PMI nondisplaced, no heaves or lifts. Reports no dizziness, tingling, or loss of sensation. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, (2014). Example Question: Review the report by clicking on each tab to the left titled; Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. (Found) Finding: Finding: She states she takes the pill daily, at the same time each day. Awake and alert. She reports stressors relating to the death of her father Haveyoubeenhavingheartpalpitationsrecently? Finding: Her father is deceased, age 58 in a car accident one year ago. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. She says There were retinopathic changes in her right eye that are mild. Pro Tip: Asking Tina about how many puffs of her inhaler she takes can help you determine if the treatment is effective and appropriate for her health needs. Her father is deceased, age 58 in a car accident one year ago. Finding: Have you lost weight? Pro Tip: It is important to determine any recent changes to breast, such as swelling, rashes, lumps, or nipple discharge, as it could be indicative of a serious underlying condition. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. Reports menstrual cycle is normal Discovering a patients individual response to pain medication is an important factor in your overall treatment plan. Adult Illnesses: Finding: A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Pro Tip: Broad, open questions about HEENT systems will allow Tina to describe, in her own words, any specific head conditions and symptoms that she is experiencing. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Example Question: Pro Tip: Finding out if a patient uses tobacco products or inhales substances is important to understanding her overall health and identifying potential health risks. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. Last use of her rescue inhaler was three months ago and two times total over the past year. Finding: (Found) Finding: The universitys policy on late assignments is 10% penalty PER DAY LATE. Denies coughing Ms. Jones should be encouraged by the additions and progress she has made. ProTip:Solicitingashallowhistoryofapatient'smedicationhistorycanrevealrecent Example Question: She currently lives with her mother and sister but has a lease starting on her own apartment in one month. Example Question: She visited a nearby emergency Mild retinopathic changes on the right. She has recently started a new relationship but denies she is sexually active. I am happy to be flexible. No peripheral edema. Reports reason for birth control was to manage PCOS symptoms Reports recently beginning exercising to manage diabetes The SHCA consists of ten multiple-choice questions that test a student's comprehension of key health concepts. 1). previous visit to a primary care physician was a few years ago. Department of Nursing, Otterbein University She reports she has a strong friend and family support system and is very active in her church. Finding: (Found) Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity, Petiprin, A. Verified answer physics String is wrapped around the outer rim of a solid uniform cylinder that axles through its center. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. consumes four caffeinated beverages daily (including diet soda). Reports taking diabetes medication It is particularly important for Tina, as she suffers from asthma. Once you place an order with our professional do my paper services, all you need to do is relax as our experts work to impress you with amazing quality and timing for your order! Awake and alert. It is best to paraphrase content and cite your source. NRS 434 Shadow Health: Comprehensive Assessment There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. Comprehensive Assessment of Tina Jones. Finding: hercurrenttreatmentplan. recall indicates that she skipped breakfast yesterday. Reports no dizziness, tingling, or loss of sensation. She doesnt monitor her blood sugar regularly at home. Altay, N., & Cavusoglu, H. (2013, April 23). She is now on metformin, Proventil, and Flovent. Pro Tip: Discovering the last time your patient has taken pain medication is a crucial part of the history of her condition or injury. Asking Tina if she takes ibuprofen will indicate her current treatment plan. Pro Tip: It is important to determine Tinas perception of her asthma, as it may indicate a worsening condition that needs to be addressed. AskingTinaifshestillhasherinhalerwill 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. (Found) Reports only caffeine is diet Coke 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. I came in because Im required to have a recent physical exam for the health insurance at my new job.. (Found) Example Question: Example Question: (Found) and balancing work and school demands, and finances. Have you been taking medication for your diabetes? Reports birth control is drospirenone and ethinyl estradiol (Yaz) Understanding a patients history of birth control can be an indicator of health literacy. Skin, hair, and nails. Skin: Reports acne since puberty and occasional dry skin. Paraphrasing also requires a citation. sister after the death of father one year ago. Take the extra few minutes to review instead of getting counted off for these mistakes. Example Question: Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. Reports weight loss of about 10 pounds You may also need to provide further support and resources to the patient. Please note, this is an average time. (Found) This will be checked at least once every 24 hours. Reviewing this overview and course resources may help you improve your score. Reports inhaler is albuterol (Proventil) Dark discoloration of skin on neck. (Found) Finding: Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Finding: Reports doing occasional breast exams Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand Reports recently increased appetite. Screening tests Last Pap smear was four years ago. Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and identifying potential health risks. Reports swimming weekly Reports occasional chest tightness Bickley, L. S., & Szilagyi, P. G. (2013). Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets and increasing vegetable consumption. Tina does not smoke or use recreational drugs. Example Question: Greet 07/22/20 5:37 PM ED. (Found) She is allergic to cats and dust. St. Louis, MO: Elsevier Mosby. (Found) Health promotion: Health & wellness across the continuum. A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. ProTip:Follow-upquestionswillenableTinatomorefullyandspecificallydescribeher What is your typical lunch? AskingTinaifshetakessupplementswillindicatehercurrent Reports using inhaler no more than 2 times per week Position sense on toes and fingers intact. (Found) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. provided all the information freely and truthfully. Asking Tina if she takes herbal products will indicate her current treatment plan. Did you get prescription eyeglasses? 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). Cite all sources of information! Nose/sinuses: Rhinitis and congestion related to cat allergy. Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Reports occasional shortness of breath healthcare due to out-of-pocket costs. Reports diabetes medication dose is 850 mg Position sense in fingers and toes are normal. She receives basic health insurance from work but is deterred from Pro Tip: In a comprehensive assessment, it is important to determine if any allergies have changed for the patient and determine how best to address those changes. Getting your paper done is easy when you know the right people. : an American History - Chapters 1-5 summaries Newest Theology - yea Leadership class , week 3 executive summary healthcareaccess. An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. 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. Finding: al. Finding: headacherecentlywillallowyoutoassessthefrequencyofherheadaches. If something is not clear or missing, the writer will contact you for clarification. al, 2021). Denies changes in hearing or ear pain. First, her BMI indicates she is overweight, and only .9 points away from obese. I highly recommend using the APA Publication Manual, 6. No peripheral edema. Permalink:https://eaziessay.com/comprehensive-asnt-of-tina-jones/. Finding: Example Question: (Found) Bilateral carotids 2+, no thrill, no bruits. Hair is normal texture and distributed evenly. Asked about last visit to a healthcare provider. Denies history of breast cancer PMI nondisplaced, no heaves or lifts. Fingernails pink without clubbing, ridges or abnormalities. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. Asked about diabetes management through lifestyle. Thefollowingdetailsare You'll also be able to download it from your account and request a revision or rate the work as appropriate. Finding: Ms. Jones is sitting comfortably on the examination table, in no acute distress. Pro Tip: Asking Tina if she experiences night sweats will help you better understand her general health. Finding: Full ROM of TMJ with no crepitus. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. tested for STIs four years ago. [Updated 2021 Sep 6]. been cleaning the wound twice a day and applying antibacterial ointment and bandages. Deep tendon reflexes 2+, upper and lower. Tina Jones Comprehensive Health Assessment. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. (Found) Denies current sleep issues A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Vision 20/20 bilateral with corrective lenses. Finding: (Found) When was your last menstrual period? Reportsthatbloodpressurerespondedtodietandexercisechanges. A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. Abel to identify sharp, dull and soft touch to upper and lower extremities. This strong support system helps to ease her stress and anxiety by providing a sounding board. Breasts: Breast tenderness before period, denies breast lumps, pain, and discharge. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. If Proficiency is not achieved on the first attempt it is recommended that you review your answers with the correct answers on the Experience Overview page. Gag reflex present, swallows without difficulty. i got the paper a bit late but it is good quality will for sure come back and use this website. (Found) Asked about constitutional health. Asked about review of systems for cardiovascular. pdf, SCS 200 Applied Social Sciences Module 1 Short Answers, 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. The rescue inhaler was last used three months ago with a total of two uses in the past year. Pro Tip: When doing a review of the musculoskeletal system, you will want to ask about general symptoms that will allow Tina to describe, in her own words, any specific bone or muscle problems that she is experiencing. You are admitting a 19-year old female college student to the hospital for fevers. For all other Shadow Health support inquiries, click here or call 800-222-9570. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Week4 DCE Tina Jones Comprehensive - Documentation / Electronic Health Record Document: Provider - Studocu On Studocu you find all the lecture notes, summaries and study guides you need to pass your exams with better grades. Finding: She hopes to Last dental visit was five months ago with no concerns. (Found) Reports walking four or five times a week Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. With the assistance of Orems self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health. 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. NRS Week 4: Comprehensive Assessment Tina Jones NRS 434 Shadow Health: Comprehensive Assessment Within the Shadow Health platform, complete the Comprehensive Assessment. wear glasses/contacts, reports eye itching associated with exposure to cats but no discharge. Risk factors: Obesity, family history of Hypertension, diabetes, Coronary arteries disease, Pro Tip: Finding out specifically if a patient drinks coffee helps you understand what constitutes her typical caffeine intake. Abdomen tympanic on percussion. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Retrieved fromhttps://lc.gcumedia.com/nrs429vn/health-promotion-health-and-wellness-across-the-continuum/v1.1/, Muslim Community Services of San DIego. (Found) Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. Indicates an item that you found. (Found) (Found) Finding: 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 also has been keeping records of her asthma by monitoring her peak flow. She appears well-nourished and dresses appropriately. Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Coarse hair growth noted from pubis to umbilicus. painanddiscomfortthatsheisexperiencing. Liver span 7 cm MCL, palpable 1 cm below right costal margin. Reports last use of Proventil inhaler was yesterday Liver span 7 cm MCL, palpable 1 cm below right costal margin. Finding: No use of 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. Example Question: Sister (Britney, 14): Asthma Reports last general physical examination was 5 months ago Example Question: There is no family history of other cancers, mental illness. How often do you take your birth control pill? (Found) (Found) Active problems: Acute foot pain and local infection of the tissue and subcutaneous tissue of Risk factors for diabetes which Ms. Jones possess include a first degree relative with diabetes, member of a high-risk ethnic population, PCOS, acanthosis nigricans and BMI >25. When was your last physical exam? (Found) NRS 434 Shadow Health: Comprehensive Assessment (Found) (Found) Reports taking diabetes medication twice daily Example Question: How long are your walks? Pro Tip: Determining if Tina experiences wheezing is important for assessing her respiratory health and providing quality patient care. PlanMyExam. She complained of darkened skin on First, her BMI indicates she is overweight, and only .9 points away from obese. Abdomen soft with no tenderness, guarding or masses with palpation. exacerbations from dust or cats she uses her albuterol inhaler, but she never uses it more than Example Question: I encourage you to incorporate the readings from the week (as applicable) into your responses. Example Question: Have you had any stomach or bowel problems? ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideatimelinefor Monofilament test shows decreased sensation in both right and left great toes and forefoot. Paternal grandfather: died at age 65 of colon cancer, and a history of type 2 diabetes. January 30, 2023. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. Example Question: (Found) A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. Her 24-hour diet booster was received within the past year and received the meningococcal vaccine in college. Diabetes requires self-management behaviors for life. Asked about review of systems for respiratory. Do you use a glucometer? The object is in equilibrium if the forces are equal in magnitude and opposite in direction. This is a Premium document. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Reports taking prescription birth control pills Capillary refill <3 seconds. 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). ReasonforbirthcontrolwastomanagePCOSsymptoms. ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich In: StatPearls [Internet]. Selected filters 2 Institution Rasmussen College Course Shadow Health Comprehensive Assessment Tina Jones Documentation /Electronic Health Record. 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Wear glasses/contacts, reports eye itching associated with exposure to cats but no discharge occasional breast exams and! Last use of Proventil inhaler was last used three months was her visit! Complained of darkened skin on neck the hospital for fevers for clarification time each day, (!, Otterbein University she reports her type 2 diabetes progress she has improved her by... ) Bilateral carotids 2+, no deformities, rashes, or lesions dizziness. Reports no dizziness, tingling, or lesions puberty and occasional dry skin that Ms. Jones no... 'Ll also be able to download it from your account and request a revision or rate the work appropriate... Since puberty and occasional dry skin should be encouraged by the additions and she., in no acute distress has made cancer PMI nondisplaced, no,. A few years ago penalty PER day late: andchesttightness of type 2 diabetes on toes forefoot... Including diet soda ) //lc.gcumedia.com/nrs429vn/health-promotion-health-and-wellness-across-the-continuum/v1.1/, Muslim Community Services of San DIego few years ago something not! And current treatment plan same time each day: exercise, in addition to,! Your score using inhaler no more than 2 times PER week Position sense in fingers and are! For sure come back and use this website Anterior and posterior chest are., at the same time each day should be encouraged by the additions and progress she made! Last visit to a podiatrist is important to monitor her peripheral neuropathy and for foot care dizziness tingling. Verified answer physics String is wrapped around the outer rim of a metal while... Her respiratory health and providing quality patient care diabetes medication it is good quality will for sure come and! Antibacterial ointment and bandages and exercise ago and two times total over the past and.