Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Neurological. No exercise. Solved essays (236) Diagnosed with PCOS four months ago. The injury occurred about one week ago. I havent had a full asthma attack in years, though. No pregnancies. than twice a week, sometimes not at all" Patient drinks alcohol about six drinks per month Lived independently since age 20, currently lives with mother and sister to support family after death of father one year ago, anticipates moving out in a few months. pdf, Fundamentals of Nursing 9th Edition Taylor Test Bank-1-10, 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, Metformin, 850 mg PO BID (last use: this morning), Drospirenone and ethinyl estradiol PO QD (last Her father is deceased, age 58 in a car accident one year ago. new job. I will be conducting an interview and later perform a physical exam. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. x4. Well-groomed, easily engages in travel. physical examination for the health insurance at my Tonsils 2+ bilaterally. Does this Look Like Your Assignment? Asthma is a lung condition that affects people of all ages. This is a Premium document. I am glad you are having your period every month. 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. place, and time. (Clarified to Do you have drainage from your ears?. Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets and increasing vegetable consumption. No nail deformities. Reports no general ear problems, no change in DNP Assignments (75) American single woman who presents for a pre- Reports 10 pound weight loss in the last 4 months ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Haveyoubeentakingmedicationforyourdiabetes? 37 C. Patient is in no apparent distress. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Typical hertreatmentplanandthedegreetowhichshecomplieswithit. Metformin QD, Yaz QD, Inhaler PRN, "never more Pain is localized to ball of foot related to wound. She was exposed to cats a few days ago and had to use her inhaler once; she reports having to use three puffs instead of the prescribed two. What is the name of the birth control pill you took? Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). Acombinationofopenandclosedquestionswillyieldbetterpatientdata. Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation. I havent had any problems with diarrhea. auscultation bilaterally without cough or wheeze. treatmentplan. When did you last use your rescue inhaler? Since then Ive just washed my face, I havent used anything special. (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 Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. Pustules noted on bilateral cheeks. Denies adverse effects of asthma medication. Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. flatulence is one of the side effect of metformin. Well, I used to smoke pot. . Will begin her new position use: yesterday), Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. PlanMyExam. Chastise symmetric with respiration clear to Patient reports no General mouth Case - Tina jones subjective heent | completed | shadow health 2 4. No recent or frequent illness, fatigue, fevers, chills, Alert and oriented to person, To accept the invitation: Sign up for free Nothing to see here The class hasn't added any study sets yet. Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. condition,experience,orsymptoms. MS Jones reports that she recently landed an employment and thus She needs to obtain a pre-employment physical assessment. 3. Reports no dizziness, tingling, or loss of sensation. She needs to obtain a pre-employment AskingTinaifshetakesnonprescriptiondrugswillindicate Mucous membranes pink and moist, tonsils 2+ bilaterally. andaccesstohealthcare. Mom has high cholesterol and blood pressure, I think. distribution. pink septum midline. Greet 07/22/20 5:37 PM ED. Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. Reports improved acne due to oral contraceptives. denies any acute concerns. 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. He had high blood pressure and cholesterol, and diabetes toothe same kind as me. Sinus palpated with no tenderness noted. last taken 6 weeks ago). Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Frontal and 850 mg twice daily. She denies any acute concerns at this visit. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. 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. Tina Jones Neurological Shadow Health Assessment Education & Empathy, Tina Jones Gastrointestinal Shadow Health Transcript. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She reports a few moles but no other hair or nail changes. Abdomen tympanic on percussion. Nasal ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideatimelinefor ProTip:Follow-upquestionswillenableTinatomorefullyandspecificallydescribeher She was last seen by a primary care doctor a few years ago. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. No wheezing, runny nose or a cough. Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. Skin, hair, and nails. treatmentplans. Abdominal. Patient states there is relief when foot is elevated, not walking on it. hercurrenttreatmentplan. : an American History, Med Surg Nursing Cheat Sheets 76 Cheat Sheets for Nursing Students nodrm pdf, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. Cannabis use from age 15 to Tina Jones is a 28-year-old African American female patient who is single and presented to the clinic with a request for a pre-employment physical examination. Skin on neck has stopped darkening and facial and body hair has improved. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. No peripheral edema. Reportslastasthmaexacerbationwasthreemonthsago. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). Grandpa Jones had colon cancer, and that caused all kinds of problems for him. appropriately with good hygiene. Essay Topics (13) Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. characteristics of performance-driven team (2) . No. OB/GYN: Menarche, age 11. Tests of cerebellar Never intubated. Reports no eye pain, DTRs 2+ and equal bilaterally in andaccesstohealthcare. Do you take your pill at the same time every day? understandingwhenapatientexperiencesacondition. 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. Position sense in fingers and toes are normal. She denies any pain acute illness, pain or discomfort. due to diet change and exercise increase. Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium. Her skin is pink, warm, with no tenting. no other hair or nail changes. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Today she denies any acute concerns. sandwich on wheat bread or low-fat pita, dinner is Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. isfollowingit. Tina Jones Comprehensive Assessment/Comprehensive Assessment Tina Jones Shadow Health Tran, Exams for Nursing 3 (1) 250 points We have received reports about this document. She wears her seat belt, drives frequently. (2018). Fluticasone propionate: 88 mcg/spray, two puffs twice daily. 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Resonant to percussion throughout. occasional shortness of breath, wheezing, and chest chief complaint The injury occurred about one week ago. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Ms. Jones reports no shortness of breath or trouble breathing. Only $35.99/year. Patient is seated upright on the examination Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. PERRLA. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. No tenderness or guarding to palpation. The scrape is red and swollen with exudate and has no odor; she reports the swelling and exudate started two days ago. . 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We Can do an Original Paper for you! Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes, Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol, Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol, Paternal grandmother: still living, age 82, hypertension, Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes. 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. Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months. Doyoutakeyourpillatthesametimeeveryday? No current dental No clicks on jaw palpation, full ROM. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. 1). currenttreatmentplan. Whatisthenameofyourdiabetesmedication? Ive maybe used it twice since I came in with those asthma problems. What is the name of your diabetes medication? Tina Jones Health History Shadow Health Information Processing, Shadow Health Tina jones Mental Health Assessment Subjective Data. . Gag reflex present, swallows without difficulty. surfaces. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. PAST MEDICAL HISTORY Diabetes PCOS Asthma Allergies Medications Metformin: 850 mg BID Flovent: 2 puffs 88 mcg/spray BID Albuterol: 90 mcg/spray MDI 2 puffs gynecological exam at Shadow Health General Decreased sensation to ProTip:Broad,openquestionswillallowTinatodescribe,inherownwords,thespecific She reports a few moles but no other hair or nail changes. Tactile fremitus present. The daily inhaler is Flovent, and the rescue inhaler is Proventil. 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. Abdomen soft with no tenderness, guarding or masses with palpation. Patience hair is well-groomed with even (2014). Tips and ExampleQuestions. Howhaveyoubeentreatingyourhypertension? Askingaboutbreathing My eyes havent been red lately. wearing glasses 3 months ago. Frontal and maxillary sinuses physical exam for the health insurance at my new

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