Musculoskeletal exam performed on Ms. Jones. High BP and high cholesterolon both sides and diabetes. Nasal Hair is normal texture and distributed evenly. Reports imporved acne due to use of oral contraceptives Facial and body hair imporved Denies any nail or hair changes. Her father is deceased, age 58 in a car accident one year ago. No pets. ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, She was last hospitalized for asthma in high school. I havent really had any stomach problems since I came in with them a while ago. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, 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! Ms. Jones states no joint pain, stiffness, swelling, or limitation. (5 days ago) Shadow Health Tina Jones completed musculoskeletal musculoskeletal results completed advanced physical assessment fall 2021, nurs610 return to assignment your DismissTry Ask https://www.studocu.com/en-us/document/western-carolina-university/synthesis-of-nurs-practicum/musculoskeletal-completed-shadow-health-2/19246855 Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. Ms. Jones reports no shortness of breath or trouble breathing. Denies myalgias and arthralgias. Asthma is a lung condition that affects people of all ages. Asking Tina if she takes herbal products will indicate her current treatment plan. The last visit to the clinic was four months ago for an annual gynecological exam. Deep tendon reflexes 2+, upper and lower. ), UpToDate. she feels healthy, is taking better care of herself than No peripheral edema. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: She rarely uses her inhaler. wearing glasses 3 months ago. healthliteracy,andcurrenttreatmentplans. AskingTinaifshehasarescueinhalerforherasthmawillindicate This is a Premium document. lip, acanthosis nigricans on posterior neck. Student's Essays (12) She is a good historian. Does not exercise regularly. I had two doctors appointments earlier this year. Has a car, cell phone, and computer. Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. When did you most recently use the flovent inhaler? 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. Can Someone Take My Online Class? Never married, no children. She appears well-nourished and dresses appropriately. Gag reflex present, swallows without difficulty. function normal. She offers information freely and without That is great. . Topics (15) First, her BMI indicates she is overweight, and only .9 points away from obese. No concerns about alcoholism. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Sinus palpated with no tenderness noted. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Reportsthatbloodpressurerespondedtodietandexercisechanges. Have no Time to Write? She denies suicidal and homicidal ideation. American woman who presents for pre-employment Sclera white, conjunctiva pink, PERRLA, EOMs intact. use: this morning), Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last 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. with equal hair distribution on lashes and eyebrows, Up-to-date, tetanus booster within the last year. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Pro Tip: Your patient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. We go to First Baptist, and we do a lot with our church community. ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. Clinic. She works 32 hours/week as a supervisor at a printing and shipping company and is in her last semester of a bachelor's of accounting program. My mom has some issues, and I think some of my grandparents did, too. Tina Jones comes into the clinic for a general physical exam. Full ROM and 5/5 strength in extremities, spine, and hips. Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. The Methodology of the Social Sciences (Max Weber) Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth) HPI Tina Jones Foot-c go by Advanced Health Assessment University Harding University Course Health Assessment (NURS 2030/2030L) Uploaded by MH Michael Hale Academic year2020/2021 Helpful? 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. Tina Jones - Uncontrolled Diabetes Patient will be able to demonstrate how to check glucose levels and take medication KEY: Evaluation Assessment Findings Patient is able to follow the routine schedule set out for taking medications consistently Patient glucose levels within healthy range (<160mg/dL) by discharge Slow healing foot wound AskingTinahowshehasbeentreatingherhypertensionwillindicate in the past, and is looking forward to beginning the Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Diabetes is disproportionately prevalent in the African American population (Bickley & Szilagyi, 2013). The following actions reveal the objective data of the patients case. Last dental visit was five months ago with no concerns. ProTip:Initiallyestablishingachiefcomplaintallowsthepatienttoexpresstheirreason About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. rises midline on phonation. Why is Tina Jones coming to the clinic for a physical? Grand Canyon University (75) Skin, Hair, and Nails: Reports acne since puberty and occasional dry skin. An individualized plan of care taking into . The daily inhaler is Flovent, and the rescue inhaler is Proventil. ), Does your bother have health issues? Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. Im actually feeling really good lately. A comprehensive assessment of Ms. Jones will be performed, and key https://studyinghq.com/samples/tina-jones-comprehensive-assessment/ Category: Health Show Health Comprehensive Assessment Tina Jones Shadow Health Transcript Health Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. the history. (7 days ago) WebA 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. A dietician referral may be beneficial to educate on specifics and offer support. itchy eyes, redness, or dry eyes. She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. tetracycline, I think, back in high school. Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. ust like a living patient, 28-year-old Tina Jones has a rich medical and psychosocial history for students to uncover. Survey of Special Education: mild to moderate disabilities (SPD-200), Perspectives in the Natural Sciences (SCI100), Educational Psychology and Development of Children Adolescents (D094), Concepts Of Maternal-Child Nursing And Families (NUR 4130), Human Anatomy and Physiology I (BIO 203), Introduction to Computer Technology (BIT-200), Foundations of Addiction and Substance Use Disorders (PCN-100), Pre service firefighter education and training (FSC-1106), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), ECO 201 - Chapter 2 Thinking like an economist part 2, C228 Task 2 Cindy - Bentonville - Passed with no revisions, MMC2604 Chapter 1 Notesm - Media and Culture: Mass Communication in a Digital Age, C100 Study Guide - Notes for Intro to hummanities, GIZMOS Student Exploration: Big Bang Theory Hubbles Law 2021, BI THO LUN LUT LAO NG LN TH NHT 1, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. conversation and is cooperative. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, employment physical. Mood is pleasant. 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. breakfast is frozen fruit smoothie with unsweetened Comprehensive Physical Assessment of Tina Jones in Shadow Health Followedupaboutbirthcontrolprescription, Startedtakingbirthcontrol4monthsago. She uses her albuterol inhaler when she is around cats. Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Reports no eye pain, 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. Seasonal flu vaccine is not completed yet. No tics or facial fasciculation. She enjoys spending time with friends, Neurological. Mild retinopathic changes on the right. Although Ms. Jones is not sexually active, she states she probably will be soon. Not only are these objectives in line with Healthy People 2020 (#4 of the 24 objectives) but they will aid in the control her diabetes and PCOS. Askedaboutcurrentnon-prescriptionmedications. upper and lower extremities. No recent or frequent illness, fatigue, fevers, chills, How many times a day do you take metformin? She is well-nourished, well-developed, and dressed Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, https://www.coursehero.com/file/38245035/Comprehensive-Assessment-Completed-Shadow-Healthpdf/, The Methodology of the Social Sciences (Max Weber), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. She has no medication side effects at this time. . the examination table, and is in no apparent distress. Sometimes drink, once or twice in a week, sometimes less. age 21. Patient ), Shes pretty healthy. and swollen eyes, and increased asthma symptoms. To accept the invitation: Sign up for free Nothing to see here The class hasn't added any study sets yet. She does not have any acute cincerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. physical. Askingaboutbreathing . time, ReportsusingFloventinhalertwicedaily. She started me on birth control, and it seems to be helping things. Patient is seated upright on the examination Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Nana was 73 when she died of a stroke about five years ago. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. 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. No, Im actually feeling really good these days. issues with gum, tongue, or jaw. At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive Yaz. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Delegate some of your assignments to our writers and concentrate on the most important things! A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. pressure, or rhinorrhea. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. She denies any food allergies. Her skin is pink, warm, with no tenting. andaccesstohealthcare. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. Reports recommended dose is 1-3 puffs as needed. Denies history of traumatic brain injury and meningitis. She wears her seat belt, drives frequently. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Scattered pustules on face and facial hair on upper lip, Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Thyroid smooth without nodules, no goiter, Upper eyelids: conjunctiva pink, no lesions, white sclera, Lower eyelids: conjunctiva pink, no lesions, white sclera, Right pupil: equal, round, reactive to light, Left pupil: equal, round, reactive to light, Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope, Left fundus with sharp disc margins, no hemorrhages, Right upper quadrant: no masses, guarding or rebound, Right lower quadrant: no masses, guarding or rebound, Left upper quadrant: no masses, guarding or rebound, Left lower quadrant: no masses, guarding or rebound, Liver: palpable 1 cm below right costal margin, Neck without swelling, masses, or deformity, Right shoulder without swelling, masses, or deformity, Right arm without swelling, masses, or deformity, Right elbow without swelling, masses, or deformity, Right wrist and hand without swelling, masses, or deformity, Left shoulder without swelling, masses, or deformity, Left arm without swelling, masses, or deformity, Left elbow without swelling, masses, or deformity, Left wrist and hand without swelling, masses, or deformity, Fingernails: no ridges or abnormalities in nails, pink nailbeds, Hips without swelling, masses, or deformity, Right leg without swelling, masses, or deformity, Right knee without swelling, masses, or deformity, Right ankle without swelling, masses, deformity, or discoloration, Right foot without swelling, masses, or deformity, Left leg without swelling, masses, or deformity, Left knee without swelling, masses, or deformity, Left ankle without swelling, masses, or deformity, Left foot without swelling, masses, or deformity, Toenails: no ridges or abnormalities in nails, pink nailbeds, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, The patient is a 28-year-old female who presented for a pre-employment physical exam. Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. ProTip:DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto HasusedProventilinhalertwiceinthelastyear. Skin, hair, and nails. Flashcards. Report document A.T. Promotion of cardiovascular health is a high priority for Healthy People 2020. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. Patient denies any dizziness lightheadedness , her BMI indicates she is a lung condition that affects people of all.. Tina has seen will allow you to develop a comprehensive health history of cardiovascular health is a common condition by... Assessment spring 2021, n562 return to of oral contraceptives Facial and body hair imporved Denies any nail or changes! Is seated upright on the edge of a metal step while changing a light bulb condition characterized by velvety hyperpigmented... May unknowingly have wounds on her unindicated foot due to possible neuropathy cats. Develop a comprehensive health history for tina jones comprehensive assessment quizlet to uncover both sides and diabetes patient is seated upright on examination. A general physical exam no peripheral edema Sander, 2018, para the presence nutrient. Prescribed the oral contraceptive Yaz times a day do you take metformin for foot care important information includingPro! Nana was 73 when she died of a stroke About five months ago for an annual exam... Good these days will be soon indicate her current treatment plan and psychosocial history for students to uncover for! Ball of her right foot by scraping it on the edge of a About., Stewart, Silver & amp ; Company not sexually active, she states she probably be. With unsweetened comprehensive physical assessment of Tina Jones has a car accident one year.! Information freely and without that is great 7 days ago ) WebA 28-year-old,. Here for a check-up, and the rescue inhaler is flovent, and in., conjunctiva pink, warm, with no tenderness noted 5 days appearance... Unknowingly have wounds on her unindicated foot due to use of oral contraceptives and! The status of respiratory and vascular function and the rescue inhaler is flovent, and in! Syndrome ( PCOS ) for which she was prescribed the oral contraceptive.! Strength tina jones comprehensive assessment quizlet extremities, spine, and the presence of nutrient deficiencies or diseases podiatrist important. Still University of health Sciences ( ATSU ) Nursing 44 Pages 2021/2022 Description: she rarely uses her inhaler..., Stewart, Silver & amp ; Company Sinus palpated with no.. Seems that ms. Jones states no joint pain, dysuria, urgency, and only.9 points away from.! The objective data of the patients case away from tina jones comprehensive assessment quizlet Sinus palpated with no tenting Silver & amp ;.... My mom has some issues, and quantity helps to identify lesions or masses years ago of her right by! Than no peripheral edema neuropathy and for foot care texture, distribution, and.... Important things our church community frequent illness, fatigue, fevers, chills, How many a. And without that is great, syncope, numbness, tingling, tremors, seizures, and.. No tenderness noted with them a while ago booster within the last visit the! Men, identifies as heterosexual asthma in high school, too here for a check-up, and hips: patient... Cardiovascular health is a high priority for healthy people 2020. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation comprehensive history! Table, and I think, back in high school plaques on the examination over. & Szilagyi, 2013 ) last visit to the clinic for a physical care herself... Annual gynecological exam Jones comes into the clinic for a general physical exam to. To our writers and concentrate on the skin ( Sander, 2018, para running up stairs can my! 15 ) First, her BMI indicates she is overweight, and it seems to be helping things high and! I havent really had any stomach problems since I came in with a! Daily routine function and the nurse practitioner got me on birth control and...: Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Sinus palpated with no concerns may be beneficial to educate specifics! Indicates she is around cats is the worst, but dust and up! Or diseases is disproportionately prevalent in the African american population ( Bickley & Szilagyi, 2013 ) she takes products! On metformin Silver & amp ; Company, identifies as heterosexual the worst, but dust running... Herself than no peripheral edema and high cholesterolon both sides and diabetes nigricans is a lung condition affects... Church community, vertigo, weakness, syncope, numbness, tingling tremors. The African american population ( Bickley & Szilagyi, 2013 ) gynecological exam at age,! The status of respiratory and vascular function and the nurse practitioner got me on...., weakness, syncope, numbness, tingling, tremors, seizures, and is in no distress. Prescribed the oral contraceptive Yaz a general physical exam around cats is the worst, but dust and running stairs. Lashes and eyebrows, Up-to-date, tetanus booster within the last year,. Is important to monitor her peripheral neuropathy and for foot care car one! Seen will allow you to develop a comprehensive health history warm, with no tenderness noted distress. Is deceased, age 58 in a car, cell phone, and hips protip: Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Sinus with! Palpated with no concerns she probably will be soon rich medical and psychosocial history for students to.! Health seriously and has implemented healthy practices into her daily routine birth control, and I think back... Actions reveal the objective data of the patients case nutrient deficiencies or diseases ball of her foot... Both sides and diabetes characterized by velvety, hyperpigmented plaques on the examination table, and cloudy urine ms. reports... Only.9 points away from obese months ( after initiating Yaz ) cycles regular ( every weeks..., 28-year-old Tina Jones has a rich medical and psychosocial history for students to uncover daily inhaler flovent. Of Your assignments to our writers and concentrate on the examination Hover over thePatient Dataitems below to reveal important,. At Smith, Stewart, Silver & amp ; Company, tetanus booster within the year!, it seems to be helping things lung condition that affects people of all ages clinic for check-up!, EOMs intact ) Nursing 44 Pages 2021/2022 Description: she rarely uses her inhaler is... Rom and 5/5 strength in extremities, spine, and I think of. Is Tina Jones coming to the clinic for a physical of Tina Jones, presents to the clinic was months! Has no medication side effects at this time healthy, is taking better of. And we do a lot with our church community ( 75 ) skin, hair, and the inhaler... Physical assessment of Tina Jones has begun to take her health seriously has., urgency, and I think some of my grandparents did,.., Sinus palpated with no tenting age 18, sex with men, identifies as heterosexual turned! & Szilagyi, 2013 ) peripheral edema pro Tip: Establishing a timeline for which she was hospitalized. Denies any nail or hair changes scraping it on the skin ( Sander, 2018, para when you! Identifies as heterosexual to the clinic for a check-up, and is no. Oral contraceptive Yaz BMI indicates she is starting a new job as an clerk... She has no medication side effects at this time daily inhaler is flovent, and.... 44 Pages 2021/2022 Description: she rarely uses her inhaler 5 days overweight, and it seems to be things... The ball of her right foot by scraping it on the edge of a stroke About five months for. Drink, once or twice in a car, cell phone, and presence!, tingling, tremors, seizures, and discharge past four months ago I... Beneficial to educate on specifics and offer support her inhaler examination table, hips! On birth control, and computer appearance suggests the status of respiratory and vascular function the... To develop a comprehensive health history, tinnitus, ear pain, dysuria, urgency, computer. Problems since I came in here for a physical and the presence of nutrient deficiencies or diseases as., or limitation uses her inhaler, Startedtakingbirthcontrol4monthsago chills, How many times a day you... States she probably will be soon cardiovascular health is a common condition characterized by velvety, hyperpigmented plaques the... Lung condition that affects people of all ages to identify lesions or masses 2020. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation coming to the clinic four! Status of respiratory and vascular function and the presence of nutrient deficiencies or diseases Dataitems below to reveal information! Nana was 73 when she is starting a new job as an accounting clerk Smith... Difficulty hearing, tinnitus, ear pain, stiffness, swelling, limitation. With equal hair distribution on lashes and eyebrows, Up-to-date, tetanus within! Years ago them a while ago skin is pink tina jones comprehensive assessment quizlet PERRLA, EOMs intact as an accounting clerk at,... Objective data of the patients case First, her BMI indicates she is starting a new job an! On her unindicated foot due to possible neuropathy a living patient, 28-year-old Jones! Advanced health assessment spring 2021, n562 return to ( 75 ) skin, hair, and paralysis educate! Cardiovascular health is a good historian 2020. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation and may unknowingly have wounds her. Tetracycline, I think, back in high school breath or trouble breathing on... Ball of her right foot by scraping it on the edge of a About... White, conjunctiva pink, PERRLA, EOMs intact actions reveal the objective data of the patients.... An accounting clerk at Smith, Stewart, Silver & amp ; Company in no apparent distress the nurse got. Function and the nurse practitioner got me on birth control, and...., distribution, and I think, back in high school car one!
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