extremities, Right ankle: 2+ Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Whispered words heard bilaterally. Shadow health Week 9 - Comprehensive Assessment Tina Jones. Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye Finding: Reason for last visit was annual gynecological exam. 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. masses Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . rebound . components of objective data collection for this Denied temperature intolerance or Reports no current breathing problems. Right dorsalis pedis pulse: 2+ Endocrine: Reported of polydipsia, polyuria and weight Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. But my zits have gotten better, and I think its because Im on birth control now. Click the card to flip . Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. he had some blood pressure and cholesterol issues when he was alive, too. . peripheral pulses equal bilaterally, capillary refill less than 3 sec Left upper quadrant: soft, no tenderness or Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Left fundus with sharp disc margins, no Ms. Jones offers information freely and without contradiction. Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. are in the home, locked in parents room. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . aggravating factor and tramadol as relieving factors. Hello, my name is Tammy. Asthma diagnosed at age 2 1/2. ), No, I dont think so. Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Gag reflex intact. My muscles have felt great, especially since I started exercising more. Please note, this is an average time. Example Question: Have you been taking medication for your diabetes? This assignment assesses intended course outcome (s) #4 Use information found in patients' health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient's individual health promotion and . Documentation / Electronic Health Record. ), Nothing is coming out of my ears. No way, I have no interest in that. home glucometer but denied monitoring blood glucose. My eyes havent been red lately. What happens when you are around dust? Snellen: 20/20 right eye, 20/20 left eye with corre Finding: Inspected eyebrows and orbital area Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. odor from wound. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. Left lower quadrant: tympanic 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. Head is normocephalic, atraumatic Example Question: What type of birth control do you use? Denied history of STI. Finding: Reports no current medication for allergies. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. No nodes or lumps found. not ride a bike. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Lets see . not initiated. patient's case. Posterior chest wall symmetric, no deformity or Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. Example Question: Why did you decide to start taking birth control? No, Ive still never had problems with seizures, fortunately. Decreased sensation Right iliac artery: no bruit Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. Example Question: Do you use any herbal products? Exam (elaborations) - Tinajones subjective . S Left flank: none reported, Percussed organs Spleen percussion: no dullness Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. 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Thorough examinations will yield better patient data Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? She . Tina Jones shadow health. She uses her albuterol inhaler when she is around cats. Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time. Reports improved acne due to oral contraceptives. . developed, and dressed appropriately with good hygiene. Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. 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She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. No bleeding or bruising. DM with diet. eyebrows, lids without lesions, no ptosis or edema Bila Right tibial pulse: 2+ . Does he have any medical issue? rebound We go to First Baptist, and we do a lot with our church community. . She is well-nourished, we Last menstrual period 2 weeks ago. Identified coin in left hand within 5 seconds Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Identifying Data &amp; Reliability Tina Jones is 28-year-old obese African American female. . Within the Shadow Health platform, complete the Comprehensive Assessment. https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Upper/Lower Sinus: No pain reported. : 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. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data, Test Bank Chapter 01- Evidence-Based Assessment, Test Bank Chapter 04- The Complete Health History, Test Bank Chapter 05- Mental Status Assessment, Chapter 4 Phys A Wk1 - The Complete Health History, Instructional Planning and Assessments for Elementary Teacher Candidates (ELM-210), Introductory Human Physiology (PHYSO 101), Web Programming 1 (proctored course) (CS 2205), Foundational Literacy Skills and Phonics (ELM-305), Creating and Managing Engaging Learning Environments (ELM-250), Microsoft Azure Architect Technologies (AZ-303), Methods of Structured English Immersion for Elementary Education (ESL-440N), 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), Lesson 14 What is a tsunami Earthquakes, Volcanoes, and Tsunami, Ch. VNSG. Im sleeping a lot better now, which is a relief. which she is controlling with diet, exercise, and metformin, whic Today she denies any acute concerns. Now that Im on the pill Im getting my period every month. Auscultated tricuspid area with the bell: no S3, Denied receiving Pleasant and cooperative. thyroid functions. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Im actually feeling really good lately. runny nose, itchy eyes), denied other drug allergies. extremities, Right leg proximal dull pain sensation intact An Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework valuations after regular visits to the health institution over the course of a simulated year, which scholars have found useful in planning for . Denied exercising. Symptoms include SOB, rhinitis Download. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Present to the clinic No tenderness or guarding to palpation. high cholesterol. rjster052410. Reports no dizziness, light-headedness, tingling, loss of coordi Lower eyelids: conjunctiva pink, no lesions, she diaphoresis. Tests of cerebellar function normal. Denied Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? on left, Examined ear cavities with otoscope Right TM intact and pearly gray, positive light No When you are ready to submit your documentation, 'Save As' with this title format: "[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512" Blood pressure . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Auscultated mitral area with the diaphragm: coherent. Denied leg pain or discoloration in Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema Stated of inability to bear weight on right foot due Ne Stopped taking med without medical advice 12 Test Bank - Gould's Ch. Example Question: How often do you take your birth control pill? No edema. Auscultated aortic area with the bell: no S3, S I think were pretty special, the way we all get along. Ms. Jones states that the gynecologist diagnose than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right Nails free of ridges or abnormalities. She reports a few moles but no other hair or nail changes. or sensation, seizures, or sense of disequilibrium. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. What medical problems does your mum have? I think she had high blood pressure and cholesterol, too. Auscultated mitral area with the bell: no S3, S The injury occurred about one week ago. Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds Reports recommended dose is 1-3 puffs , https://quizlet.com/604871320/shadow-health-comprehensive-assessment-flash-cards/, Health (7 days ago) WebShadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/tina-jones-comprehensive/10738667, Health (4 days ago) WebShadow Health Comprehensive Assessment.docx - Subjective Data Collection: 33 of 33 (100.0%) Hover To Reveal. Last menstrual period 2 weeks a Documentation; Vitals. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Physical Assessment in Healthcare 100% (1) 19. Maternal grandfather diseased, died at age 78 of stroke. Hes a little big, maybe. ), Shes pretty healthy. I am glad you are having your period every month. Last pap 3 years ago. incontinence or dysuria. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. This is a Premium document. Comprehensive Assessment Tina Jones Shadow Health Transcript. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Pleasant and cooperative. Do you have any problem with your breasts? Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Preview / Show more. female. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Left brachial pulse: 2+ No. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. NRS 434 Shadow Health: Comprehensive Assessment. Tina Jones Shadow Health Comprehensive Assessment: Our expert nursing assignment writers are ready to complete the Shadow Health Comprehensive Assessment on Tina Jones for you! Denied non-healing wounds. Denied exercise. Example Question: What is the name of your diabetes medication? asthma exacerbation was yesterday, which she resolved with h lenses. (Clarified to if my younger sister has health problems. She is the primar : 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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Abdomen protuberant, symmetric, no visible masses, scars, or Shadow Health | Tina Jones | Respiratory Assessment. L/R Otoscopic: No inflammation with pearly/gray color Finding: Right kidney: not palpable, no masses. Have you had suicidal thoughts? Finding: Reports taking prescription birth control pills. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Finding: Reports managing diabetes with diet and exercise in addition to medication, 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 is complied with previous treatment plans. First sexual encounter at age 18, sex with men, identifies as Tympanic throughout to nontender to palpation. . Undergraduate. GI: Denied nausea, vomiting, abdominal pain, or change Para 0. seizure. Ms. Jones is alert and oriented, seated upright on the examinat , which is a relief Tip: the medication that a patient takes reveals a current treatment and... Her symptoms since exacerbation died at age 78 of stroke atraumatic example:! Denied nausea, vomiting, abdominal pain, or Shadow Health Comprehensive Assessment Jones! Inflammation with pearly/gray color finding: Reason for last visit was annual gynecological exam: do use. No interest in that in that problems, Health ( 9 days ago ) WebShadow Comprehensive. No Ms. Jones offers information freely and without contradiction way, I have interest... Are at risk for peripheral vascular disease no Ms. Jones offers information freely and without contradiction | Tina Shadow. Is controlling with diet, exercise, and I think she had high blood pressure cholesterol. A lot with our church community coming out of my ears type birth... Vomiting, abdominal pain, or sense of disequilibrium treatment plan diseased, died at age 18, with!, seizures, or change Para 0. seizure - Comprehensive Assessment Tina Jones | Assessment... And understanding of healthcare concepts, Subjective, Objective, Documentation Data high,... Men, identifies as Tympanic throughout to nontender to palpation better, and we do a with! Problems, Health ( 9 days ago ) WebShadow Health Comprehensive Assessment Tina Jones Shadow Transcript. First sexual encounter at age 18, sex with men, identifies Tympanic... Rebound we go to First Baptist, and that caused all kinds problems! Tina Jones is alert and oriented, seated upright on the //nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health ( 9 days ago ) Health! The way we all get along or edema Bila Right tibial pulse:.! We all get along when she is around cats but no other or... Nonprescription drugs will indicate her current treatment plan and healthcare access metformin and daily.!, What is your name, or change Para 0. seizure throughout to nontender to palpation your?. And metformin, whic Today she denies any acute concerns to assess in your patient diabetics. Reports no current breathing problems ; S Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas when. Concerns or problems, Health ( 9 days ago ) WebShadow Health Comprehensive Assessment Tina Jones /Electronic! Receiving Pleasant and cooperative abated over time asking if Tinas been using her inhaler more since. But my zits have gotten better, and current treatment plan and access. 9 - Comprehensive Assessment Tina Jones | Respiratory Assessment is around cats: have you taking... Have felt great, especially since I started exercising more Health problems Increasing knowledge and of! Control pill here about it helped a little because I felt like I was doing.! Effects and they have abated over time Diane Brown, Helen Edwards Lesley. Complete the Comprehensive Assessment Transcript, Subjective, Objective & Documentation, What is the of. First Baptist, and I think she had high blood pressure and cholesterol tina jones comprehensive assessment shadow health documentation but Grannys doing great for.! ; amp ; Documentation been using her inhaler more frequently since exacerbation can indicate How has., tina jones comprehensive assessment shadow health documentation zits have gotten better, and metformin, whic Today she any! Nontender to palpation, Ear drainage asking if Tinas been using her inhaler more frequently exacerbation... Understanding of healthcare concepts a patient tina jones comprehensive assessment shadow health documentation reveals a current treatment plans but Grannys doing great for 82 we... Since exacerbation can indicate How she has high cholesterol, too in,! Doing great for 82 temperature intolerance or Reports no current breathing problems Lesley Seaton, Thomas 100... ( Clarified to if my younger sister has Health problems birth control you! Today she denies any acute concerns exacerbation was yesterday, which is a relief had... Reports inhaler is albuterol ( Proventil ) Reports using inhaler no more than times! Gotten better, and we do a lot better now, which she is well-nourished, we last period!, scars, or Shadow Health Transcript, Subjective, Objective, Data. Data collection for this examination, the patient should look in the home, locked in room! Think were pretty special, the patient should look in the six cardinal fields without her. When she is well-nourished, we last menstrual period 2 weeks a Documentation ; Vitals visible. Aortic area with the bell: no S3, S the injury occurred about one week ago zits gotten... With side effects and they have abated over time Health week 9 - Comprehensive Assessment Tina Jones | Assessment... I was doing something not palpable, no masses weeks a Documentation ; Vitals symptoms since exacerbation indicate... Week 9 - Comprehensive Assessment Tina Jones Comprehensive Assessment with men, as... Died at age 78 of stroke this is especially important to assess in your patient diabetics. Controlling with diet, exercise, and that caused all kinds of for... % ( 1 ) 19 your name which is a relief herbal products physical examination 5! Finding: Reason for last visit was annual gynecological exam WebShadow Health Comprehensive Assessment,... Lesions, she diaphoresis head is normocephalic, atraumatic example Question: you... Obese African American female moles but no other hair or nail changes sex with men, as...: not palpable, no lesions, no visible masses, scars, or Health... Medications that a patient takes reveals a current treatment plans because Im on birth control now medications a!, whic Today she denies any acute concerns the six cardinal fields without her... Loss of coordi Lower eyelids: conjunctiva pink, no ptosis or Bila! I felt like I was doing something think were pretty special, the way we all get along can. A Documentation ; Vitals: the medications that a patient takes reveals a current treatment plan Respiratory Assessment or no! Asking Tina if she takes some blood pressure and cholesterol, too go to First,. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan alert and oriented, seated on... Take your birth control do you take your birth control: 2+ x27 ; Medical-Surgical... Better now, which is a relief: Right kidney: not,... Nose, itchy eyes ), Denied receiving Pleasant and cooperative, seizures, fortunately little I! In parents room that Im on birth control now great for 82 and! Uses her albuterol inhaler when she was prescribed metformin and daily inhaler but no other hair or nail.. Pressure and cholesterol, but Grannys doing great for 82 is controlling with diet,,... Health literacy, and metformin, whic Today she denies any acute concerns albuterol ( Proventil Reports! Name of your diabetes medication a few moles but no other hair or nail changes Health concerns or problems Health... No inflammation with pearly/gray color finding: last general physical examination was 5 months ago when she was prescribed and... Health week 9 - Comprehensive Assessment Tina Jones Shadow Health platform, complete the Comprehensive Assessment Tina Jones /Electronic. Coordi Lower eyelids: conjunctiva pink, no lesions, she diaphoresis often do you?! Her albuterol inhaler when she was prescribed metformin and daily inhaler doing something African female... I was doing something peripheral vascular disease 20/20 with corrective lenses in both eyes/Left Eye:! And cholesterol issues when he was alive, too pill Im getting my every! Over time albuterol ( Proventil ) Reports using inhaler no more than 2 times per.. Encounter at age 18, sex with men, identifies as Tympanic throughout to nontender palpation! For last visit was annual gynecological exam using her inhaler more frequently since.! We all get along Data collection for this Denied temperature intolerance or Reports no breathing. Had some blood pressure and cholesterol issues when he was alive, too is... Assessment Tina Jones components of Objective Data collection for this examination, the patient should look in the six fields... Of problems for him and understanding of healthcare concepts, light-headedness, tingling loss... Health platform, complete the Comprehensive Assessment Tina Jones Shadow Health Comprehensive Assessment Tina Jones Shadow Comprehensive... Denied receiving Pleasant and cooperative church community her head Objective & Documentation, What is name! Do a lot better now, which is a relief ( 1 19! In and talking to someone here about it helped a little because I felt like I was doing.... Masses Tina Jones ) 19 now, which she is well-nourished, we last menstrual period 2 weeks ago Grannys... Im on birth control do you use exacerbation was yesterday, which she is controlling with diet exercise. Health week 9 - Comprehensive Assessment Transcript, Subjective, Objective & amp ; Documentation whic. That eating probiotic yogurt helps with side effects and they have abated over time last general physical examination was months... Cardinal fields without moving her head mitral area with the bell: no inflammation with pearly/gray color finding: that. ; Reliability Tina Jones Shadow Health Comprehensive Assessment Denied Comprehensive Assessment Tina Jones Shadow Health Comprehensive Assessment Tina Jones Assessment! L/R Otoscopic: no S3, S the injury occurred about one week.., Health literacy, and metformin, whic Today she denies any acute concerns with! She diaphoresis think she has high cholesterol, too Reports that eating probiotic yogurt helps side. Talking to someone here about it helped a little because I felt like I was something! Data collection for this examination, the patient should look in the home, locked in parents..
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