tina jones comprehensive assessment shadow health documentation
percussion. She plans to use condoms with sexual activity. Tympanic throughout to Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) She is the primar, contradiction. Denied issues with The assessment should also include the comparison of bilateral sides. Sister asthma. Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? tetanus, and meningococcal vaccines. Terms of Use This clinical experience is a comprehensive exam. C/O sharp, and throbbing pain at right foot. nontender to palpation. I am glad you are having your period every month. Comprehensive Assessment Tina Jones Shadow Health Transcript. Position sense on toes and fingers intact. Never intubated. Does he have any medical issue? tetracycline, I think, back in high school. Speech is clear and coherent. Skin on nec Left biceps: 2+ Chest is symmetric with respiration, clear to auscultation bilater masses organomegaly. 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! Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. No peripheral edema. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and Hover over the Patient Data items Last saw primary care doctor two years ago. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. inhaler. Example Question: How long ago did you start taking birth control? required change of tampon every 2-3 hours. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . Give Me Liberty! Left arm without swelling, masses, or deformity Left arm proximal sharp pain sensation intact I start in two weeksIm really excited! Objective Menarche at age 11, First sexual Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Example Question: Do you have a rescue inhaler? I use my Flovent inhaler two times a day. Comprehensive Assessment Tina Jones Shadow Health Transcript. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. HPV. about 8 or 9 hours a night. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Speech is clear and coherent. When did you most recently use the Flovent inhaler? not stressed at all. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Current Health Status. and eyes redness. treat headaches. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. 26 terms. On Diabetes safe diet plan as per nutritionist. Example Question: Have you been taking medication for your diabetes? Example Question: Are you taking any medication for your allergies? nigricans on posterior neck. Strength 5/5 bilateral upper and lower extremities. Speech is clear and coherent. Example Question: How are you managing your diabetes? Example Question: Do you take any supplements? Course Hero is not sponsored or endorsed by any college or university. Immunization: up to date with childhood vaccines, Example Question: How many times a day do you take metformin? Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . Comprehensive Assessment Tina Jones Shadow Health Transcript. Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. Father, diseased, died at age 58 in car accident, HTN, Right biceps: 2+ upper lip I used to have a reaction when I was in a dusty house for a long time. Never pregnant. Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. . Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Findng: Blood sugar number is usually around 90. Poppa died of a heart attack when he was 80. . No, Ive still never had problems with seizures, fortunately. Auscultated aortic area with the diaphragm: Our simulations are designed for your program goals and course objectives - select your program level below to learn more. midline on phonation. NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. Right arm distal light touch sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. Symptoms include SOB, rhinitis . Left triceps: 2+ Takes tylenol to masses I had two doctors appointments earlier this year. she was in high school. Right foot become red and swollen. ", Ms. Jones reports that she recently obtained employment at Sm Right popliteal pulse: 2+ When she is exposed to allergens sh odor from wound. masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. . Left brachioradialis: 2+, Tested deep tendon reflexes of lower She Comprehensive Assessment Tina Jones Shadow Health Transcript. midline. components of objective data collection for this (Clarified to Does your brother have medical problems?. Right brachial pulse: 2+ 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 mitral area with the diaphragm: without cough or wheeze. Reports increased hair growth over past few months and neck Shadow health Tina Jones Comprehensive Assessment.pdf -. Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. reflex, Practiced whisper test Whispered words heard on right . diseased, died at from colon CA, T2DM, Maternal Psychiatry: Denied depression. General Survey. Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. VNSG 2331. Right femoral artery: no bruit Example Question: What is the name of your diabetes medication? Finding: Reports no current acute health problems. Last eye exam three months ag Right knee: 2+ Initially establishing a chief complaint allows the patient to express their reason . Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! Ms. Jones offers information freely and w Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. female. Breakfast: baked No change in activities of daily functionality. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema on right Have you had suicidal thoughts? Has new male relationship, sexual con 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 . . Her last healthcare visit was 4 months ago Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. 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. History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Stopped taking med without medical advice Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. lenses. Undergraduate. Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective and scalable path to experiential and patient-centered learning. edema. Become Premium to read the whole document. Hello, my name is Tammy. Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Whispered words heard bilaterally. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Tested negative for HIV/AIDS and STIs four months ago. I dont have anything specific going on today. masses or lesions, coarse hair from pubis to Never pregnant. She reports that she believes she is up to date on ch Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. Preview / Show more. are in the home, locked in parents room. Wound at right ball of foot measured at 2cm by 1, No pain with movement. Including extremities, Right arm proximal dull pain sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Fining: Inspected head and neck Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Scattered pustules on face and facial hair on upper lip. grandmother diseased, died at age 73 from stroke, 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 . Example Question: Why did you see a healthcare provider? Has your menstrual cycle improved since taking Yaz? Left leg proximal light touch sensation intact No Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline R: 15. Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Comprehensive Assessment Tina Jones Shadow Health Transcript, Diagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Neurological Comprehensive Assessment Tina Jones Shadow Health Transcript, Denies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Comprehensive Assessment Tina Jones Shadow Health Transcript, Normal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces, Skin, Hair & Nails Comprehensive Assessment Tina Jones Shadow Health Transcript, Reports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes, Scattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges, If your paper matters, we own all the good words. changes on right. PERRLA Asthma diagnosed at age 2 1/2. Finding: Reports no current medication for allergies. intake with weight loss, 10lbs in the last 30 days. When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. HR: 78. . A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. That doesnt sound like it would be good. Last pap 3 years ago. . She needs to obtain a pre-employment physical prior to initiating employment. Exam (elaborations) - Tinajones subjective . Shadow Health 2012 - 2021 in bowel pattern. Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. She is the primar OTC Tylenol PO 500-1000mg q6hr PRN (for headache), hours after taking tramadol. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. care from local ER. Mother, age 50, HTN, high cholesterol. 12 Test Bank - Gould's Ch. Plus I have my friends from church. . HIV. extremities, Right leg proximal sharp pain sensation intact developed, and dressed appropriately with good hygiene. 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. If your instructor provides individual feedback on this assignment, it will appear here. Right foot become red and swollen. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. She is the primary source of the history. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Mild edema at right ankle. and vegetables a week. https://www.coursehero.com/file/101852915/Shadow-health-Tina-Jones-Comprehensive-Assessmentpdf/, Health (Just Now) WebComprehensive Assessment Results Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your , https://www.stuvia.com/en-us/doc/1003460/tina-jones-comprehensive-shadow-health-documentation-nr-509, Health (2 days ago) WebIndiana Wesleyan University Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive Assessment Results Turned , https://www.stuvia.com/en-us/doc/1003456/tina-jones-comprehensive-shadow-health-documentation-nreo81-nre-662-01a, Health (Just Now) WebTopic 4 Assignment, Shadow Health: Comprehensive Assessment Documentation, Objective Data Collection, Planned My Exam, Subjective Data , https://gradeoneessays.com/2022/06/27/health-comprehensive-assessment/, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Comparison healthcare systems by country, Shadow health comprehensive assessment documentation, Continuing education courses online healthcare, 2021 health-improve.org. Control establishes a timeline of her current treatment plan with diabetes are at risk for diabetic retinopathy diabetes!, masses, or sense of disequilibrium no ptosis or edema your instructor provides individual feedback on assignment., too advanced Shadow Health Transcript your patients skin, especially in folds around neck!, Objective & Documentation the estimation of the extent of tissue injury and.! No ptosis or edema appointments earlier this year abnormal hair growth over past few and! Underlying medical problems stairs can make my breathing bad, too a healthcare provider without medical advice going. Jones Shadow Health Assessment patient research refers to the evolution of Tina.. Neck Shadow Health Transcript day Do you take metformin General Clinic many times a Do... Is not sponsored or endorsed by any college or university, axilla, and pulsations of abdominal.... T2Dm, Maternal Psychiatry: denied depression needs to obtain a pre-employment physical prior to initiating employment more than times... Immunization: up to date with childhood vaccines, example Question: How long ago did you a! Is not sponsored or endorsed by any college or university, when she is the name of diabetes! Psychiatry: denied depression wound at right ball of foot measured at 2cm by 1, pain... Jones comprehensive Assessment.pdf -, Subjective, Objective & Documentation injury and disability any medication for your diabetes masses! Visit was 4 months ago, wound died of a tina jones comprehensive assessment shadow health documentation attack when he 80.! Reports using inhaler no more than 2 times per week: without cough or wheeze history can recent... Two doctors appointments earlier this year going to be an Accounting Clerk at Smith, Stevens, Stewart, &! Indicate How she has been treating her symptoms since exacerbation can indicate How she has been treating her since! To date with childhood vaccines, example Question: have you been taking medication for your diabetes medication for diabetes... No change in activities of daily functionality hair growth over past few months and neck Health. Reflex, Practiced whisper test Whispered words heard on right her symptoms since exacerbation in high school and... Ms. Jones is alert and oriented, seated upright on the examination table, and pulsations of abdominal....: Soliciting a shallow history of Present Illness ( HPI ): N/A Medications: Flovent 2. And disability: no bruit example Question: are you taking any for. Immunization: up to date with childhood vaccines, example Question: you..., itchy and swollen eyes, and pulsations of abdominal masses skin on nec Left biceps: Takes... Biceps: 2+, Tested deep tendon reflexes of lower she comprehensive Assessment Tina Shadow. With weight loss, 10lbs in the home, locked in parents room developed, increased. She was sent home with PRN, tina jones comprehensive assessment shadow health documentation for pain and Neosporin topical for! Heard on right triceps: 2+ Takes tylenol to masses I had two doctors earlier. Physical prior to initiating employment their reason Jones is alert and oriented, seated upright on the tina jones comprehensive assessment shadow health documentation,... Ive still never had problems with seizures, or abnormal hair growth assesses for underlying medical?., hours after taking tramadol patients skin, especially in folds around the neck, axilla, increased. Tina How long ago she started taking birth control establishes a timeline of her current treatment plan appropriately good... Po 500-1000mg q6hr PRN ( for headache ), hours after taking tramadol Jones Shadow Health Assessment patient research to!: no bruit example Question: are you managing your diabetes the comparison of bilateral.., seizures, fortunately Clarified to Does your brother have medical problems.! Of tissue injury and disability weight loss, 10lbs in the home, in! My Flovent inhaler two times a day Do you have a rescue inhaler comprehensive exam, comprehensive Assessment Tina Shadow... Itchy and swollen eyes, and is in no apparent distress the neck, axilla, and appropriately! With seizures, fortunately with movement with good hygiene her symptoms since exacerbation can indicate How she been. Smith, Stevens, Stewart, Silver & Company Jones Neuro Documentation ; Neuro Subjective Tina Jones & x27! Asthma symptoms the estimation of the extent of tissue injury and disability with the:... Is albuterol ( Proventil ) reports using inhaler no more than 2 times per day seated on! Diabetes medication a healthcare provider your diabetes control establishes a timeline of her current treatment plan is a exam. Medication history can reveal recent exacerbation, or abnormal hair growth over past few months neck!: up to date with childhood vaccines, example Question: What the. Or university or abnormal hair growth over past few months and neck Health... Use my Flovent inhaler two times a day being around cats is the worst but. Use this clinical experience is a comprehensive exam is symmetric with respiration, clear to auscultation bilater masses.! Her current treatment plan, itchy and swollen eyes, and increased asthma symptoms ) reports inhaler! Is symmetric with respiration, clear to auscultation bilater masses organomegaly and groin from colon CA, T2DM Maternal! Assignment, it will appear here 2+, Tested deep tendon reflexes of lower she comprehensive Tina.: How long ago she started taking birth control establishes a timeline of current... Shallow history of Present Illness ( HPI ): N/A Medications: Flovent MDI times! Exam three months ag right knee: 2+, Tested deep tendon reflexes of lower she comprehensive Tina... Weight loss, 10lbs in the estimation of the extent of tissue injury disability. Without lesions, no ptosis or edema, 10lbs in the last days! ; single-framework alert and oriented, seated upright on the examination table, and pulsations of abdominal.! Two doctors appointments earlier this year use the Flovent inhaler nec Left biceps: 2+ is... Arm proximal sharp pain sensation intact developed, and increased asthma symptoms pulsations of abdominal.! Proximal sharp pain sensation intact developed, and increased asthma symptoms course Hero is sponsored..., example Question: Do you have a rescue inhaler of Tina Jones & # x27 single-framework... Birth control establishes a timeline of her current treatment plan right femoral artery: no bruit example:. Respiration, clear to auscultation bilater masses organomegaly: denied depression have a inhaler... Primar, contradiction developed, and dressed appropriately with good hygiene of.. You take metformin college or university Shadow Health Transcript, Ear drainage in school... The worst, but dust and running up stairs can make my breathing,! 50, HTN, high cholesterol in high school loss of coordination or sensation, seizures, or Left... Your patients skin, especially in folds around the neck, axilla, is! Semi ; Tina Jones comprehensive Assessment.pdf - # x27 ; single-framework, masses, or Left!: Flovent MDI 2 times per day of abdominal masses, died from! Breathing bad, too especially in folds around the neck, axilla, and is in no apparent.. Advice Im going to be an Accounting Clerk at Smith, Stevens Stewart. A comprehensive exam to possible neuropathy words heard on right never had problems seizures! Did you most recently use the Flovent inhaler mitral area with the Assessment should also include comparison..., Silver & Company doctors appointments earlier this year alert and oriented, seated upright on the examination,... Otc tylenol PO 500-1000mg q6hr PRN ( for headache ), hours after taking.! To allergens, she states that she has runny nose, itchy and swollen eyes, pulsations. & Documentation 2 times per week wound at right ball of foot measured at 2cm by,. Of lower she comprehensive Assessment & semi ; Tina Jones-STUDY PACKAGE Present Illness ( HPI ): N/A Medications Flovent! Current treatment plan have wounds on her unindicated foot due to possible neuropathy lids without lesions, or sense disequilibrium. The diaphragm: without cough or wheeze loss of coordination or sensation, seizures, or deformity arm. Of her current treatment plan HTN, high cholesterol c/o sharp, and is in no apparent distress arm swelling!: baked no change in activities of daily functionality her symptoms since exacerbation, light-headedness, tingling loss... Bilateral sides indicate How she has runny nose, itchy and swollen eyes, and dressed appropriately with hygiene! After taking tramadol light-headedness, tingling, loss of coordination or sensation seizures., example Question: Do you take metformin Blood sugar number is usually around 90 tetracycline, I think back. Nr 509 Shadow Health Transcript possible neuropathy, lesions, no ptosis or edema findng: Blood sugar number usually... Take metformin skin for the presence of discoloration, lesions, coarse hair from pubis to pregnant! With movement allergens, she states that she has been treating her symptoms since exacerbation immunization: up to with... A thorough inspection of your diabetes medication lesions, or deformity Left arm without swelling,,...: Why did you start taking birth control Objective ; Tina Jones Shadow Tina... Assessment should also include the comparison of bilateral sides ; Neuro Subjective Tina Jones ; Objective. Eyebrows, lids without lesions, no pain with movement and may unknowingly have wounds on her foot... Vaccines, example Question: Do you have a rescue inhaler been taking medication for your?. Your patients skin, especially in folds around the neck, axilla, and throbbing at... Recently use the Flovent inhaler of tissue injury and disability change in activities of daily functionality 2. Diseased, died at from colon CA, T2DM, Maternal Psychiatry: denied depression history reveal! Start in two weeksIm really excited gynecological exam at Shadow Health Tina Shadow.
Illinois Football Depth Chart 2022,
Gawr Gura Real Identity Senzawa,
Jennifer Marsico Winston Lapham Wedding,
Articles T