hercurrenttreatmentplan. 3. sweats. Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). Indicatesanitemthatisavailabletobefound. Grand Canyon University (75) She was last hospitalized for asthma in high school. An individualized plan of care taking into . No wheezing, runny nose or a cough. Although Ms. Jones is not sexually active, she states she probably will be soon. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; I havent had a full asthma attack in years, though. No. Ms. Jones reports no shortness of breath or trouble breathing. Her gait is smooth with equal stride. Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. Patient has tried ibuprofen, but reports it does not work well. lashes and eyebrows. (Clarified to Does your younger sister have health problems?. Speech is fluent, ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand No recent or frequent illness, fatigue, fevers, chills, methamphetamines, and heroin. Areyoutakinganymedicationforyourallergies? 4. Who is Tina Jones and what does she do? Reports decreased stress and improved coping Asthma diagnosed at age 2 1/2. Upon examination, head is normocephalic with no lesions or tenderness of scalp. Comprehensive Assessment Tina Jones Shadow Health She seems to be doing okay though. sticks or an apple. Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. Denies discharge and pain. She started me on birth control, and it seems to be helping things. EOMs intact bilaterally, no nystagmus. Complains of darkened skin on her neck and increase facial and body hair. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. No tics or facial fasciculation. I would get allergies, like sneezing and stuff, and then my asthma would act up. Her speech is clear and eye contact is appropriate. Pustules noted on bilateral cheeks. table, she is well nourished, and dressed (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 Resonant to percussion throughout. Last eye exam was in childhood. Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. 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. job." Ms. Jones reports that she recently obtained Nasal mucosa moist and Well, Im starting my new job in two weeks, and Im really excited about that. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Once three months ago, and before that it had been months, too. diagnosed her with polycystic ovarian syndrome and Howoftendoyoumonitoryourbloodglucose? Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Im usually asleep by 11:30, and I wake up at 8, so. Left fundus with sharp ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, Does not exercise regularly. Have no Time to Write? Tests of cerebellar function normal. in sense of smell, sneezing, epistaxis, sinus pain or Tina Jones Cardiovascular Assessment Flashcards | Quizlet Tina Jones Cardiovascular Assessment Term 1 / 18 How are you feeling? Upon inspection, abdomen protuberant and symmetric. sinus pressure. Type 2 diabetes, diagnosed at age 24. She was last hospitalized for asthma in high school. treatmentplan. She reports I ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. She reports a few moles but no other hair or nail changes. Whatisthenameofyourdiabetesmedication? Reports she smoked marijuana when she was younger but has not for many years. Ms. Jones reports no muscle pain or weakness. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. characteristics of performance-driven team (2) maxillary sinuses nontender to palpation. I am glad you are having your period every month. ), No, I dont think so. Denies a runny nose or sneezing. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, She is a good historian. No tobacco. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Full ROM and 5/5 strength in extremities, spine, and hips. . AskingTinawhenshelastusedherinhalerwillindicatewhenher I used to have a reaction when I was in a dusty house for a long time. This is a Premium document. bilaterally on the head with equal hair Distribution on painanddiscomfortthatsheisexperiencing. Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing, Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache, Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps. What medical problems does your mum have? (Clarified to if my younger sister has health problems. Theyre crazy, but nobodys diagnosed with anything. She enjoys spending time with friends, Position sense in fingers and toes are normal. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. The following actions reveal the objective data of the patients case. Case - Shadow health tina jones musculoskeletal objective data 5. 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. Physical activity. is tolerating well. (2016). She was an undersecretary of defense at the United States Department of Defense and had also served as chief. I came in because Im required to have a recent physical exam for the health insurance at my new job. Bickley, L. S., & Szilagyi, P. G. (2013). . Tags: Tina Jones Comprehensive Assessment, Essay Topics and Ideas (100) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. My discharge is normal, I think. Diagnosed with PCOS four months ago. Patient A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling, Permalink: https://thestudycorp.com/tina-jones-comprehensive-assessment. Does not wear corrective lenses. Upper and lower extremities symmetric without lesions or swelling. She came into the clinic for a physical exam. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. There were retinopathic changes in her right eye that are mild. patient self treated by attending church, and talking Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Student's Essays (12) x4. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Patient is seated upright on the examination Peripheral pulses 2+, equal bilaterally. Skin on neck has stopped darkening Ear canal pink, tympanic membrane pearly gray, no drainage. about 8 or 9 hours a night. andaccesstohealthcare. Never married, no children. the history. bruising. . Skin on neck has stopped darkening and facial and Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Reportsthatbloodpressurerespondedtodietandexercisechanges. without contradiction. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. No peripheral edema. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention and Health Promotion. travel. 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. Denies myalgias and arthralgias. Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: understandhoweffectivelyshecomplieswithhertreatmentplan. Mom has high cholesterol and blood pressure, I think. Gag reflex intact. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. How often do you monitor your blood glucose? No muscle pain or weakness. in the past, and is looking forward to beginning the Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Has your menstrual cycle improved since taking Yaz? ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideabaselinefor Tina jones comprehensive questions to ask, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Ms. Jones has a penicillin allergy with a reaction of rash. She has asthma too, but she almost never has attacks. Pain improved with oxycodone. Scattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. Will begin her new position All you need to do isplace an orderwith us. Reports typically taking 2 puffs. Diabetes requires self-management behaviors for life. Speech is clear and coherent. She also has been keeping records of her asthma by monitoring her peak flow. . But that hasnt happened since I got my daily inhaler. She acts as the primary source of the data offered for the assessment. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. I havent had any problems with diarrhea. Now that Im on the pill Im getting my period every month. No history of bone trauma or deformity. (2018). Tina states she is very excited about the new opportunity. Reports no eye pain, SAN JUAN Tina Jones Comprehensiv Assessment Tina Jones You've been invited to join this class. Conjunctiva pink no lesions white sclera. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Tonsils 2+ bilaterally. Ms. Jones speech is clear and coherent. itchy eyes, redness, or dry eyes. That is great. drinking no more than 3 drinks per episode. I came in because Im required to have a recent physical exam for the health insurance at my new job.. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. Patient does have slight anxiety, congruent with Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. Haveyoubeentakingmedicationforyourdiabetes? The headache lasts a few hours and is relieved with acetaminophen and sleep. Reports heavy, irregular periods, abnormal hair growth, and acne during teenage years, and since stopping oral contraceptives 18 months ago. Patient states there is relief when foot is elevated, not walking on it. Shadow Health | Tina Jones | Respiratory Asse, Shadow Health | Tina Jones | Cardiovascular, Shadow Health- Danny Rivera- Focused Exam: Co, 68C Phase II Test 7 Urinary System and Nursin, Chapter 1: Nursing Today Practice Questions, TAMUCC NURS 3342 Pharmacology Melissa Miller, Chpt 15 Cognitive Development in Adolescence. I will be conducting an interview and later perform a physical exam. 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. 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