Pro Tip: Establishing a timeline for how frequently Tina gets blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Her last asthma related hospitalization was when she was 16. Last dental exam five months ago. Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tinas current condition and previous breathing concerns or conditions. She reports that she believes she is up to date on xxx and received the xxxx for xxx. Pro Tip: Because problems like mouth or throat cancer can be genetic, its important to understand family history to determine risk factors. Symptoms include SOB, rhinitis The static temperature and pressure at each section are indicated. Followed up about medications and relieving factors for throat symptoms. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms. Pro Tip: Tinas response to a question about taking any antihistamines will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Communication is so very important. She states that. Looking at the template, it asks for rationales. Never tested for Tested XXX four months ago. Pro Tip: Infected sinuses can manifest as nose problems. Reports sore throat began about a week ago. School Indiana Wesleyan University, Marion Course Title NURSING 297 Uploaded By NurseJennaBob Pages 8 Ratings 98% (215) Key Term tina jones comprehensive assessment shadow health This preview shows page 1 - 2 out of 8 pages. Comprehensive Assessment- Tina Jones subjective.pdf -. Pro Tip: A family history of allergies is an important factor to determine whether a patient is at risk for developing allergies. Missing some information regarding health concerns, by excluding information from screening assessments and demographics, Health concerns are not identified due to information missing from screening assessments and demographics, Completely asses patients nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions, Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions, Most of the information regarding the patients nutrition and activity levels are missing, recommendations are missing or not based on the patients age, race, gender and pre-existing medical conditions, Identifies support systems such as family members and community resources, Missing some information regarding support systems such as family members and/or community resources, Little to no information regarding social support Tina Jones shadow health, Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions, Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions, Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions, Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living, Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living. First sexual encounter at age 18, sex with men, identifies as inhaler. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. I am happy to be flexible, with advance notice. She is well-nourished, we. her daily inhaler has helped with her environmental allergies. when she received her annual gynecological exam at Shadow Do you have a history of throat problems? Asking Tina if she has dry eyes solicits information about one particular symptom. Tina Jones shadow health. Correct: Malignancies originating in the pelvis or abdomen are likely to metastasize to the left supraclavicular lymph node, also known as Virchows node. Breakfast: baked just started 5 months ago. Weight bearing as So you will need to make reference to these in APA format. Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Present to the clinic, coherent. Ms. Jones is alert and oriented, seated upright on the examinat f [Content_Types].xml ( O0H|W!tr(kOZ=~{I-lh^"%~w5 'n[oO{V$N ]^ZRA.l>pHh the day i caught my fiance cheating 2 days before our wedding. Pro Tip: Chills could be an indication of fever, which could be an indication of infection. She uses her albuterol inhaler once daily in the morning with average readings being around 9 Tina's speech. Stevens, Stewart, Silver & Company. at that visit, which she is tolerating well. intubated. Last menstrual period 2 weeks ago. Liver Span: 7cm MCL on percussion EOMs intact bilaterally, no nystagmus. If you have a question, there is a good chance one of your peers does as well. She was last hospitalized for asthma in high school. Assessments should include a history of hearing impairment and ear injuries. Asking Tina whether she has been wheezing illustrates how her asthma is presenting. Patient has been eating healthy, using recipes from online for diabetes. She states that her daily inhaler has, improved her asthma. Case - Week 4 shadow health tina jones 3. No peripheral edema. Utilize therapeutic communication techniques in obtaining a comprehensive health history and physical examination. states that she has runny nose, itchy and swollen eyes, and This is a comprehensive H & P. You will be assessing the \whole\ person. loss of 10lbs in the last month. 82 years, hypertension. Pro Tip: Changes in sense of smell could be a symptom of acute sinusitis. discoloration over last few years. Pro Tip: Tinas response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Looking for palpable nodes, redness, swelling, tenderness, drainage, loss of hearing, and pain. Cite all sources of information! Health Maintenance Tina Jones Comprehensive Assessment Final Paper. DTRs 2+ and eq Get a 10 % discount on an order above $ 100! Has smoke detectors in the home, wears seatbelt in car, and do Have you taken anything for your sore throat? She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Maternal grandfather- deceased at 65 years- colon cancer and diabetes type 2. GU: Pt stated of polydipsia and polyuria. Health Maintenance Chest is symmetric with respiration, clear to auscultation bilater With that said. Reports headaches after long periods of reading. Pro Tip: Exposure to dust can result in painful ear, nose, or throat symptoms. Pro Tip: Sinus infections can result in inner ear disturbances and thus lightheadedness. Uses sx. gD,~M?Jx Questions to Instructor Forum: This is a great place to ask course content or assignment questions. No varicose vein. Father- (58 yrs.) Denied receiving Does not consider self-care needs or activities of daily living. Denied temperature intolerance or Tina Jones Comprehensive Assessment Final Paper, PCOS: takes Drospirenone and ethinyl estradiol. It, includes interview of patient or a caregiver as is the case with adults with dementia and, for children. Ill be helping a more, experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Diabetic Neuropathy as evidence to decreased sensation on both right and left great toes and right heels. Scattered pustules on face and facial hair on upper lip, acantho Denies coffee intake, but does consume 1-2 diet sodas per day. I would need to assess vital signs, including temperature as well as obtain a rapid strep swab and a throat culture swab to asses for bacterial or viral properties and verify if an antibiotic would be needed. A review of Tinas health history indicates Tina has, been seen multiple times at the clinic prior to this visit for different reasons including, laceration of her left foot following an accident at home, exacerbation of Asthma. Tina's health history was taken, a physical. When submitting hard copy, be sure to use white paper and print out using dark ink. She came into the clinic for a physical exam. Tina is 5 feet 7 inches tall and weighs 90kg. Uses alcohol when out with friends, 2-3 times per month, reports drinking no more than 3 drinks per episode. Asking Tina how many puffs of her inhaler shes prescribed will indicate her treatment plan and the degree to which she complies with it. Resonant to percussion throughout. Tina Jones shadow health. source of the history. Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Hematology or Lymphatic: Denied history of anemia or Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Patient is oriented to time, place, and situation. Stopped taking med without medical advice she drinks occasionally with friends once or twice a week. Course Hero is not sponsored or endorsed by any college or university. 02 Physical Exam Students gather and interpret objective data to assess the patient's condition. Pro Tip: Inhaler effectiveness can vary over time for a variety of reasons. Denies family history of headache or migraine, Right: Tympanic Membrane Colorright and left ear, It is possible to develop new allergies as an adult, and so I will take that into consideration as I try to determine the cause of your symptoms., Im sorry to hear you dont feel well. Tympanic throughout to If your instructor provides individual feedback on this assignment, it will appear here. 0Yq6 CS6jQf7UZTO1U LY6VcBT]'[u-8BczezIeu1OGJ*.%H7PzI{(xw"?XW9"ZDctzeSU =.4":?rC9z^>:,kjL:(GJO^pxCio4%4>Ag\Qb yUEDE&eB (Example: Advised to lock guns up in safe). Never pregnant. Tina Jones Comprehensive Health Assessment. contact throughout the interview. When, interviewing the patient the practitioner is able to get a health history and the history of, the patients chief complaint. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems. Denied exercising. Paternal grandmother, Sister asthma. one of the virtual patients in Shadow Health. Education/Health Promotion: She stated of having Those are gotten from EBP and clinical guidelines. Throughout to if your Instructor provides individual feedback on This assignment, will. 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