Case - Tina jones shadow health all modules cases instructor keys nur . . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Her eyes gets red and itchy when she is around her Comprehensive Assessment Tina Jones Shadow Health Transcript. These are study questions in preparing for my exam. . Comprehensive Assessment Tina Jones Shadow Health Transcript. he had some blood pressure and cholesterol issues when he was alive, too. What medical problems did your father have? today. Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, 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. Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Carotid pulses 2+, no thrills. No! 2. In the Comprehensive Assessment, you earn points by performing the physical assessments. Reports no eye pain, She reports a few moles but no other hair or nail changes. Example Question: Do you have a rescue inhaler? Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection. She does not note any specic aggravating symptoms, but states, that her throat pain seems to be worse in the morning. Topic 4 Assignment, Shadow Health: Comprehensive Assessment - Documentation, Objective Data Collection, Planned My Exam, Subjective Data Collection. To obtain the documentation, go in the Health History in Shadow Health, select the 'documentation' tab. She has a history of asthma, last hospitalization was, age 16 for asthma, last chest XR was age 16. -religious preference Have you been taking medication for your diabetes? What is your relationship like with your family? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. Example Question: How often do you use your daily inhaler? I came in because Im required to have a recent physical exam for the health insurance at my new job. Comprehensive Assessment Tina Jones Shadow Health Transcript. Respiratory: Chest is symmetrical with respirations. 4. No, Im actually feeling really good these days. . She denies cough and recent illness. Decreased sensation to monofilament in bilateral plantar surfaces. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. What age were you diagnosed with asthma? NUR 602. Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. that her throat pain seems to be worse in the morning. Reports no general mouth problems, changes in episode. Hes a little big, maybe. single family home, but will move into own apartment in one month. I think were pretty special, the way we all get along. Never married, no children. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. Well-groomed, easily engages in conversation and is cooperative. Example Question: Why did you decide to start taking birth control? She rates her, little. Comprehensive Assessment Tina Jones Shadow Health Transcript. movements intact bilaterally. I dont have anything specific going on today. of a strong, thorough interview with this patient. My discharge is normal, I think. Speech is fluent, words are clear. Lab Pass (/assignment_attempts/9017767/lab_pass.pdf), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Civilization and its Discontents (Sigmund Freud), Give Me Liberty! In this guide, we will outline the steps involved in completing a SHCAP, as well as provide 50 Shadow Health Comprehensive Assessment examples that you can use to practice and improve your skills. Currently, the only assignment that does not include this method of scoring the Objective Data Collection is the Comprehensive Assessment assignment. Asking Tina if she takes vitamins will indicate her current treatment plan. Does he have any medical issue? She is the primary source of the history. Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. Blood glucose 199 Pro Tip: Healthy kidneys are not usually palpable. alcohol, and illicit drugs. e.g. -She is the primary source of the history. Head: Denies history of trauma. Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph of blurry vision after reading for extended periods. Advanced Clinical Practice for Nurse Educators (Adv. Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. 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Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. Example Question: When do you check your blood glucose? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. No lymphadenopathy. I came in because Im required to have a recent physical exam for the health insurance at my new job. Asthma diagnosed at age 2 1/2. Finding: Left fundus with sharp disc margins, no hemorrhages Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right upper quadrant: no masses, guarding or rebound. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. Indicates an item that you found. Available:Indicates an item that is available to be found. Since then Ive just washed my face, I havent used anything special. Some students may need longer. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. She has a history of hypertension which normalized when she initiated diet and exercise. Tests of cerebellar function normal. Eyes are placed bilaterally on the head with equal hair Distribution on lashes and eyebrows. Reports no change in sense of smell, exposures to sick individuals. was 5 months ago. Spring Arbor University NUR 602. Example Question: Are you taking any form of birth control? She started me on birth control, and it seems to be helping things. Comprehensive Assessment Tina Jones Shadow Health Transcript. 28 terms. Identifying Data & Reliability Objective. Today she denies any acute concerns. Mariah_Slatunas. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Paper (Clarified to if I have ear drainage. Expert Help. age 16 for asthma, last chest XR was age 16. Mental Health History Her headache lasts for a few of hours and, tylenol helps with her headache. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Comprehensive Assessment Tina Jones Shadow Health Transcript. 11 terms. Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with Verified answer. Finding: Followed up about diabetes medication, Pro Tip: Follow up questions about Tinas medication history will help you to understand her treatment plan and recent health history. The following actions reveal the objective data of the patients case. PERRLA bilaterally. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. . Course Hero is not sponsored or endorsed by any college or university. brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. high cholesterol Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol Neck: No cervical, infraclavicular lymphadenopathy. Susie is a 40 year old female with Type 2 Diabetes.She reports that over the last several days, she has been having some hypoglycemic episodes and feels it is related to medication.Her medication. I had two doctors appointments earlier this year. 3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health 2/6 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 daily Takes birth control pill at the same time every day Reports no skipped days . Exam (elaborations) - Nr 509 shadow health comprehensive assessment | objective data collection 45. -28-year-old Example Question: How are you managing your diabetes? Temp 99. . OBJECTIVE. If your instructor provides individual feedback on this assignment, it will appear here. I start in two weeksIm really excited! She does not note any specific aggravating symptoms, but states Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. I guess I had anxiety back when I was having those sleep problems. Finding:Confirmed reason for visit; Finding:Reports needing a pre-employment physical Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)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.Example . Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. alcohol, and illicit drugs. The estimated average time to complete this assignment each time is 3 hours. cats. Shadow Health 2012 - 2021 . Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. How does interviewing a heathy patient differ from interviewing a patient with a known health condition? Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. States recent 10 pound weight loss due She denies changes in her hearing, throat pain as 4/10 and her throat itchiness as 5/10. She is well-nourished, well-developed, and dressed appropriately with good hygiene. . Structuring the Assessment Use a 'holistic' health assessment form to organise the data. Exam (elaborations) - Tina jones abdominal objective data shadow health/tina jones abdominal objective data. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Scalp with no The daily inhaler is Flovent, and the rescue inhaler is Proventil. Participates in mild to moderate exercise four to five times per week consisting of walking, Tina Jones Shadow Health Comprehensive Assessment. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Example Question: How long ago did you start taking birth control? 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). She needs to obtain a pre-employment physical prior to initiating employment. An individualized plan of care taking into . Right eye ", Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the Pro Tip: Palpating the frontal sinuses checks for sinusitis. She enjoys spending time with friends, reading, Case - Nr 509 week 1 shadow health history assignment objective data collection 25. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. Asking Tina if she still has her inhaler will indicate her treatment plan and. ), Does your bother have health issues? Asking Tina if she takes herbal products will indicate her current treatment plan. Finding: Head is normocephalic, atraumatic. Medications Comprehensive Assessment Tina Jones Shadow Health Transcript, Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use: this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago). Finding: Inspected eyebrows and orbital area Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Has your menstrual cycle improved since taking Yaz? year), Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Comprehensive Assessment Tina Jones Shadow Health Transcript, 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, Neurological Comprehensive Assessment Tina Jones Shadow Health Transcript, Denies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Comprehensive Assessment Tina Jones Shadow Health Transcript, Normal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces, Skin, Hair & Nails Comprehensive Assessment Tina Jones Shadow Health Transcript, Reports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes, Scattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges, If your paper matters, we own all the good words. 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