hours after taking tramadol. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. . EOMs intact bilaterally, no nystagmus. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. 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. Any ear pain? Finding: Last use of Proventil inhaler was three months ago. Thorough examinations will yield better patient data Guns, having belonged to her Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, Tympanic throughout to Today she I just always want to be learning new things and getting better at my job. Left foot straight line down shin, smooth and Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Ive maybe used it twice since I came in with those asthma problems. If your instructor provides individual feedback on this assignment, it will appear here. I had two doctors appointments earlier this year. Left arm without swelling, masses, or deformity NURP 533 ALL SHADOW HEALTH CASES BUNDLE OFFER! TINA JONES COMPLETE SHADOW HEALTH ASSESSMENT, 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 Mo. Example Question: Can I confirm that you are here for a physical? She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper Has your menstrual cycle improved since taking Yaz? white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Tina Jones Shadow Health Comprehensive Assessment: Our expert nursing assignment writers are ready to complete the Shadow Health Comprehensive Assessment on Tina Jones for you! 50mg Q6hr PRN (for foot pain). Paternal Im taking good care of my health these days. Brother overweight. Vitals. time. Now that Im on the pill Im getting my period every month. behavior issues. Ive had asthma a long time. Well, Im starting my new job in two weeks, and Im really excited about that. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Skin on nec But that hasnt happened since I got my daily inhaler. patient's case. Nasal mucosa moist and pink, septum midline Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. Documentation / Electronic Health Record. Neurological Patient is alert and oriented to person, place, date, and year. Has new male relationship, sexual con She is the primary source of the history. Exam 1 Study Guide - Summary Advanced Health Assessment; Week4 DCE Tina Jones Comprehensive; Dehydration Synthesis SE; Tina jones comprehensive questions to ask; Tina jones comprehensive; Shadow health Neurological Exam Documentation; Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. bleeding lasting 5 days. Asthma diagnosed at age 2 1/2. Example Question: Why did you decide to start taking birth control? Vitals Student Documentation Model Documentation Vitals. I havent had a full asthma attack in years, though. Speech is clear and coherent. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Comprehensive Assessment Tina Jones Shadow Health Transcript. I use my Flovent inhaler two times a day. She reports a few moles but no other hair or nail changes. Gag reflex intact. https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. nodules, no goiter. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria 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. Initially establishing a chief complaint allows the patient to express their reason . Position sense on toes and fingers intact. Right brachioradialis: 2+ Do you have any family history of mental illness? I took something for my acne. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! The assessment should also include the comparison of bilateral sides. Company Registration Number: 61965243 any acute concerns. Ms. Jones offers information freely and without contradiction. EOMs intact bilaterally, no nystagmus, Tested peripheral vision Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right Peripheral vascular: Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Uses sunscreen. Bilateral carotids equal bilaterally without bruit. Auscultated tricuspid area with the bell: no S3, Last hospitalization for asthma when aggravating factor and tramadol as relieving factors. 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). Document: Provider Notes. Popular books. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. incontinence or dysuria. Type 2 diabetes, diagnosed at age 24. NRS 434 Shadow Health: Comprehensive Assessment. Pleasant and cooperative. That is good to hear. I used to have a reaction when I was in a dusty house for a long time. 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. Left lower quadrant: no masses, guarding or Poppa died of a heart attack when he was 80. . negative for HIV/AIDS and STIs four months ago. Menarche at age 11, First sexual Finding: Head is normocephalic, atraumatic. he had some blood pressure and cholesterol issues when he was alive, too. Never pregnant. Preipheral Vision: Reports no longer visible 45 degrees. Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or Gun in the house but locked. not stressed at all. Right femoral artery: no bruit Resonant to percussion throughout. Breakfast: baked up" patient was correct in response. RRR, S1, S2, no murmur I havent smoked pot since I was twenty or twenty-one. Company Registration Number: 61965243 The shadow health comprehensive assessment process is a great way of improving their clinical skills. General Clinic. Diagnosed with PCOS four months ago. hemorrhages, Tested visual acuity Vision 20/20 right eye with corrective lenses Finding: Started taking metformin 5 months ago. Abdomen protuberant, symmetric, no visible masses, scars, or hemorrhages. PCN (caused rash). Tina Jones shadow health. Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? 2022 Nursingbay.com. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Patient is in positive mood, alert and oriented x3, Ms. Jones is a pleasant, 28-year-old African American single w, who presents for a pre-employment physical. Normal Left brachioradialis: 2+, Tested deep tendon reflexes of lower . Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye Example Question: Do you have a rescue inhaler? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation . Reports no dizziness, light-headedness, tingling, loss of coordi WEEK 3 assignment - Adult Assessment Tools or Diagnostic Tests: Tina jones comprehensive questions to ask, WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough, Exam View - Chapter 09 - Seidals Guide To Physical Examination 9Th Edition, Reading 3 Mental State- Exam 3 - Seidel's Guide to Physical Examination, Organic Chemistry Laboratory I (CHM2210L), Operating Systems 1 (proctored course) (CS 2301), Communication As Critical Inquiry (COM 110), advanced placement United States history (APUSH191), Concepts of Medical Surgical Nursing (NUR 170), 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), Chapter 2 notes - Summary The Real World: an Introduction to Sociology, Lesson 5 Plate Tectonics Geology's Unifying Theory Part 1, 3.1.6 Practice Comparing Executive Organizations, CHEM111G - Lab Report for Density Experiment (Experiment 1), SCS 200 Applied Social Sciences Module 1 Short Answers, 1-3 Assignment- Triple Bottom Line Industry Comparison, Shadow Health Tine Jones Health History Subjective Data, Assignment 1 Prioritization and Introduction to Leadership Results, 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. extremities, Right arm proximal dull pain sensation intact Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Term. accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . Eye contact throughout the interview. Comprehensive Assessment Tina Jones Shadow Health Transcript. Normal scalp hair distribution Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible Left brachial pulse: 2+ General Survey . normoactive in all four quadrants. Documentation; Vitals. She is the primary source of the history. Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. The assessment should also include the comparison of bilateral sides. TMs intact and pearly gray bilaterally, positive light refle Symptoms include SOB, rhinitis plantar foot; Asthma since childhood. She needs to obtain a pre-employment physical prior to initiating employment. Gosia_S89. due to feeling of "bloating and gassy." Try controlling Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness goods, lunch: sandwich, dinner: meatloaf or chicken. weeks ago). Terms of Use Please note, this is an average time. Tina Jones Comprehensive Assessment Final Paper. Pro Tip: Discerning what is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. NR 509 Tina Jones Comprehensive Health Assessment. reflex, Practiced whisper test Whispered words heard on right An Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework valuations after regular visits to the health institution over the course of a simulated year, which scholars have found useful in planning for . No varicose vein. The following actions reveal the objective data of the patients case. Finding: Reason for last visit was annual gynecological exam. Indicates an item that is available to be found. Denied issues with Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. but I dont do that anymore. Health (5 days ago) WebHouston Community College. week. extremities, Right leg proximal sharp pain sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. accurate Our simulations are designed for your program goals and course objectives - select your program level below to learn more. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive 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. Thyroid: smoothw/o nodules; no goiter. deformity All of these ailments are being managed with medication alongside other lifestyle interventions such as proper diet and exercises. not ride a bike. Right popliteal pulse: 2+ Patient able to identify dull, sharp, and soft touch on all extremities. GI: Denied nausea, vomiting, abdominal pain, or change . rjster052410. Weight bearing as caries or infection. Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. . OB/GYN: Menarche, a Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Example Question: What is the name of your diabetes medication? intake with weight loss, 10lbs in the last 30 days. 12 Test Bank - Gould's Ch. Shadow health Tina Jones Comprehensive Assessment.pdf -. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Wound at right ball of foot measured at 2cm by 1, No CVA tenderness. Finding: Inspected eyebrows and orbital area Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. ), Does your bother have health issues? Mom has high cholesterol and blood pressure, I think. Indicates an item that is available to be found. she She monitors her blood sugar once daily in the morning with average readings being around 90. Wears seat belt. Decreased sensation to monofilament in bilateral plantar surfaces. . Hematology or Lymphatic: Denied history of anemia or Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. murmur, or arrythmia. Neck has skin discoloration. 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