Example Question: Do you use any herbal products? 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Last use of proventil was 3 days ago. Pro Tip: Discerning what is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Stretch marks on anterior and posterior waist. Finding: Right kidney: not palpable, no masses. Liver Span: 7cm MCL on percussion Example Question: When do you check your blood glucose? Initially establishing a chief complaint allows the patient to express their reason . The following actions reveal the objective data of the patients case. denied bilaterally. Left elbow without swelling, masses, or 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. : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. 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VNSG 2331. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. I used to have a reaction when I was in a dusty house for a long time. Para 0. Finding: Reports taking prescription birth control pills. 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. Decreased sensation to monofilament in bilateral plantar surfaces. extremities, Right arm proximal dull pain sensation intact Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower Bila Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. coherent. She uses her albuterol inhaler when she is around cats. extremities, Right leg proximal sharp pain sensation intact Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. . Pleasant and cooperative. Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs and eyes redness. My albuterol. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. PPD (negative) ~2 years ag Finding: Right shoulder without swelling, masses, or deformity, Finding: Right arm without swelling, masses, or deformity, Finding: Right elbow without swelling, masses, or deformity, Finding: Right wrist and hand without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left shoulder without swelling, masses, or deformity, Finding: Left arm 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. My discharge is normal, I think. . deformity Denied leg pain or discoloration in Brother overweight. Then a few weeks later I saw a gynecologist for a pap smear. 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. . Example Question: Have you been taking medication for your diabetes? church as support system. source of the history. Example Question: How long ago did you start taking birth control? What medical problems did your father have? 12 Test Bank - Gould's Ch. Nasal mucosa moist and pink, septum Father, diseased, died at age 58 in car accident, HTN, Comprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass Documentation Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HP 78 99% SpO2 98.9 degrees F FVC 3.91 L FEV1 3.. week. . Health Maintenance Indicates an item that is available to be found. Identified key in right hand within 5 seconds Left leg proximal dull pain sensation intact masses Finding: Reason for last visit was annual gynecological exam. Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. GU: Pt stated of polydipsia and polyuria. Left eye: equal hair distribution on lashes and 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. No edema. GI: Denied nausea, vomiting, abdominal pain, or change rebound Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S diseased, died at from colon CA, T2DM, Maternal Shadow Health - Comprehensive Assessment: Tina Jones. Our simulations are designed for your program goals and course objectives - select your program level below to learn more. Nana was 73 when she died of a stroke about five years ago. No. masses No peripheral edema. 2022 Nursingbay.com. XRay of the foot and wound care Left foot straight line down shin, smooth and The assessment should also include the comparison of bilateral sides. Patient able to identify dull, sharp, and soft touch on all extremities. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. The estimated average time to complete this assignment each time is 3 hours. Tina Jones Comprehensive Assessment Final Paper. Denied non-healing wounds. Stevens, Stewart, Silver & Company. Theyre crazy, but nobodys diagnosed with anything. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Right lower quadrant: soft, no tenderness or Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Documentation; Vitals. Endocrine: Reported of polydipsia, polyuria and weight Example Question: Do you take any supplements? Left TM intact and pearly gray, positive light patient. C/O sharp Dentition without evide HR: 78. Recent flashcard sets. "I scraped my foot a week ago and the wound is not Auscultated Erb's point with the diaphragm: Asking Tina if she takes herbal products will indicate her current treatment plan. Ms. Jones offers information freely and w extremities, Right arm proximal light touch sensation intact Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Auscultated aortic area with the bell: no S3, S We go to First Baptist, and we do a lot with our church community. 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. Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). when she received her annual gynecological exam at Shadow Right lower quadrant: tympanic Diagnosed with PCOS four months ago. Ive been feeling much better lately, though. initiated diet and exercise. Support and Contact (service.elsevier/app/home/supporthub/shadow-health/) Patents (/static/patents), Reports no muscle pain, joint pain, muscle weakness, or swelli, Bilateral upper and lower extremities without swelling, masses, care from local ER. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Denied frequent fall. Neurology: No change in mood, behavior or attention. Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. She has asthma too, but she almost never has attacks. Auscultated pulmonic area with the bell: no S3, Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. seconds She provided the health information freely during the interview. 50mg Q6hr PRN (for foot pain). Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. Right brachial pulse: 2+ Alix_Johnson55. Has new male relationship, sexual contact not initiated. Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. Ms. Jones offers information freely and without contradiction. Head is normocephalic, atraumatic. Left flank: none reported, Percussed organs Spleen percussion: no dullness bilaterally in upper and lower extremities. developed, and dressed appropriately with good hygiene. Left iliac artery: no bruit Last saw primary care doctor two years ago. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Asthma diagnosed at age 2 1/2. L/R Otoscopic: No inflammation with pearly/gray color Normal thyroid functions. Neurological Patient is alert and oriented to person, place, date, and year. 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 . grandmother, age 82, HTN. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Speech is clear and coherent. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Speech is clear and What age were you diagnosed with asthma? (Clarified to if my younger sister has health problems. Right dorsalis pedis pulse: 2+ I guess I had anxiety back when I was having those sleep problems. She has type 2 diabete Liver span: 7 cm MCL on percussion, Percussed abdomen Right upper quadrant: tympanic My mom has some issues, and I think some of my grandparents did, too. Indicates an item that you found. Left arm proximal sharp pain sensation intact Last menstrual period 2 weeks a Never pregnant. Right kidney: not palpable, no masses without cough or wheeze. S Normal scalp hair distribution changes on right. reports a few moles but no other hair or nail changes. Ask an Expert. Left tibial pulse: 2+ . Reported of difficulty ambulating due to pain. XRay of the foot and wound care, were provided in the ED. Present to the clinic, coherent. Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline edema. What is the name of the birth control pill you took? Strength 5/5 bilateral upper and lower extremities. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. H How many hours are you sleeping a night? extremities, Right ankle: 2+ click here for . Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. 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. What happens when you are around dust? rjster052410. NR 509 Tina Jones Comprehensive Health Assessment. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. Wound edge red with serosegious drain. on left, Examined ear cavities with otoscope Right TM intact and pearly gray, positive light Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Skin on nec Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. aggravating factor and tramadol as relieving factors. Today she denies any acute concerns. This clinical experience is a comprehensive exam. Finding: Last use of Proventil inhaler was three months ago. That stuff can mess you up. She was last hospitalized for asthma in high school. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . Whispered words heard bilaterally. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Im actually feeling really good lately. Right iliac artery: no bruit 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. effects which have since dissipated. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she complied with previous treatment plans. (Clarified to Do you have drainage from your ears?. Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ Oral mucosa moist without ulcerations or lesions, uvula Lets see . If your instructor provides individual feedback on this assignment, it will appear here. Shadow health Tina Jones Comprehensive Assessment.pdf -. Exam 1 Study Guide - Summary Advanced Health Assessment; Week4 DCE Tina Jones Comprehensive; Dehydration Synthesis SE; Tina jones comprehensive questions to ask; Tina jones comprehensive; Shadow health Neurological Exam Documentation; Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. required change of tampon every 2-3 hours. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Last Pap smear 4 months ago. organomegaly. Auscultated aortic area with the diaphragm: extremities, Right arm proximal sharp pain sensation intact 2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ ____ Age: _28 ___ Gender: ___F ____ SUBJECTIVE DATA: Chief Complaint (CC): Patient Tina Jones is here today for a preemployment physical. incontinence or dysuria. Lower eyelids: conjunctiva pink, no lesions, Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. Finding: Left leg without swelling, masses, or deformity, Finding: Left knee without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left ankle without swelling, masses, or deformity. No Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Finding: Left pupil: equal, round, reactive to light. ), Nothing is coming out of my ears. below to reveal important information, Left leg proximal light touch sensation intact Right lower quadrant: no masses, guarding or Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. 23 terms. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. PMI at the with polycystic ovarian syndrome and prescribed oral contracep 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. Tests of cerebellar function normal. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. Her last healthcare visit was 4 months ago Finding: Right foot without swelling, masses, or deformity 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. She maintains eye contact throughout the interview. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . and throbbing pain at right foot. Reports improved acne due to oral contraceptives. Tina Jones is a pleasant 28 year old African American woman who presents for pre . Mother, age 50, HTN, high cholesterol. grandmother diseased, died at age 73 from stroke, behavior issues. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). Example Question: Have you been having seasonal allergies? 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) Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $37.98, 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. Right arm distal sharp pain sensation intact She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. intake with weight loss, 10lbs in the last 30 days. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Left upper quadrant: no masses, guarding or rebound, Finding: Left lower quadrant: no masses, guarding or rebound, Finding: Liver: palpable 1 cm below right costal margin Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Comprehensive Assessment Tina Jones Shadow Health Transcript. No varicose vein. No lymphadenopathy. Identified coin in left hand within 5 seconds Example Question: Have you missed any days of your birth control pill? with recent right foot injury. Vitals. VNSG. Please note, this is an average time. Speech is clear and coherent. encounter at age 18, Sex with men only. Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence Inspected head and neck Scattered pustules on face and facial hair on Last pap 3 years ago. Pain was 7/10, two masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . Identifying Data & Reliability Left arm proximal dull pain sensation intact Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. Some students may need longer. Example Question: Do you take any vitamins? Left renal artery: no bruit Im sleeping a lot better now, which is a relief. contradiction. She has no medication side effects currently. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. Finding: Asked about last visit to a healthcare provider, Finding: Last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. percussion. Current Health Status. Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or Ms. Jones is alert and oriented, seated upright on the examinat Auscultated tricuspid area with the bell: no S3, 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. Including transfusion. wound. Decreased sensation midline on phonation. Left lower quadrant: tympanic She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Denied exercise. 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. Comprehensive Assessment Tina Jones Shadow Health Transcript. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Comprehensive Assessment Tina Jones Shadow Health Transcript. No pain with movement. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. Speech is clear and coherent. Example Question: What is the dose of your metformin? Liver: 1 cm below right costal margin. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Left fundus with sharp disc margins, no Auscultated pulmonic area with the diaphragm: Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History Height: 170 cm Weight: 84 kg . I mean, I still have asthma and diabetes, but both of those are under control. discoloration over last few years. Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Gag reflex intact, Tested pulse oximetry Oxygen saturation 99%, Tested lung capacity FVC is 3 L and FEV1/FVC ratio is 80%, Inspected chest wall Anterior chest wall symmetric, no deformity or Tina Jones shadow health. Comprehensive Assessment Tina Jones Shadow Health Transcript. 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