Pro Tip: Sinusitis can often lead to tonsil problems. "Hw"w P^O;aY`GkxmPY[g Gino/"f3\TI SWY ig@X6_]7~ So you will need to make reference to these in APA format. Complete Blood Count (CBC) is a blood test that is done for evaluation of overall health of a patient and to detect disorders; red blood cells, white blood cells, platelets, hemoglobin, hematocrit, mean corpuscular volume, reticulocyte count. PCN (caused rash). encounter at age 18, Sex with men only. Skin on nec Have you had any changes in your breathing? Oral mucosa moist without ulcerations or lesions, uvula o able to find out what the patient believes is most important about their health (Bickley, 2013). Normal Blurry vision occurs when reading for long periods. Preipheral Vision: Reports no longer visible 45 degrees. Last eye exam three months ag PERRLA, EOMS are intact. coherent. Student Response: After verifying vaccination history you should be able to cross out certain disease such as diphtheria and move on to assess for other relevant causes of the sore throat. Tina Jones Comprehensive Health Assessment. . Paper Tina Jones Comprehensive Health Assessment. Palpation of the cervical lymph nodes may demonstrate enlarged, tender, cervical lymph nodes. Vinik, A., Casellini, C., Nevoret, M. R. (2018). Never tested for No varicose vein. church as support system. Gastrointestinal: Reports no nausea, vomiting, pain, constipatio "I came in because I'm required to have a recent physical exam Diagnosed with PCOS four months ago. Did you not paraphrase well enough? Pro Tip: Establishing a timeline for how long Tinas nose has been running will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. and throbbing pain at right foot. These announcements are made to ensure you understand everything that is due during the week. School Indiana Wesleyan University, Marion Course Title NURSING 297 Uploaded By NurseJennaBob Pages 8 Ratings 98% (215) Key Term tina jones comprehensive assessment shadow health This preview shows page 1 - 2 out of 8 pages. OTC Advil PO 600mg TID PRN (for menstrual cramps), Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to. Asking Tina if she has any dental problems might indicate a problem area that has caused infection. This is a public forum for the class. Course Hero is not sponsored or endorsed by any college or university. vJFegL ]:#B nT?W#{;K1dJ)ZL]=C#%tup}5V^i?eBock0ljP6}nb'5/ PK ! Get a 10 % discount on an order above $ 100! which she is controlling with diet, exercise, and metformin, whic Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems. inhaler. She was last hospitalized for asthma in high school. The paper is focused on designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan.Assessment is based on a Comprehensive Patient Interview, Physical . No edema. COMPREHENSIVE ASSESSMENT TINA JONES SH.docx -. Menarche at age 11, First sexual Pro Tip: Fever could signal that the patients symptoms are caused by an infection. Patient appears stated age and in good health. She states that her daily inhaler has, improved her asthma. Pro Tip: Tinas symptoms are consistent with being exposed to allergens. Assessment is based on a Comprehensive Patient Interview, Physical Examination and development of Individualized Plan of Care that includes. caries or infection. Pro Tip: Pain severity might change for a variety of reasons. This results in bulging of the vein on either side of the artery making the vein appear to stop on either side of the artery. Pleasant and cooperative. received. Sister asthma. Blurry vision occurs after 2+ hours of reading. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation - OnlineNursingPapers | OnlineNursingPapers Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation were provided in the ED. No bleeding or bruising. Pro Tip: Establishing a timeline for how frequently Tina gets blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Pro Tip: Soliciting information about possible headache triggers will allow Tina to consider what, if any, activities, weather patterns, movements, or sensory input is correlated with her headaches. normoactive in all four quadrants. Para 0. Tina Jones Comprehensive Assessment Final Paper, Assessment Tina Jones Comprehensive Assessment Final Paper, Differential Diagnosis Tina Jones Comprehensive Assessment Final Paper, This diagnosis is because of patients history of dysmenorrhea and longer periods, and severe cramps, as a birth control was prescribed. Covered/Right Eye covered. Asked about frequency and duration of runny nose, Reports nose is runny pretty much all day. wound. Her caffeine intake is reduced to 1-2 sodas per day. Denies adverse effects of asthma medication. No change in activities of daily functionality. Always document a specific follow-up and reason: Example: f/u 1 week to evaluate antibiotic efficacy. Does not use APA. Pro Tip: Throat problems are often linked to sinusitis. Reports that the symptoms dont seem like a common cold. Patient verbalized coping well with stress and anxiety by having support from family and friends. source of the history. Well-groomed, easily engages in conversation and is cooperative. Irregular Type 2 DM: diagnosed at age 24. was on metformin NURP 533 ALL SHADOW HEALTH CASES BUNDLE OFFER! TINA JONES COMPLETE SHADOW HEALTH ASSESSMENT, Week 4 Shadow Health Tina Jones Height: 170 cm Exam Action 03/17/20 8:44 AM MDT Weight: 90 kg Exam Action 03/17/20 8:44 AM MDT - BMI: 31 Exam Action 03/17/20 8:44 AM MDT - Random blood glucose: 23. Denied secondhand smoke. Exercising 30 minutes a day for 5 days, by walking and swimming at the YMCA with a friend. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria 01 Interview Through our natural language conversation engine, students use their own words to gather subjective data and provide therapeutic communication. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! This is the most common complication of diabetic mellitus. with recent right foot injury. When she is exposed to allergens sh Guns, having belonged to her The static temperature and pressure at each section are indicated. Evaluation and treatment of polycystic ovary syndrome. Asking Tina if she thinks she is having an allergic reaction will give Tina the opportunity to compare her current symptoms with symptoms shes historically had during an allergic reaction. Wound edge red with serosegious drain. pain, vaginal discharge or itching. As per policy, no assignments are accepted after the last day of class. Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye Case - Week 4 shadow health tina jones 3. Complete Blood Count (CBC) is a blood test that is done for evaluation of overall health of a patient and to detect disorders; red blood cells, white blood cells, platelets, hemoglobin, hematocrit, mean corpuscular volume, reticulocyte count. . Never pregnant. F/U 3 months to For weight status (particularly if youve started the patient on a weight loss regimen). Followed up about medications and relieving factors for nose and eye symptoms. Have you noticed any changes to your voice? Acanthosis Nigricans (AN) is termed a common cutaneous conditions that can be a manifestation of systemic disease that is associated with insulin resistance, diabetes mellitus, obesity, internal malignancy, endocrine disorders, and drug reactions (Patel, Roach, Alinia, Huang, & Feldman, 2018). Denied non-healing wounds. Ill be helping a more, experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Education level (health literacy). Asking Tina if shes had mouth pain might indicate a problem area that has caused infection. Do you know whats causing your symptoms? click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew Tina Jones shadow health. When submitting hard copy, be sure to use white paper and print out using dark ink. Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. for menstrual pain and headaches. Patient is oriented to time, place, and situation. She has a documented medical history of, Asthma and Diabetes. Breakfast Smoothie, fruit, yogurt, and eggs. She came into the clinic for, She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. stated of increased appetite and Reports occasional sho Pro Tip: People whove experienced head injuries are at increased risk for sinusitis. The plan for addressing the health promotion and disease prevention needs for your patient should include: Age, gender and race of patient. You will develop differential diagnosis based on the chief complaint and HPI. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. seizure. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. : an American History (Eric Foner), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. She denies having any recent allergies to dust or pol, len. Utilize therapeutic communication techniques in obtaining a comprehensive health history and physical examination. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. up" patient was correct in response. Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. She has a history of hypertension which normalized when she Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Her last aXXXXX in high school. Pro Tip: Sinusitis can result in decreased smell or taste. Communication is so very important. Student Documentation Model Documentation. Last xxx months ago. Pro Tip: Because problems like mouth or throat cancer can be genetic, its important to understand family history to determine risk factors. Tina Jones Comprehensive Assessment Final Paper. Denies family history of headache or migraine, Right: Tympanic Membrane Colorright and left ear, It is possible to develop new allergies as an adult, and so I will take that into consideration as I try to determine the cause of your symptoms., Im sorry to hear you dont feel well. Assessments should include a history of hearing impairment and ear injuries. She began XXX months ago and initially had some gastrointestinal side effects which have since dissipated. Speech is clear and coherent. Uses alcohol when out with friends, 2-3 times per month, reports drinking no more than 3 drinks per episode. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), lesions, coarse hair from pubis to umbilicus. This is a comprehensive H & P. You will be assessing the \whole\ person. Ne 90 mcg/spray MDI 2 puff PRN for shortness of breath. R: 15. transfusion. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. Asthma: since childhood, takes albuterol, and Proventil. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms. She, denies any food and latex allergies. Ms. Jones started taking 30 40 mins walks and swims once a week, which she said helps her control her type 2 diabetes. Do you have any family history of throat problems? Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous. How many puffs of your inhaler are you supposed to do? Handwritten corrections are preferable to uncorrected mistakes. Objective Does not consider self-care needs or activities of daily living. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. odor from wound. Medications Tina Jones Comprehensive Assessment Final Paper. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation. Tests of cerebellar function normal. She Weight bearing as And her current home medication list include Flovent 2 puffs daily, for Asthma and rescue inhaler, Proventil 2 puffs every 4 hours as needed for shortness of. Do you have any problems with your tongue? she likes to hang out with friends and family. How often do you have a lozenge? She stated of having than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right Learning about a patients family history around vision can help you predict risk. Tina checks her blood sugar once a day, in the, Her diabetes is being treated with metformin 850 mg PO BID. Asking Tina if she has dry eyes solicits information about one particular symptom. Denied history of STI. Paper diseased, died at from colon CA, T2DM, Maternal developed, and dressed appropriately with good hygiene. She needs to obtain a pre-employment physical prior to initiating employment. No nodes or lumps found. ", Ms. Jones reports that she recently obtained employment at Sm Patient denied food, seasonal, and latex allergy. Pages 4. 02 Physical Exam Students gather and interpret objective data to assess the patient's condition. Verified answer. She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. Denies coffee intake, but does consume 1-2 diet sodas per day. reported of fever 102 last night. initiated diet and exercise. Ms. Jones states that the gynecologist diagnose OB/GYN: Menarche, a Last menstrual period 2 weeks a Lacks identification of knowledge deficit areas/patient education needs. If you have a question, there is a good chance one of your peers does as well. Reason for visit Tina Jones Comprehensive Assessment Final Paper, Patient verbalized I came in here because, Im required to have a recent physical examination for the health insurance at my new job.. Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Tina Jones Comprehensive Health Assessment. Present to the clinic, coherent. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences. XXXdiagnosed at age 2 1/2. Last menstrual period 2 weeks ago. Her last healthcare visit was 4 months ago midline. She uses her albuterol inhaler 2022 Nursingbay.com. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. 5. Often it is advantageous to have a friend proofread your paper for obvious errors. the health insurance at my new job. Lipid panel is blood test that measures total cholesterol, HDL cholesterol and LDL cholesterol, triglycerides to help determine risk of heart disease. How often did you see the dentist when you were a child? Patient is dressed appropriately for the weather. Asking Tina if she has ear pain might indicate a possible ear infection. Pro Tip: Ear problems are often genetic. Hello, my name is . Please communicate with me if you anticipate having to submit an assignment late. nodules, no goiter. But do not strictly rely on your computers spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. No tobacco. Establishing a timeline for how long Tinas eyes have been itching will also aid in treating her itchy eyes. During a comprehensive assessment, the practitioner is looking at the. Patel, N. U., Roach, C., Alinia, H., Huang, W. W., & Feldman, S. R. (2018). No Pro Tip: A history of oral surgery might indicate that Tina had former oral problems. Denied issues with Tina Jones shadow health. Diabetic neuropathies. She has changed her, diet recently to help with her diabetes. Asking Tina how frequently she has a lozenge will illustrate the extent of her pain and how effectively OTC treatment works for her throat. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Pro Tip: If left untreated, gum problems, like abscesses, can result in sinusitis. Model Note:Differential diagnosis includes sensorineural hearing loss and anatomical defects. Your paper will be evaluated based on the following criteria: 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. Describes similarity to her sisters hay fever symptoms. 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