Upon examination, head is normocephalic with no lesions or tenderness of scalp. At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive Yaz. Available: How often do you take your birth control pill? Do you have swelling? Reports drinking 2 diet Cokes per day Howhaveyoubeentreatingyourhypertension? Reports heavy, irregular periods, She denies any food allergies. Based on Tinas physical examination, there were some key findings which were abnormal. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. symptomsmostrecentlyrequiredmedicaltreatment. Howoftendoyouuseyourrescueinhaler? How many drinks do you have in a sitting? medicationforherdiabeteswillindicatehertreatmentplanandthedegreetowhichshe The following details are facts of the patients case. NRS 434 Shadow Health: Comprehensive Assessment AskingTinaifshetakesvitaminswillindicatehercurrent Asked review of systems for neurological. (2018). support her in managing stress. Have you had any stomach or bowel problems? Family History: Journal for Specialists in Pediatric Nursing. Example Question: Ms. Jones is a pleasant, 28-year-old obese African American single woman who works as a Example Question: Example Question: Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Has your asthma changed at all? Pro Tip: Asking Tina if she has been to an eye doctor will indicate the degree to which shes seen her vision as something that has needed medical attention. Environmental factors such as dust, dustmites, mold, pollen, (secondhand) smoke could contribute to an asthma exacerbation. Pro Tip: Asking Tina when she last saw an eye doctor will indicate the degree to which shes seen her vision as something that has needed medical attention. (Found) Finding: Ms. Jones has a penicillin allergy with a reaction of rash. Denies pain while breathing Denies adverse effects of diabetes medication Comprehensive Health History for Shadow Health History & Final Comprehensive Health No clicks on jaw palpation, full ROM. Do you perform breast self-exams? 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. Her 24-hour diet Example Question: Department of Nursing, Otterbein University As soon as the paper is ready, well send you a copy via email. She is the primary source of information and is reliable. Skin, hair, and nails. Finding: Communication is so very important. No use of (Found) Asking Tina what exercise she does can help you to assess her current levels of health and nutrition. The rescue inhaler was last used three months ago with a total of two uses in the past year. Example Question: Ms. Jones is sitting comfortably on the examination table, in no acute distress. Paternal grandmother: still living, age 82, hypertension. : an American History - Chapters 1-5 summaries Newest Theology - yea Leadership class , week 3 executive summary She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. AskingTinaifshetakesherbalproductswillindicateher She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. sister after the death of father one year ago. Pro Tip: Finding out specifically if a patient drinks coffee helps you understand what constitutes her typical caffeine intake. room, where she underwent negative x-rays and received tramadol for pain management. Risk factors: Obesity, family history of Hypertension, diabetes, Coronary arteries disease, Do you have any bone problems? Followed up about diabetes medication. al, 2021). Reports last menstrual period was 2 weeks ago Have you had fevers? 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. Finding: Reports diabetes medication is metformin Has your asthma medication changed? Example Question: Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. She denies any food allergies. She is a good historian. ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. (Found) Reports last general physical examination was 5 months ago Finding: Asked about current non-prescription medications. Her last severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious Using Orems self-care model for asthmatic adolescents. Getting your paper done is easy when you know the right people. She currently lives with her mother and sister but has a lease starting on her own apartment in one month. Awake and alert. Finding: (Found) She denies any acute concerns at this visit. Cultural competence and cultural awareness is needed in nursing especially when gathering information and assessing a patient to effectively empower and promote health (Grand Canyon University, 2018). Adult Illnesses: These allergens aggravate her asthma symptoms, so she tries to avoid them. 850 mg twice daily. Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. gallbladder and liver disease. Finding: : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Civilization and its Discontents (Sigmund Freud), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Pro Tip: Asking Tina if she experiences night sweats will help you better understand her general health. Selected filters 2 Institution Rasmussen College Course Shadow Health Comprehensive Assessment Tina Jones Documentation /Electronic Health Record. Reports dust allergy When she experiences He had hypertension, high cholesterol, and type 2 diabetes. Tina Jones comes into the clinic for a general physical exam. Subjective Data Collection: 33 of 33 (100.0%) 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. (SHADOWHEALTHCOMPREHENSIVEASSESSMENTTINAJONESDOCUMENTATION/ELECTRONICHEALTHRECORD.) Category: Health Detail Health Tina Jones Comprehensive Health Assessment. First, her BMI indicates she is overweight, and only .9 points away from obese. When was the last time you used your inhaler? Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. Is your paper made up of someone elses thoughts more than your own? (7 days ago) WebAlthough Ms. Jones can answer over 100,000 questions, you should only need to ask a fraction of these to obtain a complete health history. Pro Tip: Determining the exact amount of weight loss can indicate whether its within expected ranges, or extreme, which may indicate an underlying health problem. Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Mucous membranes pink and moist, tonsils 2+ bilaterally. Pro Tip: Finding out how many nights per week/month your patient consumes alcohol gives insight into potential habits or abuse. She reports stressors relating to the death of her father Denies vaping (Found) (Found) Have you been coughing? 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. Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and identifying potential health risks. Finding: She used to take metformin but stopped taking it Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Indicatesanitemthatisavailabletobefound. I am happy to be flexible. Full ROM and 5/5 strength in extremities, spine, and hips. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Her snacks consist of pretzels or French fries. What is the name of your diabetes medication? Are you taking any form of birth control? A dietician referral may be beneficial to educate on specifics and offer support. She appears well-nourished and dresses appropriately. Paternal grandfather: died at age 65 of colon cancer, and a history of type 2 diabetes. COMPREHENSIVE HISTORY (Subjective Data), Date & Time: 1/20/2023 at 8pm Reports she smoked marijuana when she was younger but has not for many years. Have you noticed any problems with your head? Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. 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:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Finding: (Found) Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. Pro Tip: Determining the last time Tina used her inhaler will help you gain an up-to-date picture of her condition and determine the efficacy of her current medication. Screening tests Last Pap smear was four years ago. Thanks for the paper. andaccesstohealthcare. Finding: She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. hertreatmentplanandthedegreetowhichshecomplieswithit. Finding: changes. Example Question: Exploring Gender in Science, Technology, and Mathematics. Pro Tip: Determining if Tina has experienced any adverse effects of her diabetes medication will help you determine the efficacy and appropriateness of her medication. (Found) Asked about current prescription medications. Have you experienced any urinary problems? 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. WK7Assgn 1Payette A - Assignment for week 7, WK9Assgn 1 The patient is a 70 year old Caucasian female that presents with complaints, WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough, Focused Episodic SOAP Note for Sore Throat, Week 4 Skin Assignment Picture 2 (Stretch Marks), Business Environment Applications II: Process, Logistics, and Operations (D079), Bachelor of Secondary Education Major in Filipino (BSED 2000, FIL 201), Professional Nursing Concepts III (5-8-8) (HSNS 2118), Art History I OR ART102 Art History II (ART101), 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), Summary Reimagining Global Health - Chapter 5 & 6, Eden Wu.Focused Exam Respiratory Syncytial Virus Completed Shadow Health, Chapter 15 Anxiety and Obsessive-Compulsive Disorders, Lunchroom Fight II Student Materials - En fillable 0, Summary Give Me Liberty! 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