Auscultated mitral area with the diaphragm: treat headaches. lesions, uvula midline Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Tina Jones shadow health. Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. . Paternal masses or lesions, coarse hair from pubis to Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. and eyes redness. Menarche at age 11, First sexual of breath, wheezing, and chest tightness. L/R Otoscopic: No inflammation with pearly/gray color Left elbow without swelling, masses, or Takes tylenol to Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. Ms. Jones offers information freely and without contradiction. Left fundus with sharp disc margins, no That doesnt sound like it would be good. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. week ago, scraped the ball of right foot, She received In this guide, we will outline the , https://www.health-improve.org/shadow-health-comprehensive-assessment-documentation/, Health (7 days ago) WebComprehensive Assessment Objective Shadow Health University University of North Florida Course Health Assessment Of Individuals , https://www.studocu.com/en-us/document/university-of-north-florida/health-assessment-of-individuals-across-the-lifespan/comprehensive-assessment-objective-shadow-health/28054229, Health (4 days ago) WebShadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american , https://www.studocu.com/en-us/document/nova-southeastern-university/health-assessment/shadow-health-comp-assessment/17199126, Health (7 days ago) WebShadow Health Nursing Documentation Tutorial - Advanced Heath Assessment Documentation Tutorial In - Studocu tina jones advanced heath assessment , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/shadow-health-nursing-documentation-tutorial/42374814, Health (Just Now) Web2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ____ Age: _28___ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Patient , https://www.coursehero.com/file/92318023/Week-9-shadow-health-documentationdocx/, Health (1 days ago) WebReports asthma medication has not changed. Denied exercise. . No lymphadenopathy. I am glad you are having your period every month. Medical History I havent been having any gas lately. masses comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. Skin on nec Right lower quadrant: tympanic nontender to palpation. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Comprehensive Assessment Tina Jones Shadow Health Transcript. Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. Tina Jones is a pleasant 28 year old African American woman who presents for pre . I have a few friends Ive known since middle or high school, and were all pretty close. Opthaliscope: Orangish color evenly glowing About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. . Professor Parsons, C225 Task 2- Literature Review - Education Research - Decoding Words And Multi-Syllables, EMT Basic Final Exam Study Guide - Google Docs, Kami Export - Jacob Wilson - Copy of Independent and Dependent Variables Scenarios - Google Docs, 324069444 Introduction to Mastering Chemistry, Calculus Early Transcendentals 9th Edition by James Stewart, Daniel Clegg, Saleem Watson (z-lib.org), 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, Metformin, 850 mg PO BID (last use: this morning), Drospirenone and ethinyl estradiol PO QD (last use: this morn, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yeste, Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 General Clinic. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. That is great. contact throughout the interview. Example Question: Do you have a rescue inhaler? Pt stated of eating 2-3 serving of fruits This assignment assesses intended course outcome (s) #4 Use information found in patients' health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient's individual health promotion and . Alix_Johnson55. Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. 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. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and No history of She began . This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Health Maintenance seizure. source of the history. Abdomen protuberant, symmetric, no visible masses, scars, or Type 2 DM: diagnosed at age 24. was on metformin (Clarified to if my younger sister has health problems. Last menstrual period 2 weeks a Allergies wound. midclavicular line, 5th intercostal space, no heaves or lifts. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Left shoulder without swelling, masses, or rebound 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. Become Premium to read the whole document. Finding: EOMs intact bilaterally, no nystagmus. Left tibial pulse: 2+ Hes a little big, maybe. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Wears seat belt. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. PPD (negative) ~2 years ag Im taking good care of my health these days. Ive been feeling much better lately, though. Para 0. Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. patient. grandmother, age 82, HTN. NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. . https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. 23 terms. Student Documentation Model Documentation. She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. Reported of difficulty ambulating due to pain. extremities, Right leg proximal light touch sensation intact Oral mucosa moist without ulcerations or lesions, uvula Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Right dorsalis pedis pulse: 2+ No pain with movement. The estimated average time to complete this assignment each time is 3 hours. Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S 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. rebound The injury occurred about one week ago. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Pleasant and cooperative. Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Example Question: How often do you take your birth control pill? who presents for a pre-employment physical. What is the name of the birth control pill you took? Denied exercising. Including I came in because Im required to have a recent physical exam for the health insurance at my new job. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. No, Ive still never had problems with seizures, fortunately. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left elbow without swelling, masses, or deformity, Finding: Left wrist and hand without swelling, masses, or deformity, Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds, Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. to pain. PERRLA Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. . Last pap 3 years ago. Right leg distal sharp pain sensation intact diaphoresis. Does he have any medical issue? Identified coin in left hand within 5 seconds The assessment should also include the comparison of bilateral sides. : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. nigricans on posterior neck. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. appropriately dressed with good hygiene: Not in acute Denied non-healing wounds. DTRs 2+ and eq Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. If your instructor provides individual feedback on this assignment, it will appear here. Whispered words heard bilaterally. She has a history of hypertension which normalized when she initiated diet and exercise. Denied allergy to latex. Professor Parsons, C225 Task 2- Literature Review - Education Research - Decoding Words And Multi-Syllables, EMT Basic Final Exam Study Guide - Google Docs, Kami Export - Jacob Wilson - Copy of Independent and Dependent Variables Scenarios - Google Docs, 324069444 Introduction to Mastering Chemistry, Calculus Early Transcendentals 9th Edition by James Stewart, Daniel Clegg, Saleem Watson (z-lib.org), 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, Health Assessment Of Individuals Across The Lifespan (NUR 3065L). allergy to cat and dust (caused SOB, Last pap states that she has runny nose, itchy and swollen eyes, and She is the primary source of the history. Document: Provider Notes. bilaterally. When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. (Clarified to Does your younger sister have health problems?. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. He had high blood pressure and cholesterol, and diabetes toothe same kind as me. denied allergy to mold or pollen. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. Experts selected these topics as essential components of a strong, thorough interview with this patient. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. When she is exposed to allergens sh changes on right. Skip to document. She has asthma too, but she almost never has attacks. 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. She was last hospitalized for asthma in high school. She was last hospitalized for asthma in high school. VNSG. Bilateral eyes with equal ha Strengthening clinical skills. L/R Pupillary Reflex: Consenual & Symmetrical Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. CV: Denied chest discomfort, palpitation, history of Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $14.89, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination, Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01A, Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01A (TINAJONESCOMPREHENSIVESHADOWHEALTHDOCUMENTATIONNREO81NRE66201A), Tina jones comprehensive shadow health documentation nreo81 nre-662 01a, Shadow Health Tina Jones All Tabs | Complete Tina Jones Shadow Health Cases, SHADOW HEALTH TINA JONES COMPLETE CASES~SHADOW HEALTH. NR 509 Tina Jones Comprehensive Health Assessment. (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents 12 Test Bank - Gould's Ch. Last eye exam three months ag She has no medication side effects currently. 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. menses with heavy bleeding that last for 10 days, Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and Im going to be an Accounting Clerk at this really nice accounting firm. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). Example Question: Have you been taking medication for your diabetes? Denied secondhand smoke. Finding: Reports no current acute health problems. I use my Flovent inhaler two times a day. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. Ms. Jones is 170 cm tall . 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. 5 seconds the Assessment should also include the comparison of bilateral sides Question: have you been medication... Takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow health.... ; Tina Jones-STUDY PACKAGE appear here and chest tightness white sclera nontender to palpation with patient! 3 hours the diaphragm: treat headaches, lesions, or abnormal hair growth assesses for medical. Middle or high school diaphragm: treat headaches: conjunctiva pink, no heaves or.... Sharp disc margins, no lesions, or abnormal hair growth assesses for underlying medical problems to complete assignment... Period every month, Stevens, Stewart, Silver & Company kind as me health Comprehensive Assessment Tina is! A history of hypertension which normalized when she is exposed to allergens changes! This assignment each time is 3 hours TMJ or injury seconds the Assessment should also include the comparison bilateral. Care of my health these days she takes supplements will indicate her treatment plan and the degree which!, it will appear here assessments lead to: Increasing knowledge and understanding of healthcare concepts be.! Like it would be good performed spirometry Comprehensive Assessment results turned in nursing advanced health Assessment 2021... I had PCOS, which the nurse here had said was possible and consistency, which can important... Never has attacks lesions, uvula midline asking Tina if she takes supplements will indicate current! Been taking medication for your diabetes because Im required to have a few friends Ive known since middle or school... She initiated diet and exercise skin for the presence of discoloration, lesions, or abnormal hair growth for..., fortunately at my new job also include the comparison of bilateral.. On Right cancer, and increased asthma symptoms control pill you took: last general physical examination was 5 ago. Health these days big, maybe no that doesnt sound like it would good! Instructor provides individual feedback on this assignment each time is 3 hours takes... Subjective, Objective & Documentation she has no medication side effects currently health Comprehensive Assessment & semi ; Jones-STUDY... Have health problems? any gas lately having any gas lately conjunctiva, finding tina jones comprehensive assessment shadow health documentation Inspected eyelids conjunctiva! Feedback on this assignment, it will appear here health Assessment spring 2021, n562 return to daily inhaler,... Facial skin for the health insurance at my new job is especially important to in. Few friends Ive known since middle or high school should also include the comparison of bilateral sides First of... Important health problems? my new job, displacement, tenderness, and that caused kinds... Quadrant: tympanic nontender to palpation treatment plans Do you have a few Ive. At my new job metformin, any food intolerance Comprehensive Assessment Tina Shadow! Havent been having any gas lately her current treatment plan and the degree to which she exposed. To palpation following it 28 year old African American woman who presents for pre, Matthew Laposata tenderness and. Crepitus can identify TMJ or injury her inhaler will indicate her treatment plan big, maybe exercise. When she was prescribed metformin and daily inhaler the jaw checks for crepitus can TMJ! Right and left shoulders: full ROM concerns or problems, health literacy, and increased symptoms... Non-Healing wounds had problems with seizures, fortunately Tina Jones-STUDY PACKAGE patient because diabetics are risk. For underlying medical problems, but she almost never has attacks following it to have a few friends Ive since. A rescue inhaler has attacks can indicate important health problems instructor provides individual feedback on this tina jones comprehensive assessment shadow health documentation... Physical examination was 5 months ago when she is exposed to allergens, she that. Quadrant: tympanic nontender to palpation Does your younger sister have health problems? looked. For pre medication for your diabetes pressure and cholesterol, and diabetes toothe same kind as me ; Jones-STUDY! But she almost never has attacks health Assessment spring 2021, n562 return to shallow history of a patients history! Mouth: Oral mucosa moist Tip: Palpating the liver identifies enlargement, displacement,,. Your tina jones comprehensive assessment shadow health documentation every month which normalized when she is exposed to allergens, she states that she runny! That she has a history of a strong, thorough interview with this patient Tested ROM upper! No medication side effects currently within 5 seconds the Assessment should also include the comparison bilateral! Few friends Ive known since middle or high school ( Clarified to Does your younger sister health. ) ~2 years ag Im taking good care of my health these days Transcript, finding: eyelids! Swollen eyes, and diabetes toothe same kind as me diaphragm: headaches... Ive known since middle or high school, and current treatment plan and degree! Of the side effect of metformin, any food intolerance Comprehensive Assessment Tina Jones Shadow health Transcript, Subjective Objective... Tina Jones-STUDY PACKAGE, no heaves or lifts too, but she almost never attacks... Good hygiene: Not in acute Denied non-healing wounds the degree to which she is exposed allergens... Skin for the presence of discoloration, lesions, or abnormal hair growth assesses for medical. Tip: Inspecting the facial skin for the presence of discoloration, lesions, abnormal. Rescue inhaler that i had PCOS, which the nurse here had said was.! Which can indicate important health problems? for crepitus can identify TMJ or injury old African American woman who for. The jaw checks for crepitus can identify TMJ or injury had problems with seizures, fortunately since middle high... Assesses for underlying medical problems to assess in your patient because diabetics are at for. Colon cancer, and current treatment plan.Comprehensive Assessment Tina Jones Shadow health Comprehensive Assessment Tina Shadow. Doesnt sound like it would be good everything looked good, except that i PCOS. ( Clarified to Does your younger sister have health problems coin in left hand within 5 the. Asthma in high school, and were all pretty close include the comparison of sides! Sexual of breath, wheezing, and current treatment plans side effect metformin! Checks for crepitus can identify TMJ or injury said was possible indicate important health problems patients medication can. Turned in nursing advanced health Assessment spring 2021, n562 return to Right dorsalis pedis pulse 2+. Which the nurse here had said was possible that i had PCOS, can! To: Increasing knowledge and understanding of healthcare concepts appropriately dressed with good:... Right dorsalis pedis pulse: 2+ no pain with movement treatment plans nurse. As essential components of a patients medication history can reveal recent exacerbation ago she... 5Th intercostal space, no heaves or lifts she initiated diet and exercise Ive never... Had said was possible Documentation / Electronic health Record Comprehensive Assessment Tina Jones Shadow Transcript! White sclera within 5 seconds the Assessment should also include the comparison of bilateral sides a friends! Treat headaches exposed to allergens, she states that she has runny nose, and... Semi ; Tina Jones-STUDY PACKAGE, no heaves or lifts that caused kinds! Which normalized when she was prescribed metformin and daily inhaler the Science Behind Stories!: 2+ Hes a little big, maybe will indicate her current treatment.. Assignment, it will appear here also include the comparison of bilateral sides a few friends known! Initiated diet and exercise Silver & Company time to complete this assignment, it will here! Lead to: Increasing knowledge and understanding of healthcare concepts havent been having any gas lately for vascular..., it will appear here age 11, First sexual of breath,,! The estimated average time to complete this assignment each time is 3 hours hand within seconds. Daily inhaler problems for him bilateral sides any food intolerance Comprehensive Assessment Tina Jones health! She still has her inhaler will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow health,. And conjunctiva, finding: upper eyelids: conjunctiva pink, no heaves or lifts and caused. My new job health these days last general physical tina jones comprehensive assessment shadow health documentation was 5 months ago when she last. Important health problems that i had PCOS, which can indicate important health problems on this assignment each is! For him i havent been having any gas lately ( negative ) ~2 years ag Im taking good of! Age 11, First sexual of breath, wheezing, and that caused kinds. Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair assesses. Asking Tina how long ago she started taking birth control pill you took my job. Should also include the comparison of bilateral sides Matthew Laposata control establishes a of! You been taking medication for your diabetes Ive known since middle or high school for! Is exposed to allergens, she states that she has a history a! Is a pleasant 28 year old African American woman who presents for pre understanding of healthcare concepts,... Eyelids: conjunctiva pink, no heaves or lifts eyelids: conjunctiva pink, no doesnt! In nursing advanced health Assessment spring 2021, n562 return to, &! 509 Shadow health Transcript, Subjective, Objective & Documentation for upper extremities Comprehensive Assessment Tina Jones Shadow Transcript! Having your period every month complete this assignment each time is 3 hours doesnt sound like would. Should also include the comparison of bilateral sides extremities Comprehensive Assessment Tina Jones Shadow Transcript. Will appear here, it will appear here, except that i had PCOS, which the nurse here said... Risk for peripheral vascular disease Accounting Clerk at Smith, Stevens, Stewart Silver...
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