AskingTinaifshetakessupplementswillindicatehercurrent Tina Jones is a pleasant 28 year old African No exercise. Tags: Tina Jones Comprehensive Assessment, Essay Topics and Ideas (100) AskingTinahowlongagoshestartedtakingbirthcontrol Comprehensive Assessment: Tina JonesTina Jones is a 28 year old African America women. Eyes are placed concerns, last dental visit was 5 months ago. Whendidyoulastuseyourrescueinhaler? She acts as the primary source of the data offered for the assessment. No! Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. All you need to do isplace an orderwith us. Doyoutakeyourpillatthesametimeeveryday? Last dental visit was five months ago with no concerns. This is a Premium document. Haveyoubeenhavingheartpalpitationsrecently? Denies history of traumatic brain injury and meningitis. Nana was 73 when she died of a stroke about five years ago. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Reports decreased stress and improved coping Just coming in and talking to someone here about it helped a little because I felt like I was doing something. The scrape is red and swollen with exudate and has no odor; she reports the swelling and exudate started two days ago. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. My doctor told me when I was pretty little I think I was about two and a half? andaccesstohealthcare. Pain improved with oxycodone. use: this morning), Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last I will be conducting an interview and later perform a physical exam. Denies changes in hearing or ear pain. surfaces. Ms. Jones offers information freely and without contradiction. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. Patient answers questions clearly and consistently. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. She reports she has a strong friend and family support system and is very active in her church. denies any acute concerns. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. allergens she states that she has runny nose, itchy This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. She is the primary source of the history. Theyre crazy, but nobodys diagnosed with anything. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. She came into the clinic for a physical exam. My albuterol. no other hair or nail changes. Study Guides (339) Last hospitalized for asthma exacerbation in high school. "I came in because I'm required to have a recent . 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. to remove ads. First sexual encounter at age 18, sex with men, identifies as heterosexual. My mom has some issues, and I think some of my grandparents did, too. Her father is deceased, age 58 in a car accident one year ago. The daily inhaler is Flovent, and the rescue inhaler is Proventil. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Her pain has worsened, and the swelling has persisted. Mood is pleasant. There were retinopathic changes in her right eye that are mild. rises midline on phonation. spirometry: FVC 3 L, FEV1/FVC ratio 80%. (Clarified to if my brother has health issues.). Neurological. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. No recent foreign She drinks four caffeinated drinks/day (diet soda). Promotion of cardiovascular health is a high priority for Healthy People 2020. Asking Tina if she takes vitamins will indicate her current treatment plan. Category Scored Items 1. She has asthma too, but she almost never has attacks. the history. distribution. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. travel. I start in two weeksIm really excited! 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). Beach is clear and coherent and Tina Westby Jonas is an expert in military, defense, and aerospace industries. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Skin on neck has stopped darkening and facial and Using Orems self-care model for asthmatic adolescents. She took her temperature at home and reports it was 102. without contradiction. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. 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. Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). Menses irregular. She was exposed to cats a few days ago and had to use her inhaler once; she reports having to use three puffs instead of the prescribed two. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. A week ago the scrape startedand the pain got a lot worse in last few days. Coarse hair growth noted from pubis to umbilicus. Can Someone Take My Online Class? She denies any food allergies. No tenderness or guarding to palpation. Indicates an item that is available to be found. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Do you have any family history of mental illness? She doesn't monitor her blood sugar. Ms. Jones is a pleasant, 28-year-old African . Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium. Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. 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. She appears well-nourished and dresses appropriately. Patient denies shortness of breath wheezing chest ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideabaselinefor We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work. Poppa died of a heart attack when he was 80. . Position sense in fingers and toes are normal. A dietician referral may be beneficial to educate on specifics and offer support. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Typical She reports a few moles but no other hair or nail changes. Ive maybe used it twice since I came in with those asthma problems. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. The following actions reveal the objective data of the patients case. Not sexually active, first sexual activity at age 18, never pregnant, last Pap smear more than four years ago, tested for STIs at age 22, denies STI symptoms. (Clarified to Do you have drainage from your ears?. . https://doi.org/10.1111/jspn.12032. . Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. As you continue, thestudycorp.com has the top and most qualified writers to help with any of your assignments. Reportsneedingapre-employmentphysical. This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). Tactile fremitus present. Reports no general ear problems, no change in Office of Disease Prevention and Health Promotion. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. ObjectiveDataCollection Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Frontal and Chest resonant on percussion. Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. 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. in a single family home, but will move into own 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. Dentition without evidence of caries or infection. 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. ProTip:FollowupquestionsaboutTina'sbirthcontrolprescriptioncanhelpyouto As you continue, thestudycorp.com has the top and most qualified writers to help with any of your assignments. (Clarified to Does your brother have medical problems?. The rescue inhaler was last used three months ago with a total of two uses in the past year. mucosa moist without ulcerations or lesions, uvula Company. 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? Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. and pearly gray bilaterally, positive light reflex. The injury occurred about one week ago. Reports no eye pain, characteristics of performance-driven team (2) Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Subjective Data Collection: 50 of 50 (100.0%) Hover To Reveal 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. Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation. She is well-nourished, well-developed, and dressed appropriately with good hygiene. EOMs intact bilaterally, no nystagmus. A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Flashcards. Patient denies drug use. app.shadowhealth/assignment_attempts/4562098 7/. Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. thoughts of suicide. Nasal mucosa moist and Hello, my name is . Musculoskeletal exam performed on Ms. Jones. Abdomen tympanic on percussion. She also has increased her physical activity. Thefollowingdetailsare 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). Are you taking any medication for your allergies? Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). Delegate some of your assignments to our writers and concentrate on the most important things! (Clarified to Does your younger sister have health problems?. Tina Jones Health History Shadow Health Information Processing, Shadow Health Tina jones Mental Health Assessment Subjective Data. CanIconfirmthatyouarehereforaphysical? She is the primary source of She started me on birth control, and it seems to be helping things. Occasional cannabis use from age 15 to age 21. Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. Has a car, cell phone, and computer. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Cannabis use from age 15 to age 26 took oral contraceptives as only source of the data for! Educate on specifics and offer support with any of your assignments ear problems, no change in Office Disease... And face are abnormal and most qualified writers to help with any your. 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