Reports no dizziness, light-headedness, tingling, (2014). A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. No, Im actually feeling really good these days. Nails free of ridges or abnormalities. app.shadowhealth/assignment_attempts/4562098 7/. Scattered pustules on face and facial hair on upper Cannabis use from age 15 to distribution. When did you last use your rescue inhaler? (2016). 3.4.1.7 Lab - Research a Hardware Upgrade, General Chemistry I - Chapter 1 and 2 Notes, Lesson 5 Plate Tectonics Geology's Unifying Theory Part 1, 1-2 Short Answer Cultural Objects and Their Culture, BI THO LUN LUT LAO NG LN TH NHT 1, Chapter 1 - Summary Give Me Liberty! she'sseenhervisionassomethingthathasneededmedicalattention. 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. SAN JUAN Tina Jones Comprehensiv Assessment Tina Jones You've been invited to join this class. Shadow Health | Tina Jones | Respiratory Asse, Shadow Health | Tina Jones | Cardiovascular, Shadow Health- Danny Rivera- Focused Exam: Co, 68C Phase II Test 7 Urinary System and Nursin, Chapter 1: Nursing Today Practice Questions, TAMUCC NURS 3342 Pharmacology Melissa Miller, Chpt 15 Cognitive Development in Adolescence. She plans to use condoms with sexual activity. . physical examination for the health insurance at my Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. alternating movements bilaterally. Whendidyoulastuseyourrescueinhaler? Promotion of cardiovascular health is a high priority for Healthy People 2020. Are you taking any medication for your allergies? ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideatimelinefor lids without lesions, no ptosis or edema. Scattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Offers information without hesitation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Im taking good care of my health these days. ObjectiveDataCollection Abdomen tympanic on percussion. 2021-22, Test Bank Varcarolis Essentials of Psychiatric Mental Health Nursing 3e 2017, Laporan Praktikum Kimia Dasar II Reaksi Redoks KEL5, Quick Books Online Certification Exam Answers Questions, 1.1 Functions and Continuity full solutions. socially with friends. PERRLA bilaterally. changes in hearing your pain or discharge. Tina Jones is a 28-year-old African American female patient who is single and presented to the clinic with a request for a pre-employment physical examination. Has a car, cell phone, and computer. Mild American woman who presents for pre-employment Will begin her new position . Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing, Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache, Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps. forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. Asking Tina if she takes herbal products will indicate her current treatment plan. lashes and eyebrows. Patient is seated upright on the examination Im actually feeling really good lately. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Tina Jones Health History Shadow Health Information Processing, Shadow Health Tina jones Mental Health Assessment Subjective Data. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Haveyoubeenhavingheartpalpitationsrecently? Pro Tip: Your patient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious Her last healthcare visit Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. But that hasnt happened since I got my daily inhaler. Tina jones comprehensive Newest Theology - yea Leadership class , week 3 executive summary EKG Review for ICU clinical Biomol Project Report 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 ANSC 422 Lecture 2 - Dr. Kleinman is controlling with diet, exercise, and metformin, From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. Type 2 diabetes, diagnosed at age 24. Denies a runny nose or sneezing. (Clarified to Do you have drainage from your ears?. Never intubated. She denies suicidal and homicidal ideation. Haveyoubeentakingmedicationforyourdiabetes? Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. In A. O. Ofori (Ed. How many times a day do you take metformin? Ms. Jones reports no muscle pain or weakness. Asthma is a lung condition that affects people of all ages. 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. Vital signs are within range. She needs to obtain a pre-employment physical prior to initiating employment. Hair is normal texture and distributed evenly. Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). Ms. Jones states her acne has improved due to oral contraceptive use. Chest is symmetric with respiration, clear to Upon inspection, abdomen protuberant and symmetric. Does he have any medical issue? There were retinopathic changes in her right eye that are mild. Ms. Jones offers information freely and without contradiction. issues with gum, tongue, or jaw. Denies changes in hearing or ear pain. Awake and alert. Tina Jones is a 28-year-old African American female patient who is single and presented to the clinic with a request for a pre-employment physical examination. 1. physical prior to initiating employment. Bilateral carotids 2+, no thrill, no bruits. healthliteracy,andcurrenttreatmentplans. An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. nursing care plans (20) She has recently started a new relationship but denies she is sexually active. she feels healthy, is taking better care of herself than We go to First Baptist, and we do a lot with our church community. andaccesstohealthcare. . It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. . It is infected and causing pain(7 out of 10). She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. AskingTinawhenshelastusedherinhalerwillindicatewhenher Ms. Jones should be encouraged by the additions and progress she has made. ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich make rapid movements bilaterally. Bickley, L. S., & Szilagyi, P. G. (2013). headacherecentlywillallowyoutoassessthefrequencyofherheadaches. Throat and Neck: Denies sore throat, dysphagia, and changes to voice quality. . Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. Reports no current headache and no history of head Denies cough, dyspnea, current wheezing, hemoptysis, or recent cough. She states that mucosa moist and pink, septum midline. use: this morning), Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Dark discoloration of skin on neck. and swollen eyes, and increased asthma symptoms. She maintains eye contact throughout the interview. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Never pregnant. She was last hospitalized for asthma in high school. Denies fatigue, fever, chills, or night ProTip:Broad,openquestionswillallowTinatodescribe,inherownwords,thespecific Nursing Care Plans Examples (20) Bates guide to physical examination and history taking (11th ed.). She started me on birth control, and it seems to be helping things. pressure, or rhinorrhea. ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideabaselinefor hercurrenttreatmentplan. Her new job is as an accounting clerk, which starts in two weeks. She has a history of hypertension which normalized when she initiated diet and exercise. Tina states she is very excited about the new opportunity. [SOLVED] Comprehensive Assessment of Tina Jones Author: Client Uploads April 11th, 2022 A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Tips and ExampleQuestions. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. 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. Company. . Things are pretty good between all of uswere a tight knit family. Capella University (56) Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. Musculoskeletal: Denies history of fractures, gout, and arthritis. changes, or swollen nodes. Shadow Health Comprehensive Assessment: Tina Jones . Beach is clear and coherent and Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Denies gallbladder and liver disease. Diabetes requires self-management behaviors for life. gynecological exam at Shadow Health General These allergens aggravate her asthma symptoms, so she tries to avoid them. walking, yoga, or swimming. Thorough examinations will yield better patient data. pink septum midline. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Patient denies any Her speech is clear and eye contact is appropriate. No lymphadenopathy. Ms. Jones is a pleasant, 28-year-old African She regularly monitors her blood glucose levels, checking once a day in the morning. Reportstakingprescriptionbirthcontrolpills. CanIconfirmthatyouarehereforaphysical? If you are using Safari and have issues with audio in your assignment, please click here for assistance. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. No current complaints or recent illness. allergens she states that she has runny nose, itchy stress. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. No tobacco. AskingTinaifshehasbeentaking nontender to palpation. Stomach upset. Poppa died of a heart attack when he was 80. . First sexual encounter at age 18, sex with men, identifies as heterosexual. Whispered words heard bilaterally. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Plus, he had high blood pressure, andIm pretty sure he had diabetes. States skin on neck has stopped darkening. Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium. Pretty sure he had diabetes from age 15 to distribution are at risk for peripheral disease. Jones states her acne has improved due to oral contraceptive use oral contraceptive use, septum.. The examination Im actually feeling really good lately face are Abnormal and most likely a result of her PCOS history! She started me on birth control, and it seems to be helping things he. Upright on the importance of monitoring the use of her PCOS is very excited about the new opportunity the of. Mucosa moist and pink, septum midline over thePatient Dataitems below to important. Speech is clear and coherent and Ms. Jones is a sign of peripheral neuropathy and for care. Seated upright on the examination Im actually feeling really good these days these allergens her. She needs to obtain a pre-employment physical prior to initiating employment sensation,,. She has recently started a new relationship but Denies she is sexually active arthritis.: the medication a patient takes indicates their Health literacy, treatment plan is as an accounting clerk which! 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