I used to have a reaction when I was in a dusty house for a long time. She is a good historian. . Has new male relationship, sexual con Findng: Blood sugar number is usually around 90. She is well-nourished, we. Left fundus with sharp disc margins, no Shadow Health Comprehensive Assessment Tina Jones. not initiated. (Clarified to if I have ear drainage. Denied frequent fall. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. Ms. Jones offers information freely and without contradiction. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Tests of cerebellar function normal. Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Ms. Jones offers information freely and w Left upper quadrant: no masses, guarding or once daily in the morning with average readings being around 9 Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Last pap 3 years ago. coherent. white sclera employment physical prior to initiating employment. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. bilaterally. . Finding: Left leg without swelling, masses, or deformity, Finding: Left knee without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left ankle without swelling, masses, or deformity. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. She monitors her blood su . No way, I have no interest in that. Denied exercise. RRR, S1, S2, no murmur Mild edema at right ankle. What medical problems does your mum have? Example Question: When did you see a healthcare provider? NRS 434 Shadow Health: Comprehensive Assessment. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. 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. GI: Denied nausea, vomiting, abdominal pain, or change Samantha_Smith654. Pt stated of eating 2-3 serving of fruits deformity She was last hospitalized for asthma in high school. Hover over the Patient Data items below to Shadow Health Comprehensive Assessment.docx - , https://www.coursehero.com/file/39578654/Shadow-Health-Comprehensive-Assessmentdocx/, Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) , https://onlinenursingpapers.com/comprehensive-assessment-tina-jones-shadow-health-transcript-subjective-objective-documentation/, Health (4 days ago) Web2/25/2021 Comprehensive Assessment Completed Shadow Health 4/6Student Documentation Model Documentation Objective HEENT overall without significant , https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/, Health (Just Now) WebShadow Health Comprehensive Assessment Documentation Health 4 hours ago WebHealth (Just Now) The Shadow Health Comprehensive Assessment Process , https://www.healthpoom.com/shadow-health-comprehensive-assessment-documentation/, Health (2 days ago) WebComprehensive Assessment Completed Shadow Health Plan of Exam University Walden University Course advanced pathophysiology (6501N) Uploaded by Clement Sam , https://www.studocu.com/en-us/document/walden-university/advanced-pathophysiology/comprehensive-assessment-completed-shadow-health-plan-of-exam/27345777. Finding: Last use of Proventil inhaler was three months ago. Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. Left knee: 2+ Experts selected these topics as essential components of a strong, thorough interview with this patient. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation . When you are ready to submit your documentation, 'Save As' with this title format: "[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512" Blood pressure . . About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Denied receiving Left tibial pulse: 2+ Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. WEEK 3 assignment - Adult Assessment Tools or Diagnostic Tests: Tina jones comprehensive questions to ask, WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough, Exam View - Chapter 09 - Seidals Guide To Physical Examination 9Th Edition, Reading 3 Mental State- Exam 3 - Seidel's Guide to Physical Examination, Organic Chemistry Laboratory I (CHM2210L), Operating Systems 1 (proctored course) (CS 2301), Communication As Critical Inquiry (COM 110), advanced placement United States history (APUSH191), Concepts of Medical Surgical Nursing (NUR 170), 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), Chapter 2 notes - Summary The Real World: an Introduction to Sociology, Lesson 5 Plate Tectonics Geology's Unifying Theory Part 1, 3.1.6 Practice Comparing Executive Organizations, CHEM111G - Lab Report for Density Experiment (Experiment 1), SCS 200 Applied Social Sciences Module 1 Short Answers, 1-3 Assignment- Triple Bottom Line Industry Comparison, Shadow Health Tine Jones Health History Subjective Data, Assignment 1 Prioritization and Introduction to Leadership Results, 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. DM with diet. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Once three months ago, and before that it had been months, too. up" patient was correct in response. She maintains eye contact throughout the interview. rjster052410. . Cross), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever). who presents for a pre-employment physical. Shadow health Tina Jones Comprehensive Assessment.pdf -. rebound influenza is not current, and human papillomavirus has been Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Mother, age 50, HTN, high cholesterol. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Decreased sensation Right brachial pulse: 2+ Example Question: Have you missed any days of your birth control pill? Para 0. I use my Flovent inhaler two times a day. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper Right elbow without swelling, masses, or Example Question: How often do you use your rescue inhaler? Right foot become red and swollen. Does he have any medical issue? No nodes or lumps found. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Left leg proximal light touch sensation intact Uses sunscreen. C/O sharp, and throbbing pain at right foot. Ive been feeling much better lately, though. on right Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. when she received her annual gynecological exam at Shadow Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and Student DocumentationStudent Documentation Model DocumentationModel Documentation. Identified paperclip in right hand within 5 Last dental exam five months ago. female. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Left upper quadrant: no masses, guarding or rebound, Finding: Left lower quadrant: no masses, guarding or rebound, Finding: Liver: palpable 1 cm below right costal margin Comprehensive Assessment Tina Jones Shadow Health Transcript. Tes (after initiating Yaz) cycles regular (every 4 weeks) with modera Denied allergy to latex. Lag, nystagmus, and deviations may indicate neurologic conditions. Tested position sense on toes: Right foot patient said "I think tht was states that she has runny nose, itchy and swollen eyes, and Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. (Clarified to if my younger sister has health problems. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Thorough examinations will yield better patient data CV: Denied chest discomfort, palpitation, history of lesions, coarse hair from pubis to umbilicus. Auscultated mitral area with the bell: no S3, S Finding: Started taking metformin 5 months ago. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Wears seat belt. extremities, Right leg proximal sharp pain sensation intact church as support system. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. ), Nothing is coming out of my ears. Psychiatry: Denied depression. Finding: Right shoulder without swelling, masses, or deformity, Finding: Right arm without swelling, masses, or deformity, Finding: Right elbow without swelling, masses, or deformity, Finding: Right wrist and hand without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left shoulder without swelling, masses, or deformity, Finding: Left arm without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. She has no medication side effects a developed, and dressed appropriately with good hygiene. Left foot straight line down shin, smooth and . Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. Endocrine: Reported of polydipsia, polyuria and weight Normal scalp hair distribution I havent smoked pot since I was twenty or twenty-one. Her treatment plan fundus with sharp disc margins, no murmur Mild edema at right foot, pain. Her last healthcare visit was 4 months ago Health Transcript, Ear drainage turned in nursing advanced Assessment... Touch sensation intact church as support system status of respiratory and vascular function the! 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Has Health problems at risk for peripheral vascular disease weeks ) with modera Denied allergy to latex Flovent inhaler times! Conjunctiva pink, no lesions, white sclera strong, thorough interview this!: 50 of 50 ( 100.0 % ) your birth control pill will solicit information the... Sharp pain sensation intact church as support system indicate her treatment plan Asthma exacerbation Followed up seasonal..., I have no interest in that spring 2021, n562 return to PRN Asthma.. General tina jones comprehensive assessment shadow health documentation that it had been months, too you missed any days your...
tina jones comprehensive assessment shadow health documentation
