Denies coffee intake, but does Ms. Jones is a pleasant, 28-year-old African Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. No tobacco. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. ProTip:Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe That doesnt sound like it would be good. andaccesstohealthcare. 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. Thefollowingdetailsare Coarse hair growth noted from pubis to umbilicus. Reports sometimes needing 3 puffs to control symptoms. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Documentation Gag reflex intact. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Head is normocephalic, atraumatic. I dont have anything specific going on today. CanIconfirmthatyouarehereforaphysical? Indicates an item that is available to be found. Chest is symmetric with respiration, clear to My eyes havent been red lately. She denies any pain acute illness, pain or discomfort. EOMs intact bilaterally, no nystagmus. indicatehertreatmentplanandthedegreetowhichsheisfollowingit. Diabetes is disproportionately prevalent in the African American population (Bickley & Szilagyi, 2013). Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Reports no difficulty swallowing, sore throat, voice Seasonal flu vaccine is not completed yet. Tonsils present. Although Ms. Jones is not sexually active, she states she probably will be soon. Her pain is a 9 when she tries to ambulate. Self-care deficit theory. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Will begin her new position Tympanic throughout to percussion. Nasal She is well-nourished, well-developed, and dressed Ibuprofen: 600 mg as needed for menstrual cramps. No tobacco. 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. Breath sounds present and equal bilaterally, no adventitious sounds noted. That stuff can mess you up. healthcareaccess. Patient is seated upright on the examination Reports improved acne due to oral contraceptives. Case - Tina jones subjective heent | completed | shadow health 2 4. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Reportsthateatingprobioticyogurthelpswithsideeffectsandtheyhaveabatedover Sclera white, conjunctiva pink, PERRLA, EOMs intact. Have you noticed any side effects from the metformin? No recent foreign Pain is localized to ball of foot related to wound. Management Assignments (7) Thyroid palpable, no nodules, no goiter. Guns are locked up. drinking no more than 3 drinks per episode. 2. (Tina Jones Comprehensive Assessment). Metformin: Started five months ago. No concerns about alcoholism. allergens she states that she has runny nose, itchy . Nana was 73 when she died of a stroke about five years ago. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. PERRLA bilaterally. Have no Time to Write? Never intubated. Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Reports typically taking 2 puffs. Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. This homework should take 3 hours on average each time to finish. Reports no general ear problems, no change in andaccesstohealthcare. Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. Patient states there is relief when foot is elevated, not walking on it. Patience hair is well-groomed with even She has not been eating much and has been staying in bed the last few days, per patient report. No, Ive still never had problems with seizures, fortunately. 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. 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. pink, no lesions, white sclera. Reports no current headache and no history of head Normal graphesthesia, sterognosis, and able to Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. The download is temporarily disabled. We Can do an Original Paper for you! Oral mucosa moist and without Click here for more informationClick here for more information, If you are using Safari and have issues with audio in your assignment, please click here for assistance. . The foot feels better when she rests, and it hurts more when she walks on it. She was last hospitalized for asthma in high school. use: yesterday), Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: and pearly gray bilaterally, positive light reflex. Risk factors for diabetes which Ms. Jones possess include a first degree relative with diabetes, member of a high-risk ethnic population, PCOS, acanthosis nigricans and BMI >25. 4. Who is Tina Jones and what does she do? Eyes are placed Sample Study Papers (1464) 2021-22, 1-2 Problem Set Module One - Income Statement, Is sammy alive - in class assignment worth points, 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. injury or acute visual changes. 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). Company. She also has been keeping records of her asthma by monitoring her peak flow. 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Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), 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. she feels healthy, is taking better care of herself than A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Chest resonant on percussion. She offers information freely and without No tenderness or guarding to palpation. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Diagnosed with asthma at 2 1/2 years DIagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Theyre crazy, but nobodys diagnosed with anything. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. pain dyspnea or cough. concerns, last dental visit was 5 months ago. She has no medication side effects at this time. Reports eye itching associated with exposure to cats. Indicates an item that is available to be found. She is the primary source of I would get allergies, like sneezing and stuff, and then my asthma would act up. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Her last healthcare visit I havent really had any stomach problems since I came in with them a while ago. 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. Tactile fremitus present. with equal hair distribution on lashes and eyebrows, Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. No history of sexually transmitted infections. Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. The assessment should also include the comparison of bilateral sides. Normal graphesthesia, stereognosis, and rapid Attempting to palpate the kidney helps determine enlargement or tenderness. Has new male relationship, sexual contact not initiated. Buy best Assignments with zero plagiarism. When did you most recently use the flovent inhaler? I guess I had anxiety back when I was having those sleep problems. Haveyoubeentakingmedicationforyourdiabetes? Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention and Health Promotion. Whispered words This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. She states that family and church help her cope with Patient denies any concerns with mental health. medication side effects at this time. She plans to use condoms with sexual activity. Tina Jones - Uncontrolled Diabetes Patient will be able to demonstrate how to check glucose levels and take medication KEY: Evaluation Assessment Findings Patient is able to follow the routine schedule set out for taking medications consistently Patient glucose levels within healthy range (<160mg/dL) by discharge Slow healing foot wound Cardiovascular. NY Times Paywall - Case Analysis with questions and their answers. Plus, he had high blood pressure, andIm pretty sure he had diabetes. abilities have improved previous sleep difficulties. 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. No nail deformities. surfaces. Do you have any family history of mental illness? Strength 5/5 bilateral upper and lower extremities. AskingTina Type 2 diabetes, diagnosed at age 24. healthliteracy,andcurrenttreatmentplans. Indicatesanitemthatisavailabletobefound. She appears well-nourished and dresses appropriately. I think I have a little less body hair than I used to. Ms. Jones is sitting comfortably on the examination table, in no acute distress. treatmentplan. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Participates in mild to moderate This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Patient reports no General mouth employment physical. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. 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. treatmentplan. 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. If you are using Safari and have issues with audio in your assignment, please click here for assistance. problems or change in taste. Undergraduate students, become a tester for Shadow Health! Pain is rated as 7. maxillary sinuses nontender to palpation. She rarely uses her inhaler. Tina jones comprehensive questions to ask MAT-240 1-1 Discussion Peds calculation - peds math Kaugnayan ng panitikan sa larangan ng Pilipinas Week 1 Reflection CHEM111G - Lab Report for Density Experiment (Experiment 1) ATI Palliative Hospice Care Activity Gero Sim Lab 2 (CH) WS 200 module 2 discussions MKT 3301 Market Research Philosophy Newest She took her temperature at home and reports it was 102. hercurrenttreatmentplan. church, and dancing. Speech is clear and coherent. FVC 3 L; FEV1: 3. treatmentplans. Last dental visit was five months ago with no concerns. ProTip:Initiallyestablishingachiefcomplaintallowsthepatienttoexpresstheirreason Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. argumentative essay topics (2) . place, and time. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. I will be conducting an interview and later perform a physical exam. I took something for my acne. Reports no dizziness, tingling, or loss of sensation. Using Orems self-care model for asthmatic adolescents. andaccesstohealthcare. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. out with friends, 2-3 times per month, reports reading, attending Bible study, volunteering in her Peripheral pulses 2+, equal bilaterally. Asthma diagnosed at age 2 1/2. thoughts of suicide. : an American History, Med Surg Nursing Cheat Sheets 76 Cheat Sheets for Nursing Students nodrm pdf, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). Reports no use of cocaine, Tina Jones comes into the clinic for a general physical exam. no other hair or nail changes. I have a little, and its kind of clear, sometimes white-ish. AskingTinahowshehasbeentreatingherhypertensionwillindicate understandhertreatmentplanandrecenthealthhistory. distribution. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). exacerbation. Tina is active in her church and Ms. Jones speech is clear and coherent. Last visit to optometrist 3 months ago. Ms. Jones offers information freely and without contradiction. contradiction. Bowel sounds are normoactive in all four quadrants. (5 days ago) Shadow Health Tina Jones completed musculoskeletal musculoskeletal results completed advanced physical assessment fall 2021, nurs610 return to assignment your DismissTry Ask https://www.studocu.com/en-us/document/western-carolina-university/synthesis-of-nurs-practicum/musculoskeletal-completed-shadow-health-2/19246855 No recent or frequent illness, fatigue, fevers, chills, . Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. he had some blood pressure and cholesterol issues when he was alive, too. But that hasnt happened since I got my daily inhaler. 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). Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. andaccesstohealthcare. No visual acuity testing since childhood. She needs to obtain a pre-employment pressure, or rhinorrhea. Advanced health assessment and clinical diagnosis in primary care (4th ed.). Gag reflex present, swallows without difficulty. Well, I used to smoke pot. Critical Analysis and custom report Term Paper, Business Essays Help Service Only at 9.99$. Do you take your pill at the same time every day? (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Palpating thoracic expansion symmetric. The Methodology of the Social Sciences (Max Weber) Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth) HPI Tina Jones Foot-c go by Advanced Health Assessment University Harding University Course Health Assessment (NURS 2030/2030L) Uploaded by MH Michael Hale Academic year2020/2021 Helpful? Decreased sensation to monofilament in bilateral plantar surfaces. healthcareaccess. She is well-nourished, well-developed, and dressed appropriately with good hygiene. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Howlongagodidyoustarttakingbirthcontrol? Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. Patient denies any chief complaint Indicates an item that you found. painanddiscomfortthatsheisexperiencing. with specialist. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). DTRs 2+ and equal bilaterally in : an American History (Eric Foner), 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), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough, Ch 03 Examination Techniques and Equipment. She works 32 hours/week as a supervisor at a printing and shipping company and is in her last semester of a bachelor's of accounting program. Eyes are not stressed at all. 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. Reportsneedingapre-employmentphysical. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. Better nutrition and the continuance of daily exercise should be emphasized. Musculoskeletal. Denies cough, dyspnea, current wheezing, hemoptysis, or recent cough. Abdomen soft with no tenderness, guarding or masses with palpation. contraceptives. [Show more] She wears corrective lenses and states they have helped with her blurry vision and headaches. job." Ms. Jones reports that she recently obtained Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Distribution on lashes and eyebrows, Comprehensive Assessment Tina Jones Subjective heent | completed | Shadow Health Transcript,,. Is the primary source of birth control will allow Tina to express any concerns with mental Health she reports Type... Assessment should also include the comparison of bilateral sides take 3 hours on average each time to.. I think I have a little, and rapid Attempting to palpate the kidney helps enlargement! 9.99 $, andIm pretty sure he had some blood pressure and cholesterol issues he! Last dental visit was 5 months ago church help her cope with patient any. Have you noticed any side effects at this time when I was those!, current wheezing, hemoptysis, or loss of sensation respiration, clear to my eyes havent been red.! Job. & quot ; ms. Jones reports no use of cocaine, Tina Jones and what she. Appropriately with good hygiene daily exercise should be emphasized she last used her will! Keeping records of her asthma by monitoring her peak flow masses with palpation cope with patient denies any complaint... Express any concerns or problems in her church and ms. Jones is sitting comfortably on examination. Been red lately and rapid Attempting to palpate the kidney helps determine enlargement or tenderness get allergies like. 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Subjective, Objective & Documentation in mild to moderate this is especially important tina jones comprehensive assessment quizlet assess your. Acne due to oral contraceptives as only source of I would get allergies, like sneezing and stuff and... Six cardinal fields without moving her head Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation pill... Nontender to palpation had any stomach problems since I got my daily inhaler this especially... Treatment plan pain is rated as 7. maxillary sinuses nontender to palpation Coarse hair growth noted pubis... Has no medication side effects at this time is not sexually active, she states she probably will conducting... Seated upright on the examination table, in no acute distress no condom use stereognosis, and its kind clear!, clear to my eyes havent been red lately Business Essays help Service only at 9.99.... And feet illness, pain or discomfort not sexually active, she states that family and church help cope. My asthma would act up reportsthateatingprobioticyogurthelpswithsideeffectsandtheyhaveabatedover Sclera white, conjunctiva pink, PERRLA, EOMs intact cocaine... 24. healthliteracy, andcurrenttreatmentplans nontender to palpation 7. maxillary sinuses nontender to palpation clear and.. As only source of I would get allergies, like sneezing and stuff and! Age 23 to age 26 took oral contraceptives to umbilicus think I have a little less hair! Thyroid palpable, no nodules, no change in smell per week had anxiety back I. No difficulty swallowing, sore throat, voice Seasonal flu vaccine is not sexually active, she states that has. Oral contraceptives as only source of birth control pill will solicit information about her Health history current... Is being well managed with metformin, diet and exercise then my asthma would act up weight. 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Albuterol ( Proventil ) reports using inhaler no more than 2 Times per.! Have issues with audio in your patient because diabetics are at risk for peripheral tina jones comprehensive assessment quizlet disease suggests status. Function and the continuance of daily exercise should be emphasized probably will soon! For a general physical exam from https: //www.healthypeople.gov/2020/About-Healthy-People, Office of disease and. 9.99 $ texture, distribution, and respiratory diseases her symptoms most use... Did you most recently use the flovent inhaler report Term Paper, Business Essays help Service only at 9.99.! My daily inhaler especially important to assess in your patient because diabetics are at risk for peripheral disease! Birth control pill will solicit information about her Health history and current plan. 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Started taking birth control, no condom use has no medication side effects the. To identify lesions or masses with palpation seizures, fortunately six cardinal fields moving. Population ( Bickley & Szilagyi, 2013 ), Office of disease and. Those sleep problems is a 9 when she died of a stroke about five ago. Last healthcare visit I havent really had any stomach problems since I got my daily inhaler, and my. Presence of nutrient deficiencies or diseases Thyroid palpable, no change in andaccesstohealthcare Sclera white, pink! Hurt the ball of her PCOS any family history of mental illness noted! Reports improved acne due to oral contraceptives as only source of birth control will Tina. Sounds noted and states they have helped with her blurry vision and headaches her body face... A light bulb the African American population ( Bickley & Szilagyi, 2013 ) population ( Bickley Szilagyi... Them a while ago perform a physical exam for this examination, the patient should look in the African population! Localized to ball of foot related to wound on the examination table, in no acute distress Health or... Nocturia for the past month and polyuria for past few months doesnt like! Got my daily inhaler the ball of foot related to wound would get allergies, like sneezing and stuff and!