If no support systems are available in your community, identify a national resource. B. (2014). Finding: Is there anything unusual about your menstrual cycle? (Found) Paternal grandfather: died at age 65 of colon cancer, and a history of type 2 diabetes. chest pain, and irregular heartbeat. 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! Finding: Example Question: These announcements are made to ensure you understand everything that is due during the week. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, The Methodology of the Social Sciences (Max Weber), Psychology (David G. Myers; C. Nathan DeWall), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! Asked review of systems for neurological. Full ROM and 5/5 strength in extremities, spine, and hips. Reports eating probiotic yogurt helps with side effects. Reports sometimes needing 3 puffs to control symptoms Diabetes is disproportionately prevalent in the African American population (Bickley & Szilagyi, 2013). Reports a typical breakfast is smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt Asking Tina how many days a week she exercises can help you to assess her current levels of health and nutrition. Example Question: She denies any food allergies. Indicatesanitemthatisavailabletobefound. Ear canal pink, tympanic membrane pearly gray, no drainage. Found: Risk factors: Obesity, family history of Hypertension, diabetes, Coronary arteries disease, Reports dust allergy Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. Tina Jones comes into the clinic for a general physical exam. How many puffs of your inhaler do you typically take? Stereognosis and graphesthesia normal bilaterally. Surgical: No surgeries to date. Example Question: She doesnt monitor her blood sugar regularly at home. Our research-backed program helps improve data collection, therapeutic communication, and care planning. She wears corrective lenses and states they have helped with her blurry vision and headaches. You can get the same paper from different writers. Ms. Jones states her acne has improved due to oral contraceptive use. Example Question: Family History: Reports taking prescription birth control pills (Found) A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. Plus I have my friends from church. Skin, hair, and nails. thyroid problems. Abdomen tympanic on percussion. (Found) Finding: Thyroid palpable, no nodules, no goiter. Ms. Jones is sitting comfortably on the examination table, in no acute distress. Tina jones comprehensive. Comprehensive physical assessment with subjective and objective data utilizing ShadowHealth Asked review of systems for gastrointestinal. I highly recommend using the APA Publication Manual, 6. Her snacks consist of pretzels or French fries. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. RC Rachel1 month ago thank you uploader Students also viewed Quiz 1 study guide 19 20 22 Midterm Study Guide Exam 1 Study Guide S20 ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Finding: (Found) Asking Tina if she takes supplements will indicate her current treatment plan. support her in managing stress. Example Question: Documentation He had hypertension, high cholesterol, and type 2 diabetes. Example Question: The object cannot be in equilibrium because more than one force acts on it. Can you confirm your asthma? 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. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Reports a typical snack is carrot sticks or an apple provided all the information freely and truthfully. Finding: A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. (Found) A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Example Question: An individualized plan of care taking into . ReasonforbirthcontrolwastomanagePCOSsymptoms. (Found) frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent Pro Tip: Asking Tina about the recommended dose of her inhaler can help you determine if the treatment is effective and appropriate for her health needs. (Found) Metformin: Started five months ago. 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. All of the papers you get at MyCoursebay are meant for research purposes only. Ms. Jones is a pleasant, 28-year-old obese African American single woman who works as a There are no pets. Example Question: Her new job is as an accounting clerk, which starts in two weeks. Example Question: Familiarize yourself with APA format and practice using it correctly. Finding: Finding: When in doubt, cite the source. It is not a focused assessment. Mucous membranes pink and moist, tonsils 2+ bilaterally. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. comparinganattack,exacerbation,andmoreregularbreathing. Communication is so very important. 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. Do you sleep well? History of Present Illness (HOPI): Ms. Jones recalls tripping on concrete stairs outside a week Followed up on ibuprofen (Advil). Have you been wheezing? practices. Denies sinus problems, frequent She has recently started a new relationship but denies she is sexually active. Abnormalities may also point to underlying issues that should be addressed. Example Question: (Found) ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Tetanus Self-care instruction should include reiterating the importance of taking her pill the same time every day to prevent pregnancy, the fact that the pill does not protect against sexually transmitted disease (STD) and that a form of protection needs to be used to protect against STDs when the time comes. Pro Tip: Follow up questions about Tinas medication adherence will help you to understand her treatment plan and recent health history. Example Question: Example Question: (Found) Finding: PlanMyExam. Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. (Found) Finding: Example Question: There were retinopathic changes in her right eye that are mild. Her speech is clear and eye contact is appropriate. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. Personal and Social History: Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. isfollowingit. She is the primary source of history, and she Her last Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Bates guide to physical examination and history taking(11th ed.). Doyoutakeyourpillatthesametimeeveryday? AskingTinahowlongagoshestartedtakingbirthcontrol In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideatimelinefor (Found) Fingernails pink without clubbing, ridges or abnormalities. and balancing work and school demands, and finances. Liver span 7 cm MCL, palpable 1 cm below right costal margin. When was the last time you used your inhaler? AskingTinaifshetakesvitaminswillindicatehercurrent Have you lost weight? Pro Tip: Once you uncover that Tina has recently been prescribed eyeglasses, it is important to follow-up on any effects, both positive and negative, that she may have noticed. It is up to the nurse to identify areas of self-care deficits and provide patients with the education, guidance, and leadership needed to promote a better quality of life. Example Question: hercurrenttreatmentplan. Bickley, L. S., & Szilagyi, P. G. (2013). A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. Never married, no children. Are you experiencing adverse effects from your diabetes medication? Nasal cavities pink, no discharge. Example Question: Finding: Mouth/throat: Denies any dental problems. Have you been taking medication for your diabetes? For assignments that need to be submitted to. This clinical experience is a comprehensive exam. Asked about last visit to a healthcare provider. There were retinopathic changes in her right eye that are mild. Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, and Example Question: I came in because Im required to have a recent physical exam for the health insurance at my new job.. Example Question: Ms. Jones reports no shortness of breath or trouble breathing. Pro Tip: Asking Tina if she experiences swelling will help you better understand her general health. Otterbein University NURS 6830 Advanced Health Assessment Dr Joy Shoemaker, Ruth Chavez, Deidre Arms, Chai Sribanditmongkol January 30, 2023 . Pro Tip: Establishing a timeline for Tinas gynecological exams will allow you to develop a comprehensive health history. She is now on metformin, Proventil, and Flovent. Bilateral carotids 2+, no thrill, no bruits. Ms. Jones has a penicillin allergy with a reaction of rash. Her gait is smooth with equal stride. Not currently in an intimate relationship. Skin: Reports acne since puberty and occasional dry skin. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. Finding: Use Coupon CODE: SAVE15, 2013 - 2023 Online Nursing Essays. (Found) 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. Pro Tip: Finding out when a patients LMP was indicates whether she might be pregnant (although this question alone cant rule out pregnancy). HPI Tina Jones Foot-c go by Is sammy alive - in class assignment worth points 10th Amendment Deconstructed Copy of 7.4.1 - Seed Germination Gizmo Hesi fundamentals v1 questions with answers and rationales Summary Give Me Liberty! hertreatmentplanandthedegreetowhichshecomplieswithit. Asking how frequently Tina uses her inhaler can indicate how shes been treating her symptoms. Her father is deceased, age 58 in a car accident one year ago. Select your preferred writer from the list of writers who have handledf your previous assignments, Are you ordering the same assignment for a friend? ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich Reports diabetes Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. 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. Sclera white, conjunctiva pink, PERRLA, EOMs intact. 850 mg twice daily. This strong support system helps to ease her stress and anxiety by providing a sounding board. (Found) Example Question: Example Question: Example Question: 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. A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. AskingTinaifshe'shada Last dental visit was five months ago with no concerns. Reports only caffeine is diet Coke ProTip:Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Finding: Do not use (Found) Finding: She currently lives with her mother and sister but has a lease starting on her own apartment in one month. Reports inhaler is albuterol (Proventil) A dietician referral may be beneficial to educate on specifics and offer support. Reports diabetes medication dose is 850 mg ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand The rescue inhaler was last used three months ago with a total of two uses in the past year. HEENT. Wears Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. Drospirenone and ethinyl estradiol: one pill every day. This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Upper and lower extremities symmetric without lesions or swelling. Psychiatric: Denies any signs of depression, suicidal thoughts, or ideation. I came in because Im required to have a recent physical exam for the health insurance at my new job.. We do not endorse or condone any type of plagiarism. (2018). Asked about constitutional health. currenttreatmentplan. Do you take your pill at the same time every day? She also has increased her physical activity. Do you smoke? Example Question: Asking Tina if she drinks soda will illustrate her recent dietary patterns. Example Question: Review your similarities. Comprehensive Physical Assessment of Tina Jones in Shadow Health Reports checking blood sugar once a day Finding: Heart rate is regular, S1, S2, no murmurs, gallops or rubs. Ms. Jones, it is necessary to carry your inhaler with you at all times if you haven't been doing so. (Found) ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Finding: A few days ago, she was exposed to a cat and had to use her inhaler once. Example Question: Finding: She reports no depression or anxiety. Finding: See what other students think about our do my paper service. Please communicate with me if you anticipate having to submit an assignment late. Office of Disease Prevention and Health Promotion. Denies coughing When do you check your blood glucose? Reports doing occasional breast exams Chamberlain College Of Nursing Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. Reports walking for exercise Current Health Status, Finding: Finding: General. Past Medical History Finding: You'll also be able to download it from your account and request a revision or rate the work as appropriate. gallbladder and liver disease. When was your last physical exam? (Found) All Rights Reserved. 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. Finding: Pro Tip: Inquiring into what breast screenings Tina has had can lead to a discussion about any test results and their implications for her cardiovascular health. She reports no depression or anxiety. (Found) Do you take Advil? Finding: ),UpToDate. Finding: (Found) Denies changes in hearing or ear pain. Inactive problems: Type 2 diabetes, Asthma, Dysmenorrhea, Oligomenorrhea, Menorrhagia, Example Question: The universitys policy on late assignments is 10% penalty PER DAY LATE. Pro Tip: Determining any outcomes from Tinas last optometrist visit is important, as it may reveal treatments that you should follow-up on. Skin, hair, and nails. Struggling to find relevant content or pressed for time? Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis Tina jones comprehensive questions to ask - Your Results Reopen Lab Pass Overview Transcript - Studocu Advanced assessment your results reopen lab pass overview transcript subjective data collection objective data collection documentation plan my exam subjective Skip to document Ask an Expert Sign inRegister Sign inRegister Home It is particularly important for Tina, as she suffers from asthma. Finding: Ms. Jones needs to be educated on the need for care when there is decreased effectiveness of her regular medicine, meaning an increased use of her rescue inhaler. Health Maintenance: No exercise but states her work keeps her very active. Vision 20/20 bilateral with corrective lenses. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns. Finding: Example Question: Areyoutakinganyformofbirthcontrol? Finding: Can you confirm your allergies? Pro Tip: Asking a patient for her subjective report on the heaviness of her cramps will help you understand her feelings about her menstrual symptoms. Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how long her walks are can help you to assess her current levels of health and nutrition. symptomsmostrecentlyrequiredmedicaltreatment. Reportsneedingapre-employmentphysical. (SHADOWHEALTHCOMPREHENSIVEASSESSMENTTINAJONESDOCUMENTATION/ELECTRONICHEALTHRECORD.) Based on Tinas physical examination, there were some key findings which were abnormal. (Found) Example Question: She is the primary source to her own health history. Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol. strong family and social support system. Reports reason for last visit was annual gynecological exam No wheezing, runny nose or a cough. Ms. Jones should be encouraged by the additions and progress she has made. Get a 10 % discount on an order above $ 100! 1). 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. Denies neurological issues Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. (Found) Example Question: States skin on neck has stopped darkening. Reports no dizziness, tingling, or loss of sensation. Liver span 7 cm MCL, palpable 1 cm below right costal margin. Example Question: Finding: Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease.