A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Retrieved from http://www.uptodate.com. Study Guides (339) prescribed oral contraceptives at that visit, which she She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. 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. I havent been having any gas lately. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, She acts as the primary source of the data offered for the assessment. (Clarified to Does your brother have medical problems?. Tina jones comprehensive - Comprehensive Assessment Results | Turned In Health Assessment for the - Studocu Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. I will be conducting an interview and a physical exam. Throat and Neck: Denies sore throat, dysphagia, and changes to voice quality. Tips and ExampleQuestions. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. tightness. employment physical. Now that Im on the pill Im getting my period every month. No current complaints or recent illness. . She has a history of hypertension which normalized when she initiated diet and exercise. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. As you continue, thestudycorp.com has the top and most qualified writers to help with any of your assignments. reading, attending Bible study, volunteering in her 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 no general mouth Has new male relationship, sexual contact not initiated. sinus pressure. Left disc round with sharp margins. I havent smoked pot since I was twenty or twenty-one. Howoftendoyouuseyourrescueinhaler? Have you been taking medication for your diabetes? Have you missed any days of your birth control pill? Just coming in and talking to someone here about it helped a little because I felt like I was doing something. How long ago did you start taking birth control? spirometry: FVC 3 L, FEV1/FVC ratio 80%. Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). andaccesstohealthcare. She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. She came into the clinic for a physical exam. Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. he had some blood pressure and cholesterol issues when he was alive, too. Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand ), No, I dont think so. Strength 5/5 bilateral upper and lower extremities. Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. Im going to be an Accounting Clerk at this really nice accounting firm. problemscanelicitaresponseaboutrecenttroubles. She reports a few moles but no other hair or nail changes. Denies changes in hearing or ear pain. Musculoskeletal. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. the history. Respiratory. She needs to obtain a pre-employment Comprehensive Physical Assessment of Tina Jones in Shadow Health Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. She offers information freely and without . Herzing University (39) The following actions reveal the objective data of the patients case. Dark discoloration of skin on neck. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Denies fatigue, fever, chills, or night no other hair or nail changes. . Ms. Jones offers information freely and without contradiction. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious . Reports 10 pound weight loss in the last 4 months Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months. Headaches are described as a "tight and throbbing feeling behind the eyes." Self-care deficit theory. I am glad you are having your period every month. Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes, Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol, Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol, Paternal grandmother: still living, age 82, hypertension, Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes. Can I confirm that you are here for a physical? and facial and body hair has improved. Tactile fremitus present. Journal for Specialists in Pediatric Nursing. bruising. chief complaint This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Tina jones comprehensive Destroying Altering Tables and Views EDUC 327 The Teacher and The School Curriculum Document Anthropological Perspective Chapter 01 - Fundamentals of Nursing 9th edition - test bank Active Learning Template: Basic Concept Examen Psicometrico PNP 2 Newest Theology - yea Leadership class , week 3 executive summary Skin, hair, and nails. (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. 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. Doyoutakeyourpillatthesametimeeveryday? Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. That doesnt sound like it would be good. Case - Shadow health tina jones musculoskeletal objective data 5. ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand Her last healthcare visit This strong support system helps to ease her stress and anxiety by providing a sounding board. Reports no blanching in fingertips when exposed to cold. Pro Tip: Palpating the frontal sinuses checks for sinusitis. The following details are facts of the patients case. 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). Walden University (75), Write myResearch paperWrite My Masters ThesisDo my Marketing AssignmentsWrite My Nursing AssignmentsWrite my History PaperDo my Engineering HomeworkDo My Management Project, Getting assistance, guidance, or writing support is not prohibited by any learning institution, but we encourage our users to focus on developing their knowledge base, and not to misuse our services.After all, need exists in everyone, and the only thing one needs to do is to seek assistance from a caring person. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. ProTip:Initiallyestablishingachiefcomplaintallowsthepatienttoexpresstheirreason Menses irregular. But that hasnt happened since I got my daily inhaler. In A. O. Ofori (Ed. Mild ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich 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. No tobacco. No exercise. No, Im actually feeling really good these days. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. We Can do an Original Paper for you! 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. indicatehertreatmentplanandthedegreetowhichsheisfollowingit. Upper and lower extremities symmetric without lesions or swelling. Does not wear corrective lenses. Vision 20/20 bilateral with corrective lenses. andaccesstohealthcare. Exam 1 Study Guide - Summary Advanced Health Assessment; Chapter 10- breast - Summary Bates' Guide to Physical Examination and History Taking, 11th Ed + Bates' Visual Guide to Physical Assessment; EXAM 1 HA - Study Guide - Exam 1; Heent soap example - Soap note; Week4 DCE Tina Jones Comprehensive; Week 3 SOAP note - SOAP note week 3 tina jones She tried ibuprofen, but it didn't work well. Patient reports no General mouth Mucous membranes pink and moist, tonsils 2+ bilaterally. Patient denies any concerns with mental health. St. Louis, MO: Elsevier Mosby. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, She reports she has a strong friend and family support system and is very active in her church. Upon inspection, abdomen protuberant and symmetric. Since then Ive just washed my face, I havent used anything special. At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive Yaz. Reports improved acne due to oral contraceptives. Up-to-date, tetanus booster within the last year. Diabetes requires self-management behaviors for life. 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Experts selected these examinations as essential components of objective data collection for this patient. establishesatimelineofhercurrenttreatmentplan. (2018). Liver span 7 cm MCL, palpable 1 cm below right costal margin. Thefollowingdetailsare Skin on neck has stopped darkening and facial and body hair has improved. was 4 months ago, when she received her annual Patient Her skin is pink, warm, with no tenting. Ibuprofen: 600 mg as needed for menstrual cramps. treatmentplans. AskingTinahowlongagoshestartedtakingbirthcontrol Scattered pustules on face and facial hair on upper Fingernails pink without clubbing, ridges or abnormalities. Neurological. Management Assignments (7) allergens she states that she has runny nose, itchy Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. maintains eye contact throughout the interview. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. Can Someone Take My Online Class? Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. Denies history of recurrent urinary tract infections and kidney stones. Although Ms. Jones is not sexually active, she states she probably will be soon. Tonsils 2+ bilaterally. Student's Essays (12) PERRLA. I guess I had anxiety back when I was having those sleep problems. nursing care plans (20) The assessment should also include the comparison of bilateral sides. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. Her last healthcare visit this strong support system and is very active in her church few moles but no hair. 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