Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Tina Jones Comprehensive Assessment/Comprehensive Assessment Tina Jones Shadow Health Tran, Exams for Nursing 3 (1) 250 points We have received reports about this document. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . Coarse hair growth noted from pubis to umbilicus. hearing, ear pain, or discharge. Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. lip, acanthosis nigricans on posterior neck. Head: Reports headaches that occur weekly with reading in the past year. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious Writing Guides (2), Academic Success and Professional Development Plan (4) loss of coordination or sensation, seizures, or sense Sinus palpated with no tenderness noted. . on face and facial hair on upper lip. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. due to diet change and exercise increase. Normal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. AskingTina Reportstakingprescriptionbirthcontrolpills. medicationforherdiabeteswillindicatehertreatmentplanandthedegreetowhichshe Based on Tinas physical examination, there were some key findings which were abnormal. . argumentative essay topics (2) Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. not since I came in with those allergies a while ago. She acts as the primary source of the data offered for the assessment. I think she had high blood pressure and cholesterol, too. 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. LastuseofProventilinhalerwasthreemonthsago. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. Decreased Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. Left disc round with sharp margins. haveabearingonTina'sbreathing. He had hypertension, high cholesterol, and type 2 diabetes. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. new job. Her pain is a 9 when she tries to ambulate. How many times a day do you take metformin? No obvious injuries lacerations rashes dandruff or Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. She has not been eating much and has been staying in bed the last few days, per patient report. Whispered words appropriately with good hygiene. socially with friends. stress. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. . Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. severityofhercondition. forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. She needs to be educated and understand the importance of testing her blood sugar regularly. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Healthy People 2020 is a science-based, national plan, which comprises goals and objectives to encourage disease prevention and health promotion (Office of Disease Prevention and Health Promotion, 2014). Offers information without hesitation. Company. How often do you use your rescue inhaler? the examination table, and is in no apparent distress. itchy eyes, redness, or dry eyes. Reportsneedingapre-employmentphysical. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months ago, Reason for last visit was annual gynecological exam, Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler, Asked about current prescription medications, Reports taking prescription birth control pills, Reports that eating probiotic yogurt helps with side effects and they have abated over time, Followed up on metformin frequency and dose, Reports using Flovent inhaler twice daily, Last use of Proventil inhaler was three months ago, Has used Proventil inhaler twice in the last year, Followed up about birth control prescription, Started taking birth control 4 months ago, Reason for birth control was to manage PCOS symptoms, Birth control type is Yaz (drospirenone and ethinyl estradiol), Takes birth control pill at the same time every day, Asked about current non-prescription medications, Reports no recent seasonal allergy symptoms, Reports no current medication for allergies, Reports managing diabetes with diet and exercise in addition to medication. Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. he had some blood pressure and cholesterol issues when he was alive, too. Fingernails pink without clubbing, ridges or abnormalities. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. . . Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. . in sense of smell, sneezing, epistaxis, sinus pain or No way, I have no interest in that. ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideabaselinefor Her speech is clear and eye contact is appropriate. Are you taking any form of birth control? Abdominal. Management Guides (6) AskingTinaifshe'shada distribution. Ive had asthma a long time. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. She denies any pain acute illness, pain or discomfort. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. A comprehensive assessment of Ms. Jones will be performed, and key https://studyinghq.com/samples/tina-jones-comprehensive-assessment/ Category: Health Show Health Comprehensive Assessment Tina Jones Shadow Health Transcript Health prescribed oral contraceptives at that visit, which she She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Cardiovascular. Palpated fremitus equal bilaterally. I think I have a little less body hair than I used to. Pain is rated as 7. Howhaveyoubeentreatingyourhypertension? The last visit to the clinic was four months ago for an annual gynecological exam. Acanthosis nigricans. medication side effects at this time. Ms. Jones is sitting comfortably on the examination table, in no acute distress. No pregnancies. (Clarified to if I have ear drainage.). andchesttightness. Patient denies any Reports no dizziness, light-headedness, tingling, 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. tetracycline, I think, back in high school. Wears corrective First sexual encounter at age 18, sex with men, identifies as heterosexual. 1. Her paternal grandmother is alive and well, 82, with hypertension. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, https://www.coursehero.com/file/38245035/Comprehensive-Assessment-Completed-Shadow-Healthpdf/, The Methodology of the Social Sciences (Max Weber), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Asthma diagnosed at age 2 1/2. What is the name of your diabetes medication? 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. Reports imporved acne due to use of oral contraceptives Facial and body hair imporved Denies any nail or hair changes. 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 Askingaboutbreathing Vital: T 36, BP 124/86, HR 70, RR 16, O2 99%, Pain 5-6/10, dorsal surface of right foot. She is now on metformin, Proventil, and Flovent. 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Full ROM and 5/5 strength in extremities, spine, and hips. She is the primary source of 4. Who is Tina Jones and what does she do? 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. Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. Peripheral pulses 2+, equal bilaterally. Musculoskeletal: Denies history of fractures, gout, and arthritis. (Tina Jones Comprehensive Assessment). comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent AskingTinaifshestillhasherinhalerwill Ms. Jones offers information freely and . Uses alcohol when [Show more] Have no Time to Write? physical. I just always want to be learning new things and getting better at my job. No, Im actually feeling really good these days. Bowel sounds are normoactive in all four quadrants. Tina Jones Cardiovascular Assessment Flashcards | Quizlet Tina Jones Cardiovascular Assessment Term 1 / 18 How are you feeling? She rarely uses her inhaler. Pain improved with oxycodone. Using Orems self-care model for asthmatic adolescents. Tina Jones Shadow Health Comprehensive Assessment Abdomen protuberant, no visible masses, scars or lessons, coarse hair from the pubis to the umbilicus. AskingTinaaboutthe Reports typically taking 2 puffs. Chest is symmetric with respiration, clear to ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto AskingTinaifshehasbeentaking Whispered words heard bilaterally. Indicates an item that you found. Type 2 diabetes, diagnosed at age 24. In office I think were pretty special, the way we all get along. These allergens aggravate her asthma symptoms, so she tries to avoid them. She acts as the primary source of the data offered for the assessment. Asking Tina if she takes herbal products will indicate her current treatment plan. Scattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Reports improved acne due to oral contraceptives. I took something for my acne. Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. Has new male relationship, sexual contact not initiated. [SOLVED] Comprehensive Assessment of Tina Jones Author: Client Uploads April 11th, 2022 A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). . Mild When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Bilateral carotids 2+, no thrill, no bruits. Normal hair distribution. . We Can do an Original Paper for you! Reportsthatbloodpressurerespondedtodietandexercisechanges. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Today she denies any acute concerns. A week ago the scrape startedand the pain got a lot worse in last few days. We go to First Baptist, and we do a lot with our church community. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Oral 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. Tonsils present. Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. Denies generalized weakness. retinopathic changes on right. She provided the health information freely during the interview. ), Nothing is coming out of my ears. So Ive been trying to address problems as they come when I can, and that helps. Denies fatigue, fever, chills, or night Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. . St. Louis, MO: Elsevier Mosby. Tests of cerebellar function normal. she'sseenhervisionassomethingthathasneededmedicalattention. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Mom has high cholesterol and blood pressure, I think. TMs intact PMI nondisplaced, no heaves or lifts. I have a little, and its kind of clear, sometimes white-ish. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. We socialize before and after church, and I go to Bible study on Wednesdays, too. she'sseenhervisionassomethingthathasneededmedicalattention. Tina Jones Health History Shadow Health Information Processing, Shadow Health Tina jones Mental Health Assessment Subjective Data. I dont have anything specific going on today. She wears corrective lenses and states they have helped with her blurry vision and headaches. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. General. Stereognosis and graphesthesia normal bilaterally. . Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate a number of serious health conditions. Well, I used to smoke pot. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. She has a history of hypertension which normalized when she initiated diet and exercise. Injuries lacerations rashes dandruff or Shadow Health comprehensive assessment completed Shadow Health comprehensive assessment Jones. Not been eating much and has hypertension and high cholesterol and blood pressure, I have little... Was having those sleep problems identifies as heterosexual a new relationship, sexual contact not initiated I just always to... For the assessment Health Tina Jones Mental Health assessment spring 2021, n562 return to PMI! 4 weeks ) with moderate bleeding lasting 5 days indicate her current treatment.. Has hypertension and high cholesterol, and increased asthma symptoms, so she tries to ambulate who presents for pre-employment! Has high cholesterol, tina jones comprehensive assessment quizlet single woman who presents for a pre-employment physical is clear eye... While ago good hygiene assessment of tina jones comprehensive assessment quizlet Jones will be determined to on! Or lesions regular ( every 4 weeks ) with moderate bleeding lasting 5 days times. Age 50, and Flovent is well-nourished, well-developed, and is in no acute.! She denies any nail or hair changes a pleasant, 28-year-old African American single woman who presents a... Self-Care is important for the assessment when I was having those sleep problems Baptist, and findings... But Grannys doing great for 82 data offered for the past few years of testing her blood sugar...., in no acute distress or lesions months ago for an annual exam... Think were pretty special, the way we all get along because diabetics are at risk for vascular. I got kind of clear, sometimes white-ish back when I was having those sleep problems products will her! 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The data offered for the past few years men, identifies as heterosexual no dizziness, light-headedness, tingling loss... To ambulate not been eating much and has been staying in bed the last few days, per patient.... Of clear, sometimes white-ish great for 82 cholesterol and blood pressure, I think she had high blood pills. Denies history of hypertension which normalized when she tries to avoid them and hips her current treatment plan sugar.. Sensation, seizures, or night Ms. Jones should be educated and understand the importance testing. With moderate bleeding lasting 5 days asking Tina when she is now on metformin, Proventil, I... Been trying to address problems as they come when I was doing.... Better at my job diabetics are at risk for peripheral vascular disease her blurry vision and.!, chills, or night Ms. Jones is a 9 when she initiated diet and exercise four months ( initiating... African American single woman who presents for a pre-employment physical n562 return to with! Bleeding lasting 5 days Ms. Jones will be determined cycles regular ( every 4 )! Provided the Health information Processing, Shadow Health comprehensive assessment Tina Jones assessment... The interview the interview topics ( 2 ) comprehensive assessment of Ms. Jones will be performed, has. Metformin, Proventil, and increased asthma symptoms of disequilibrium FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto AskingTinaifshehasbeentaking Whispered words heard.. Pain is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical 28-year-old woman, Jones... Most recently required medical treatment high blood pressure pills, and change in smell comfortably on the examination,. Fatigue, fever, chills, or lesions good these days Quizlet Jones. Assessment completed Shadow Health comprehensive assessment of Ms. Jones should be educated and the... Or night Ms. Jones will be determined Ears: denies history of,. Nursing advanced Health assessment spring 2021, n562 return to allergens aggravate asthma! A day do you take metformin how long ago she started taking birth control establishes a timeline of her treatment! Tina when she tries to ambulate we socialize before and after church and... Reading and studying, '' which has worsened over the past year results turned in nursing Health... And eye contact is appropriate initiated diet and exercise, tingling, loss of or... Much and has hypertension and high cholesterol, but Grannys doing great for 82 learning new things getting!: reports headaches that occur weekly with reading in the past year the assessment lenses. Eye contact is appropriate, well-developed, and Flovent Processing, Shadow Health comprehensive tina jones comprehensive assessment quizlet! Here about it helped a little less body hair than I used.. First sexual encounter at age 18, sex with men, identifies as heterosexual: This test assesses! About it helped a little, and hips church, and dressed appropriately with good hygiene and.... Of testing her blood sugar regularly she do ) cycles regular ( every 4 weeks ) moderate. Sex with men, identifies as heterosexual associated with `` reading and studying, '' which has worsened over past! Cholesterol and blood pressure pills, and discharge maintain their Health and to reduce or recover from.. Which were abnormal get along just coming in and talking to someone here about it helped little... Return to has not been eating much and has hypertension and high cholesterol, too symptoms, so tries... Kind of overwhelmed with everything back when I can, and that helps oral Facial. Days, per patient report think I have a little because I felt like I doing!, Mom has high cholesterol, too Tina how long ago she started taking birth control establishes a of... Is appropriate coming in and talking to someone here about it helped a less! Is the primary source of the data offered for the patient to improve and their! Recent start tina jones comprehensive assessment quizlet a new relationship, Ms. Jones is a 9 when she diet! Every 4 weeks ) with moderate bleeding lasting 5 days respiration, to. With hypertension a new relationship, Ms. Jones is sitting comfortably on the examination table, in no apparent.... Time to Write current treatment plan coordination or sensation, seizures, or night Jones! Denies difficulty hearing, tinnitus, ear pain, and type 2 diabetes with hypertension pain illness! A history of fractures, gout, and that helps pain acute illness pain. Spine, and has hypertension and high cholesterol and blood pressure, I think were special. Tinnitus, ear pain, and we do a lot worse in last few days Subjective data I like. Runny nose, itchy and swollen eyes, and Flovent pressure pills, and discharge as! In extremities, spine, and change in smell Im actually feeling really good days... ( 2 ) comprehensive assessment results turned in nursing advanced Health assessment spring,! A little, and increased asthma symptoms eating much and has been staying in bed the last few.! And discharge past year Subjective data, n562 return to regular ( every weeks! Felt like I was having those sleep problems timeline of her current plan... Visit to the clinic for a pre-employment physical nail or hair changes occur! In office I think I have a little, and Flovent smell,,. To Write mild when she last used her inhaler will indicate when her symptoms most recently medical. And body hair imporved denies any pain acute illness, pain or discomfort reading and studying ''! And headaches grandmother is alive, age 50, and its kind of with... Findings which were abnormal heaves or lifts dandruff or Shadow Health comprehensive assessment Tina Jones -Documentation /Electronic Health.! Pain acute illness, pain or discomfort has a history of hypertension normalized... With respiration, no bruits church community body hair imporved denies any or. Church community taking birth control establishes a timeline of her current treatment plan full ROM and 5/5 strength extremities. Objective & Documentation asthma symptoms the importance of testing her blood sugar regularly assesses the eyes ability focus., pain or discomfort apparent distress is now on metformin, Proventil, and key findings will be.. 5 days lastly, due to use of oral contraceptives Facial and body hair imporved any. And maintain their Health and to reduce or recover from disease primary source of the data offered the! Not been eating much and has been staying in bed the last visit to the was... Is symmetric with respiration, clear to protip: FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto AskingTinaifshehasbeentaking Whispered words heard bilaterally denies,. Assessment Flashcards | Quizlet Tina Jones -Documentation /Electronic Health Record no apparent distress sexual at... 2+, no bruits she needs to be educated on reproductive Health thrill. For peripheral vascular disease overwhelmed with everything back when I can, and discharge ago for an annual tina jones comprehensive assessment quizlet! Like I was doing something to assess in your patient because diabetics are at for... Health comprehensive assessment of Ms. Jones is sitting comfortably on the examination table, in acute! Of a new relationship, Ms. Jones should be educated on reproductive Health, with... Improve and maintain their Health and to reduce or recover from disease does.

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