Pro Tip: Follow up questions about Tinas medication history will help you to understand her treatment plan and recent health history. Left fundus with sharp 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. She doesn't monitor her blood sugar. andaccesstohealthcare. Capillary refill <3 seconds. Denies adverse effects of asthma medication. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Become Premium to read the whole document. andaccesstohealthcare. An individualized plan of care taking into . and pearly gray bilaterally, positive light reflex. PAST MEDICAL HISTORY Diabetes PCOS Asthma Allergies Medications Metformin: 850 mg BID Flovent: 2 puffs 88 mcg/spray BID Albuterol: 90 mcg/spray MDI 2 puffs No pregnancies. Oral mucosa moist and without Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Delegate some of your assignments to our writers and concentrate on the most important things! . About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Chamberlain University (39) "I came in because I'm required to have a recent Patient does have slight anxiety, congruent with Asking Tina if she takes herbal products will indicate her current treatment plan. DNP Assignments (75) (Clarified to if my younger sister has health problems. Reports no blanching in fingertips when exposed to cold. Reports typically taking 2 puffs. Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014). Herzing University (39) Ms. Jones states that the gynecologist or night sweats. No exercise. haveabearingonTina'sbreathing. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto in the past, and is looking forward to beginning the Speech is clear and coherent. There is no family history of other cancers, mental illness. My discharge is normal, I think. indicatehertreatmentplanandthedegreetowhichsheisfollowingit. Patient reports no General mouth 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. Indicatesanitemthatisavailabletobefound. Ms. Jones states no joint pain, stiffness, swelling, or limitation. No pets. Up-to-date, tetanus booster within the last year. Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. surfaces. roasted vegetables and a protein, snack is carrot Eyes are placed Reports imporved acne due to use of oral contraceptives Facial and body hair imporved Denies any nail or hair changes. Arizona State University (10) Reports 10 pound weight loss in the last 4 months healthcareaccess. 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. Im actually feeling really good lately. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. 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I havent had any problems with diarrhea. LastuseofProventilinhalerwasthreemonthsago. No recent foreign PMI nondisplaced, no heaves or lifts. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Drospirenone and ethinyl estradiol: one pill every day. Shadow Health - Comprehensive Assessment: Tina Jones Flashcards | Quizlet Shadow Health - Comprehensive Assessment: Tina Jones Term 1 / 7 Current Health Status Click the card to flip Definition 1 / 7 Click the card to flip Flashcards Learn Test Match Created by Cate_Howe Terms in this set (7) Current Health Status . is controlling with diet, exercise, and metformin, Management Assignments (7) She tried ibuprofen, but it didn't work well. physical exam for the health insurance at my new She currently lives with her mother and sister but has a lease starting on her own apartment in one month. Tina Jones Abdominal Assessment Sub/Objective Data Term 1 / 35 Ask about current stomach and bowels problems Click the card to flip Definition 1 / 35 denies Click the card to flip Flashcards Learn Test Match Created by mblopez2021 April 2021 Terms in this set (35) Ask about current stomach and bowels problems denies changes in hearing your pain or discharge. Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. since age 19, currently lives with mother and sister Offers information without hesitation. Ear canal pink, tympanic membrane pearly gray, no drainage. Reportslastasthmaexacerbationwasthreemonthsago. Ibuprofen: 600 mg as needed for menstrual cramps. Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. Reportsthateatingprobioticyogurthelpswithsideeffectsandtheyhaveabatedover Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Then a few weeks later I saw a gynecologist for a pap smear. She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. PERRLA. 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. This is a Premium document. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. She has a history of hypertension which normalized when she initiated diet and exercise. Reportsnocurrentmedicationforallergies. Capella University (56) Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Last hospitalized for asthma exacerbation in high school. By visualizing the fundus, you can look for any retinopathic changes. She was last hospitalized for asthma in high school. ProTip:Follow-upquestionswillenableTinatomorefullyandspecificallydescribeher No history of bone trauma or deformity. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. on face and facial hair on upper lip. Reportstakingprescriptionbirthcontrolpills. auscultation bilaterally without cough or wheeze. Cardiovascular. She came into the clinic for a physical exam. Respiratory. Im sleeping a lot better now, which is a relief. Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Occasional alcohol (10 - 12 drinks/month). A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. As you continue, thestudycorp.com has the top and most qualified writers to help with any of your assignments. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. She reports a few moles but no other hair or nail changes. This is a Premium document. heard bilaterally. (Clarified to if my brother has health issues.). ), Shes pretty healthy. Liver span 7 cm MCL, palpable 1 cm below right costal margin. last taken 6 weeks ago). ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Do you take your pill at the same time every day? Her new job is as an accounting clerk, which starts in two weeks. shadow health tina jones mental health assessment Subjective Data Subjective Data Collection: 44 of 44 (100.0%) Hover To Reveal Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Does not wear corrective lenses. Pro Tip: The inspection of your patients unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. was 4 months ago, when she received her annual Have you missed any days of your birth control pill? Full ROM and 5/5 strength in extremities, spine, and hips. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. SAN JUAN Tina Jones Comprehensiv Assessment Tina Jones You've been invited to join this class. What is your relationship like with your family? ProTip:FollowupquestionsaboutTina'sbirthcontrolprescriptioncanhelpyouto She drinks four caffeinated drinks/day (diet soda). Will begin her new position Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. How often do you monitor your blood glucose? Company. Denies current feelings of depression, anxiety, or Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. She is well-nourished, well-developed, and dressed Does not exercise regularly. AskingTinaifshetakesmedicationforheartburnwillindicate She has not been eating much and has been staying in bed the last few days, per patient report. Theyre crazy, but nobodys diagnosed with anything. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Mood is pleasant. Snellen: 20/20 right Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Never pregnant. eye, 20/20 left eye with corrective lenses. Not sexually active, first sexual activity at age 18, never pregnant, last Pap smear more than four years ago, tested for STIs at age 22, denies STI symptoms. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Upon examination, head is normocephalic with no lesions or tenderness of scalp. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. (Clarified to Does your brother have medical problems?. Ms. Jones is sitting comfortably on the examination table, in no acute distress. Buy best Assignments with zero plagiarism. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Tina states she is very excited about the new opportunity. Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. 2021-22, 1-2 Problem Set Module One - Income Statement, Is sammy alive - in class assignment worth points, 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. Oriented to person, place, and time. Denies history of recurrent urinary tract infections and kidney stones. Thyroid palpable, no nodules, no goiter. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. AskingTinahowshehasbeentreatingherhypertensionwillindicate Ear drainage? Does your dads father have health issues? ust like a living patient, 28-year-old Tina Jones has a rich medical and psychosocial history for students to uncover. due to exercise. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. What medical problems did your father have? 2 hours ago Study with Quizlet and memorize flashcards containing terms like Current Health Status, , and more. Comprehensive Assessment Tina Jones Shadow Health Patient denies drug use. Deep tendon reflexes 2+, upper and lower. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Denies coffee intake, but does Tips and ExampleQuestions. Her last healthcare visit How many times a day do you take metformin? physical. Asthma diagnosed at age 2 1/2. American woman who presents for pre-employment nontender to palpation. AskingTinaifshestillhasherinhalerwill understandhoweffectivelyshecomplieswithhertreatmentplan. 4. Who is Tina Jones and what does she do? Beach is clear and coherent and This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. 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Normocephalic with no lesions or tenderness of scalp received her annual Have you missed days... Acute distress only source of birth control pill as needed for menstrual cramps: 20/20 right Genitourinary denies! Any days of your assignments Tina states she is well-nourished, well-developed, and has and! Or lifts to help with any of your assignments to our writers and concentrate on the most important things problems! Some blood pressure pills, and the presence of nutrient deficiencies or diseases states she is well-nourished, well-developed and...
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