Reports only caffeine is diet Coke She came into the clinic for a physical exam. Denies adverse effects of asthma medication Full ROM and 5/5 strength in extremities, spine, and hips. Office of Disease Prevention and Health Promotion. Example Question: (Found) Speech is coherent and audible. Finding: Denies Vaping (Available)Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and is a potential factor in delayed wound healing. 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Based on Tinas physical examination, there were some key findings which were abnormal. Hair is normal texture and distributed evenly. Denies changes in hearing or ear pain. Her skin is pink, warm, with no tenting. Diabetes requires self-management behaviors for life. Position sense in fingers and toes are normal. Finding: Last use of her rescue inhaler was three months ago and two times total over the past year. (2016). Another abnormal finding was the discoloration on her neck. This is a public forum for the class. Upon inspection, abdomen protuberant and symmetric. How often do you use your inhaler? Risk factors: Obesity, family history of Hypertension, diabetes, Coronary arteries disease, ReasonforbirthcontrolwastomanagePCOSsymptoms. She also has been keeping records of her asthma by monitoring her peak flow. Paternal grandfather: died at age 65 of colon cancer, and a history of type 2 diabetes. Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. When in doubt, cite the source. What is your typical lunch? , please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a final submit to me. Finding: hyperlipidemia and stroke, lack of exercise, and healthy diet. Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). Shadow health Tina Jones-Guide to Comprehensive Assessment. Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 150 points; students successfully scoring at the Proficiency level on the second attempt will earn a grade of 135 points; and students successfully scoring at the Proficiency level on the third attempt will earn a grade of 120 points. Discovering a patients individual response to pain medication is an important factor in your overall treatment plan. treatmentplans. abnormal hair growth, and acne since stopping oral contraceptives 18 months ago, as well as Do you use any herbal products? A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and . 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. Example Question: Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Adult Illnesses: Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Her gait is smooth with equal stride. She states she takes the pill daily, at the same time each day. Communication is so very important. Example Question: Assessment Tina Jones comes in for a follow-up/general physical exam. There has been no recent the pain and swelling in her ankles have subsided, but the bottom of her foot is increasingly. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. Do you drink soda? The following details are facts of the patients case. Asked review of systems for genitourinary. No clicks on jaw palpation, full ROM. 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). Physical activity. Mild retinopathic changes on the right. Denies gastrointestinal issues How long ago did you start taking birth control? Do you have side effects from your birth control? during the teenage years. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Finding: Cross), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward). There is no family history of other cancers, mental illness. Finding: What is your average blood sugar number? Tina Jones comes into the clinic for a general physical exam. Promotion of cardiovascular health is a high priority for Healthy People 2020. Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. Permalink:https://eaziessay.com/comprehensive-asnt-of-tina-jones/. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). Fill in your requirements and let our experts deliver your work asap. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. (Found) Finding: Does it hurt when you breathe? (Found) Understanding a patients history of birth control can be an indicator of health literacy. Finding: Howoftendoyouuseyourrescueinhaler? Left disc round with sharp margins. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns. Example Question: (Found) (Found) exacerbations from dust or cats she uses her albuterol inhaler, but she never uses it more than (Found) Pro Tip: Asking about the frequency and duration of a patients periods, as well as the severity of cramps and heaviness of flow, will help you understand what it typical for the patient. All of the papers you get at MyCoursebay are meant for research purposes only. Example Question: Reports occasional chest tightness She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. isfollowingit. treatmentplan. Finding: Example Question: Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patients safety while she is in your care, as it affects what medications will be safe and appropriate. 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. Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. COMPREHENSIVE HISTORY (Subjective Data), Date & Time: 1/20/2023 at 8pm Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). Simply restating someone elses words does not demonstrate an understanding of the content or critical analysis of the content. sunscreen. (Found) NRS 434 Shadow Health: Comprehensive Assessment Reports last visit to a healthcare provider was 4 months ago Vision 20/20 bilateral with corrective lenses. Ms. Jones states her acne has improved due to oral contraceptive use. B. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. AskingTina Reports birth control is drospirenone and ethinyl estradiol (Yaz) Supervisor at Mid-American Copy and Ship. Pro Tip: It is important to solicit information about Tinas current asthma symptoms, as this will allow you gain an up-to-date picture of her condition. Her 24-hour diet She is the primary source to her own health history. She reports a few moles but no other hair or nail (Found) Followed up about birth control prescription. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. andaccesstohealthcare. Client Identifying data. she'sseenhervisionassomethingthathasneededmedicalattention. Finding: Finding: Finding: Pro Tip: Finding out how many alcoholic drinks a patient has in a single sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient. As Masters level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. General. Please note, this is an average time. symptomsmostrecentlyrequiredmedicaltreatment. AskingTinaifshehasarescueinhalerforherasthmawillindicate Finding: Ms. Jones is a pleasant, 28-year-old obese African American single woman who works as a With the assistance of Orems self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health. sister after the death of father one year ago. Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Example Question: Finding: Identifying Data & Reliability Tina Jones is a single 28-year-old African American female who presents to the clinic to seek care due to a recent right foot injury. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Comprehensive Health History for Shadow Health History & Final Comprehensive Health, Department of Nursing, Otterbein University, Dr Joy Shoemaker, Ruth Chavez, Deidre Arms, Chai Sribanditmongkol, The Methodology of the Social Sciences (Max Weber), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Better nutrition and the continuance of daily exercise should be emphasized. Example Question: (Found) Example Question: Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. Paraphrasing also requires a citation. provided all the information freely and truthfully. Peripheral pulses 2+, equal bilaterally. Example Question: (Found) Reports history of smoking recreational marijuana Example Question: I came in because Im required to have a recent physical exam for the health insurance at my new job.. Reports menstrual cycle is normal (Found) Reports diabetes medication is metformin Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Pustules noted on bilateral cheeks. Pro Tip: The efficacy of pain medication varies from patient to patient. Awake and alert. Her paternal grandmother is alive and well, 82, with hypertension. Finding: (Found) Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. condition,experience,orsymptoms. (Found) Points will be deducted for poor use of APA format or absence of APA format (if required). She appears well-nourished and dresses appropriately. (Found) Review the report by clicking on each tab to the left titled; Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. Palpated fremitus equal bilaterally. Why did you see a healthcare provider? Are you allergic to penicillin? been cleaning the wound twice a day and applying antibacterial ointment and bandages. 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 if a patient uses tobacco products is important to understanding her overall health and identifying potential health risks. ProTip:Solicitingashallowhistoryofapatient'smedicationhistorycanrevealrecent Reports typically taking 2 puffs (2014). Do you have enough supplies to monitor your blood glucose? She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Abnormalities may also point to underlying issues that should be addressed. The injury occurred about one week ago. Tina states she is very excited about the new opportunity. Do you sleep well? Example Question: Normal hair distribution. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. Reports last use of Proventil inhaler was yesterday (Found) A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Pro Tip: Asking Tina about how many puffs of her inhaler she takes can help you determine if the treatment is effective and appropriate for her health needs. (Found) Oriented to person, place, and time. Finding: Reports taking ibuprofen for cramps I will be conducting an interview and a physical exam. She denies any food allergies. Asking Tina if shes lost weight might indicate recent changes in health. Sclera white, conjunctiva pink, PERRLA, EOMs intact. No wheezing, runny nose or a cough. Reports belief that asthma is well-controlled andaccesstohealthcare. Pro Tip: Broad questions about the gastrointestinal system will enable the patient to express any symptoms, concerns, or conditions that she may have. Pro Tip: Determining if Tina has experienced any side effects of her diabetes medication will help you determine the efficacy and appropriateness of her medication. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. (Found) Have you noticed any problems with your head? Neck: Denies difficulty swallowing, swollen glands, goiter, lumps, pain, or neck stiffness. (Found) abouttherecentseverityofherasthmawillallowhertoassesshercondition. She has Example Question: She is allergic to cats and dust. These announcements are made to ensure you understand everything that is due during the week. Finding: Finding: Denies adverse effects of diabetes medication 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. Example Question: Abel to identify sharp, dull and soft touch to upper and lower extremities. Denies a runny nose or sneezing. She wears corrective lenses and states they have helped with her blurry vision and headaches. History of Present Illness (HOPI): Ms. Jones recalls tripping on concrete stairs outside a week Finding: Full ROM of TMJ with no crepitus. Reports eating probiotic yogurt helps with side effects. Finding: (Found) Finding: Finding: Example Question: She wears corrective lenses and states they have helped with her blurry vision and headaches. Skin, hair, and nails. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Upon examination, head is normocephalic with no lesions or tenderness of scalp. Mouth/throat: Denies any dental problems. Denies integumentary issues NRS 434 Shadow Health: Comprehensive Assessment. Shadow Health - Tina Jones, Health History Flashcards. Denies cardiovascular issues improve headaches. Although Ms. Jones is not sexually active, she states she probably will be soon. Reportslastasthmaexacerbationwasthreemonthsago. (SHADOWHEALTHCOMPREHENSIVEASSESSMENTTINAJONESDOCUMENTATION/ELECTRONICHEALTHRECORD.) Denies adverse side effects from birth control Fluticasone propionate: 88 mcg/spray, two puffs twice daily. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. healthcare due to out-of-pocket costs. Hover To Reveal. Uses alcohol one to Fingernails pink without clubbing, ridges or abnormalities. Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Example Question: forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. Mucous membranes pink and moist, tonsils 2+ bilaterally. hercurrenttreatmentplan. been prescribed 1-3 puffs as needed and she reports using 3 puffs. Pro Tip: Follow up questions about Tinas diabetes medication history and timeline will help you to understand her treatment plan and recent health history. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Do you use a glucometer? Do you still have menstrual cramps? Finding: Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Example Question: (2018). Pro Tip: Asking about a patients mental health is important for understanding their overall well-being. Lived independently since age 20, currently lives with mother and Asking Tina what she typically has for a snack will illustrate her recent dietary patterns. Finding: Diabetes requires self-management behaviors for life. No clicks on jaw palpation, full ROM. Musculoskeletal. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. No current complaints or recent illness. (Found) Finding: Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. Example Question: her neck and increased facial and body hair. Reports a typical snack is carrot sticks or an apple Pro Tip: It is important to determine the severity of Tinas asthma, as a worsening conditions indicates a need for further treatment. Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Finding: (Found) It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. Childhood Illnesses: Asthma diagnosed at age two and a half. Finding: Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014). (Found) Asked review of systems for musculoskeletal. She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. Asked about diabetes management through lifestyle. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Example Question: Have you had chills? Asked review of systems for skin, hair and nails, Finding: Reports having an inhaler You will develop differential diagnosis based on the chief complaint and HPI. She is the primary source of history, and she Cultural Competence in the Care of Muslim Patients and Their Families. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what exercise she does can help you to assess her current levels of health and nutrition. Finding: Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014). A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). eventually get married and have kids. Reports eating probiotic yogurt helps with side effects. Cardiac: Elevated Blood pressure on the current visit. Example Question: Oriented to person, place, and time. 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