthcontrolprescription, Startedtakingbirthcontrol4monthsago. understandingwhenapatientexperiencesacondition. Pustules noted on bilateral cheeks. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Example Question: She denies any food allergies. Last When in doubt, cite the source. There are no pets. Denies cardiovascular issues Use PMH (past medical history) to help . Finding: Her Bickley, L. S., & Szilagyi, P. G. (2013). Mild retinopathic changes on the right. Dr Joy Shoemaker, Ruth Chavez, Deidre Arms, Chai Sribanditmongkol Neck: Denies difficulty swallowing, swollen glands, goiter, lumps, pain, or neck stiffness. (Found) Pro Tip: Asking Tina about how many puffs of her inhaler she takes can help you determine if the treatment is effective and appropriate for her health needs. Reports walking for exercise Psychiatric: Denies any signs of depression, suicidal thoughts, or ideation. Ms. Jones should be encouraged by the additions and progress she has made. Pro Tip: Discovering the reason a patient has been taking pain medication is a crucial part of the history of her condition or injury. Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. Ms. Jones is a pleasant, 28-year-old obese African American single woman who works as a Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. 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. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). Finding: Comprehensive Assessment Tina Jones Shadow Health (Found) establishesatimelineofhercurrenttreatmentplan. Example Question: Paternal uncle: alcoholism Can you confirm your diabetes? Cardiac: Elevated Blood pressure on the current visit. Are you having any health problems? Coarse hair growth noted from pubis to umbilicus. hercurrenttreatmentplan. strong family and social support system. ago, twisting her right ankle, and scraping the ball off her foot. Reports diabetes HPI Tina Jones Foot-c go by Is sammy alive - in class assignment worth points 10th Amendment Deconstructed Copy of 7.4.1 - Seed Germination Gizmo Hesi fundamentals v1 questions with answers and rationales Summary Give Me Liberty! (Found) Brother (Michael, 25): Overweight. Pro Tip: Determining if Tina has abnormal, persistent, or recurring coughs is important for assessing her respiratory health and providing quality patient care. Liver span 7 cm MCL, palpable 1 cm below right costal margin. Example Question: Pro Tip: Asking Tina about how many puffs of her inhaler she typically takes can help you determine if the treatment is effective and appropriate for her health needs. Uses alcohol one to ASSESSMENT: Tina Jones comes in for a follow-up/general physical exam. Areyoutakinganymedicationforyourallergies? Abdominal. study, volunteering in her church, and dancing. Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. Reports she smoked marijuana when she was younger but has not for many years. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, The Methodology of the Social Sciences (Max Weber), Psychology (David G. Myers; C. Nathan DeWall), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! Points will be deducted for poor use of APA format or absence of APA format (if required). Pro Tip: Asking about the frequency and duration of a patients periods, as well as the severity of cramps and heaviness of flow, will help you understand what it typical for the patient. 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. The last dental exam was a few years ago. Denies The goal is to produce 100% unique and original papers, Our homework writers will provide you with copies of sources used on your request. Finding: Finding: 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. Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. Upon examination, head is normocephalic with no lesions or tenderness of scalp. Finding: Ms. Jones needs to be educated on the need for care when there is decreased effectiveness of her regular medicine, meaning an increased use of her rescue inhaler. Pro Tip: Asking Tina if she experiences unusual fatigue will help you better understand her general health. Did you not paraphrase well enough? Finding: Based on these findings, along with guidance from the central goals of Healthy People 2020, a plan of care specialized to Ms. Jones was created, considering her age and culture. *Price with a welcome 15% discount applied. Ms. Jones states her acne has improved due to oral contraceptive use. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. Tina Jones Comprehensive Health Assessment. What is the recommended dosage for your inhaler? 850 mg twice daily. Finding: AskingTinaifshehasarescueinhalerforherasthmawillindicate Example Question: When do you check your blood glucose? I will be conducting an interview and a physical exam. patient. Her gait is smooth with equal stride. Heart rate is regular, S1, S2, no murmurs, gallops or rubs. Better nutrition and the continuance of daily exercise should be emphasized. Left disc round with sharp margins. Example Question: Reports recommended dose is 1-3 puffs as needed sexually active; first sexual experience at age 18 never pregnant; and no miscarriage. Do you have any mental health problems? She appears well-nourished and dresses appropriately. Hypertension, Obesity, Polycystic ovarian syndrome. Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions exacerbation. 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. Axillary and cervical lymph nodes palpated, no lymphadenopathy. Her speech is clear and eye contact is appropriate. Comprehensive Health History for Shadow Health History & Final Comprehensive Health A "pass" on the SHCA means that the student has answered all ten questions correctly. Do you have enough supplies to monitor your blood glucose? How long have you been taking metformin? Comprehensive Assessment of Tina Jones. Example Question: Skin, hair, and nails. AskingTinaifshe'shada Followed up about diabetes medication. andaccesstohealthcare. Reports taking birth control pill at the same time every day Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. Example Question: hertreatmentplanandthedegreetowhichshecomplieswithit. Palpated fremitus equal bilaterally. (Found) Finding: Ms. Jones is sitting comfortably on the examination table, in no acute distress. ProTip:Follow-upquestionswillenableTinatomorefullyandspecificallydescribeher Dual shoulder shrug against resistance, able to turn head in both directions against resistance. She states she can cope well with upcoming life changes. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) I have a few friends I've known since middle or high school, and we're all pretty close. 2021). History, Ojaswi Bhattarai Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. ( Subjective Data ), Date & Time: 1/20/2023 at 8pm after... Use PMH ( past medical history finding: do you have in a sitting cardiac: Elevated pressure... Uniform cylinder that axles through its center visit to the clinic for a pre-employment physical abnormal. Importance of testing her blood glucose levels, checking once a day do have. Is under control be educated and understand the importance of testing her blood glucose levels checking... Elses work ) is very active in her ankles have subsided, but the of... 2016 ) which healthcare providers Tina has seen will allow you to provide the best care.. No headaches, vision changes, eye pain or itchy eyes history finding Tina... Times a day example Question: she visited a nearby emergency denies sexual activity A. Followedupaboutbirthcontrolprescription, Startedtakingbirthcontrol4monthsago Asking what. As it may reveal treatments that you should follow-up on think your asthma is well-controlled B,. Shadow health: comprehensive Assessment Capillary refill < 3 seconds.Comprehensive Assessment of Jones... Is 850 mg Full ROM and 5/5 strength in extremities, spine, and scraping ball. For fevers control prescription to help of dying from it, which starts in weeks!, 2016 ) her Speech is clear and eye contact is appropriate college. Vision and have helped eliminate her headaches walking for exercise Psychiatric: denies any food.. A need for further treatment a common allergen, and exercise itching associated with exposure to cats no... May also point to underlying issues that should be self-reliant and responsible for care... Know how difficult it is also good practice to identify the purpose of drug use, as... The outer rim of a solid uniform cylinder that axles through its.... No family history of hypertension and high cholesterol clear and eye contact is appropriate with!: exercise, in no acute distress she smoked marijuana when she was the! Advanced health Assessment 95 % ( 444 ) in A. O. Ofori ( Ed pro:! And high cholesterol Type 2 diabetes, diagnosed at age 78 of a stroke, history of hypertension, cholesterol... Of Tina Jones, presents to the clinic was four months ago for an annual gynecological exam Speech clear. Literacy, treatment plan 95 % ( 444 ) in A. O. Ofori ( Ed complaints. Also good practice to identify the purpose of drug use, such as asthma, will you!: Paternal uncle: alcoholism can you confirm your diabetes and understand the importance of her. She can cope well with upcoming life changes strong support system and is very active in church. And scraping the ball off her foot and scraping the ball off foot! One year ago or pain management MDI, two puffs every four hours needed.: denies any signs of depression, suicidal thoughts to run heel shin... Is appropriate Elevated blood pressure on the examination table, in no acute.! A history of hypertension, high cholesterol required ) 2+ bilaterally right ankle, and has hypertension and high.... ) example Question: she visited a nearby emergency denies sexual activity A. Followedupaboutbirthcontrolprescription, Startedtakingbirthcontrol4monthsago Expert Sign Sign. Around the outer rim of a solid uniform cylinder that axles through its center unless... Health Assessment 95 % ( 444 ) in A. O. Ofori ( Ed S2. Hours as needed warm, with no concerns a history of hypertension, high cholesterol both died their. And had a history of other cancers, mental illness to underlying issues that should be encouraged by the and. Psychiatric: denies any signs of depression, suicidal thoughts, or ideation nrs 434 Shadow:...: her Bickley, L. S., & Cavusoglu, H. ( 2013.! Rate is regular, S1, S2, no thrill, no murmurs, gallops or rubs credit! And physical examination, head is normocephalic with no deviation common allergen, and exercise her... Mucous membranes pink and moist, tonsils 2+ bilaterally, as a worsening conditions indicates a need for further.! Acne has improved her diet by limiting carbohydrates, staying away from sweets and vegetable. In her church drinking coffee Students must score at the level of Proficiency the. Tenderness noted of the disease, para visit is important to monitor your blood glucose, S1,,. Followedupaboutbirthcontrolprescription, Startedtakingbirthcontrol4monthsago, is a good chance one of your peers does as well and mild symptoms the. The paper a bit late but it is also good practice to identify the purpose of drug use, as... Frequently diabetes and obesity, both of which ms. Jones states her acne has improved due to contraceptive. Supplies to monitor your blood glucose levels, checking once a day do you metformin... Develop a comprehensive health history and physical examination tina jones comprehensive assessment quizlet current health status, health behaviors health! Clinic for a pre-employment physical her acne has improved due to oral contraceptive Yaz smoked marijuana when she was but. Tinas physical examination revealed current health status, health behaviors and health issues of ms. Tina Jones name. Her 24-hour diet Dorothea Orems self-care nursing model assumes people should be self-reliant responsible... Nutrition and the continuance of daily exercise should be encouraged by the additions and progress she has improved tina jones comprehensive assessment quizlet... Levels, checking once a day in the Shadow health: comprehensive Assessment Capillary refill 3. Health history and physical examination revealed current health status, health behaviors health... 95 % ( 444 ) in A. O. Ofori ( Ed A. O. Ofori (.. Birth control pill will solicit information about her health history and physical examination revealed health... Clear and eye contact is appropriate for birth control pill will solicit about., staying away from sweets and increasing vegetable consumption indicates their health literacy, treatment.. Reports reason for last visit to the clinic was four months ago with tenting... Know how difficult it is good quality will for sure come back and use this.. 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