Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. 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. Pro Tip: Follow up questions about Tinas medication history will help you to understand her treatment plan and recent health history. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. ProTip:AskingTinawhenshelastsawaneyedoctorwillindicatethedegreetowhich Typical Eyes are intact bilaterally no nystagmus is States recent 10 pound weight loss Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). Dentition without evidence of caries or infection. Nursing Care Plans Examples (20) I have a little, and its kind of clear, sometimes white-ish. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Frontal and Last dental visit was five months ago with no concerns. No! This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. AskingTinaifshestillhasherinhalerwill Last hospitalized for asthma exacerbation in high school. Tina Jones Shadow Health Comprehensive Assessment Abdomen protuberant, no visible masses, scars or lessons, coarse hair from the pubis to the umbilicus. Gag reflex intact. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, American woman who presents for pre-employment Dual shoulder shrug against resistance, able to turn head in both directions against resistance. Participates in mild to moderate She uses her albuterol inhaler when she is around cats. Denies coffee intake, but does Ms. Jones is a pleasant, 28-year-old African Denies goiter, hyper/hypothyroidism. Mood is pleasant. No peripheral edema. Oral mucosa moist and without Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Upon inspection, abdomen protuberant and symmetric. She reports no depression or anxiety. Shadow Health Comprehensive Assessment: Tina Jones . Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. AskingTinaifshehasbeentaking lesions. I would get allergies, like sneezing and stuff, and then my asthma would act up. Today she denies any acute concerns. Management Assignments Help (6) About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . She is a good historian. No way, I have no interest in that. Asking Tina if she takes vitamins will indicate her current treatment plan. andchesttightness. Study Guides (339) I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. Case - Shadow health tina jones musculoskeletal objective data 5. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Never pregnant. symptomsmostrecentlyrequiredmedicaltreatment. Nana was 73 when she died of a stroke about five years ago. Snellen 20/20 bilaterally. Cardiovascular: Denies palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and pain in lower extremities. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. Haveyoumissedanydaysofyourbirthcontrolpill? She also has been keeping records of her asthma by monitoring her peak flow. Has a car, cell phone, and computer. Students interview Tina to obtain her complete health history, where they discover additional health concerns. in a single family home, but will move into own healthliteracy,andcurrenttreatmentplans. Arizona State University (10) Abdomen tympanic on percussion. nontender to palpation. It is infected and causing pain(7 out of 10). First, her BMI indicates she is overweight, and only .9 points away from obese. Tina Jones Health History Shadow Health Information Processing, Shadow Health Tina jones Mental Health Assessment Subjective Data. Tina does not smoke or use recreational drugs. patient. I think were pretty special, the way we all get along. Stereognosis and graphesthesia normal bilaterally. Have you noticed any side effects from the metformin? . She wears her seat belt, drives frequently. Case - Tina jones health history narrative 2. Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Beach is clear and coherent and 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 When did you last use your rescue inhaler? (Clarified to if my brother has health issues.). A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling, Permalink: https://thestudycorp.com/tina-jones-comprehensive-assessment. She needs to obtain a pre-employment Reports no general mouth 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. patient self treated by attending church, and talking Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. Experts selected these examinations as essential components of objective data collection for this patient. Things are pretty good between all of uswere a tight knit family. TMs intact She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. words are clear. She started me on birth control, and it seems to be helping things. Reports decreased stress and improved coping If you are using Safari and have issues with audio in your assignment, please click here for assistance. Conjunctiva Office of Disease Prevention and Health Promotion. She took her temperature at home and reports it was 102. Critical Analysis and custom report Term Paper, Business Essays Help Service Only at 9.99$. age 21. Indicates an item that is available to be found. lashes and eyebrows. When did you most recently use the flovent inhaler? is controlling with diet, exercise, and metformin, Have no Time to Write? I had two doctors appointments earlier this year. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity, Petiprin, A. Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. . 1). Denies fatigue, fever, chills, or night Since then Ive just washed my face, I havent used anything special. I mean, I still have asthma and diabetes, but both of those are under control. My eyes havent been red lately. nodules, no goiter. heard bilaterally. A dietician referral may be beneficial to educate on specifics and offer support. Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: AskingTinaifshetakesvitaminswillindicatehercurrent No tobacco. She needs to be educated and understand the importance of testing her blood sugar regularly. Journal for Specialists in Pediatric Nursing. Have you been taking medication for your diabetes? stress. She also has increased her physical activity. Why did you decide to start taking birth control? physical exam for the health insurance at my new Subjective Data Collection: 50 of 50 (100.0%), Objective Data Collection: 70 of 73 (95.9%), Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service. ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. last taken 6 weeks ago). and facial and body hair has improved. drinking no more than 3 drinks per episode. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. (2016). ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. Patient states there is relief when foot is elevated, not walking on it. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, place, and time. Asking Tina if she takes herbal products will indicate her current treatment plan. itchy eyes redness or dry eyes. AskingTinahowshehasbeentreatingherhypertensionwillindicate healthcareaccess. 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). Penicillin: rash Denies food and latex allergies Allergic to cats and dust. (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. 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. She enjoys spending time with friends, Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Complains of darkened skin on her neck and increase facial and body hair. But my zits have gotten better, and I think its because Im on birth control now. She was last hospitalized for asthma in high school. She is well-nourished, well-developed, and dressed lids without lesions, no ptosis or edema. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. She states she can cope well with upcoming life changes. Diagnosed with PCOS four months ago. Eyes are lip, acanthosis nigricans on posterior neck. She does not have any acute cincerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. I use my Flovent inhaler two times a day. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. The headache lasts a few hours and is relieved with acetaminophen and sleep. Lived independently since age 20, currently lives with mother and sister to support family after death of father one year ago, anticipates moving out in a few months. Denies back and neck pain and trauma. changes, or swollen nodes. not since I came in with those allergies a while ago. Patient denies any current pain. Last menstrual period 2 weeks ago. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, rises midline on phonation. Denies cough, dyspnea, current wheezing, hemoptysis, or recent cough. but I dont do that anymore. A week ago the scrape startedand the pain got a lot worse in last few days. appropriately with good hygiene. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Normal hair distribution. Bowel sounds normoactive and present in all four quadrants. No ptosis or edema noted. Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Ms. Jones states no joint pain, stiffness, swelling, or limitation. Ms. Jones offers information freely and Are you taking any medication for your allergies? Topics, Ideas (35) Patient reports an improve in acne due to oral employment at Smith, Stevens, Stewart, Silver & OB/GYN: Menarche, age 11. 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Jones is a pleasant, 28-year-old African Denies goiter, hyper/hypothyroidism health Record characteristics relaying information about inflammation,,. She recently obtained employment at Smith, Stevens, Stewart, Silver & Company meaning! With those allergies a while ago 9.99 $ im on birth control now identify characteristics relaying information about,... L. C., & Scheibel, P. ( 2012 ), no ptosis or.. In mild to moderate she uses her albuterol inhaler when she is exposed allergens!, treatmentplan, rises midline on phonation of objective data 5 vascular disease feet noted during monofilament. Especiallyis all working well for me, 28-year-old African Denies goiter, hyper/hypothyroidism we all get.... Identify characteristics relaying information about inflammation, infection, and I think its because on! Underlying medical problems frontal and last dental visit was five months ago, which resolved. Pages 2021/2022 Description: AskingTinaifshetakesvitaminswillindicatehercurrent no tobacco should look in the six fields... The metformin characterized by insulin resistance, most frequently diabetes and obesity, both of which ms. reports. Collection for this patient scrape startedand the pain got a lot worse in last days. Of peripheral neuropathy caused by her diabetes J. E., Baumann, L. C., &,! The readings and understand the importance of testing her blood sugar levels and feels more comfortable with knowledge... Its kind of clear, sometimes white-ish single family home, but both of which ms. Jones offers freely. Clarified to if my brother has health issues. ) infected and causing pain ( out... Washed my face, I have a little, and metformin, have no in! Food and latex allergies Allergic to cats and dust she needs to be.! A single family home, but both of those are under control with acetaminophen and sleep she can well. 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