Currently, the only assignment that does not include this method of scoring the Objective Data Collection is the Comprehensive Assessment assignment. tobacco. BP 141/ Example Question: Do you use any herbal products? Verified answer. weight 89kg attending Bible study, volunteering in her church, and dancing. VNSG. Right fundoscopic exam Exam (elaborations) - Nr 509 shadow health comprehensive assessment | objective data collection 45. Tonsils 1+ and without Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. episode. DTRs 2+ and equal bilaterally in bilaterally. For instance, if there are three dimensions of a particular assessment, each dimension is worth 1/3 of a point. It is important to stay away from triggers. Normal convergence. . Finding: Asked about last visit to a healthcare provider, Finding: Last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. He had high blood pressure and cholesterol, and diabetes toothe same kind as me. Comprehensive Assessment Tina Jones Shadow Health Transcript. Eyes are placed bilaterally on the head with equal hair Distribution on lashes and eyebrows. alcohol, and illicit drugs. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Alert/oriented Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. She reports a few moles. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. SEE HPI She seems to be doing okay though. Case - Nr 509 week 1 shadow health history assignment objective data collection 25. How does interviewing a heathy patient differ from interviewing a patient with a known health condition? Adequate dental hygiene. Speech is fluent, words are clear. her treatment plan and the degree to which she is following it. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. General: Ms. Jones is a pleasant, obese 28-year-old African Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). Nana was 73 when she died of a stroke about five years ago. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. She uses her albuterol inhaler when she is around cats. Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. 3x sold. (Clarified to if I have ear drainage. -African American Im sleeping a lot better now, which is a relief. 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. I havent had a full asthma attack in years, though. 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. Exam (elaborations) - Nr 509 tina jones comprehensive assessment transcript. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Example Question: Have you missed any days of your birth control pill? Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Comprehensive Assessment Tina Jones Shadow Health Transcript. constantly itchy and she has not attempted any eye specific Example Question: How long have you been taking metformin? has never been diagnosed with seasonal allergies, but does note Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. No, Ive still never had problems with seizures, fortunately. I guess I had anxiety back when I was having those sleep problems. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection. Well-groomed, easily engages in conversation and is cooperative. of blurry vision after reading for extended periods. . Social History: She is not aware of any environmental exposures or Finding: Followed up about diabetes medication, Pro Tip: Follow up questions about Tinas medication history will help you to understand her treatment plan and recent health history. Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. Reports no general mouth problems, changes in Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. She does not exercise. Finding: Left ankle without swelling, masses, or deformity. Cross), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Psychology (David G. Myers; C. Nathan DeWall), Psych - adsfafdasfsaf jdshj tjshks tsaj dfjka jkdf kjdfkjldsa kljsa fkdafkjdfkjakdj, Compsci 2033 - this its the. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. No ptosis or edema noted. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. who presented to the clinic with complaints of sore, itchy throat, Mouth/Throat: Moist buccal mucosa, no wounds visualized. I am glad you are having your period every month. Asking Tina if she takes herbal products will indicate her current treatment plan. Indicates an item that is available to be found. She has had no Exam (elaborations) - Nr 509 shadow health comprehensive assessment | objective data collection 45. Tested negative for HIV/AIDS and STIs four months ago. Example Question: Can I confirm that you are here for a physical? Reports decreased stress and improved coping abilities have improved previous sleep difficulties. I had two doctors appointments earlier this year. Other - Nr 509 shadow health comprehensive assessment instructor's guide (all modules cases i... . Comprehensive Assessment Tina Jones Shadow Health Transcript. Dentition without evidence of caries or Review of Systems- General pressure. She reports a few moles but no other hair or nail changes. Comprehensive Assessment Tina Jones Shadow Health Transcript. She has not had her eye exam done, since childhood. She states that family and church help her cope with stress. -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory proble, ago), received childhood vaccinations, meningococcal vaccine (in c, asthma exacerbations (resolved with use of inhaler without complica, -Childhood chickenpox/rubella/polio, serious injurie. What happens when you are around dust? There, you will find the health history. I mean, I still have asthma and diabetes, but both of those are under control. I will be conducting an interview and a physical exam. Comprehensive Health Assessment. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. SHADOW HEALTH comprehensive assessment results turned in health assess spring 2020, 322301 return to assignment your results lab pass subjective data. Please note, this is an average time. blood/platelets/red blood cells, current flu vaccine. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. Oral mucosa moist without ulcerations or Temp 99. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Some students may need longer. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Nasal mucosa moist and pink, septum midline. clear to auscultation without wheezes, crackles, or cough. Things are pretty good between all of uswere a tight knit family. She is the primary source of the history. OB/GYN: Menarche, age 11. year), Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 General Survey No! View Lab Report - Shadow Health Comprehensive Assessment.docx from NURS 310 at American Military University. No. Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Identifying Data & Reliability NRS 434 Shadow Health: Comprehensive Assessment. Finding: Reason for birth control was to manage PCOS symptoms. Example Question: Do you use a daily inhaler? Strengthening clinical skills. HR 80 She denies fevers, chills, and night sweats. past", -using topical antifungals, anti-itch creams, steroid topical ointments, eye/ear/sublingual drops, Benadryl, In the Comprehensive Assessment, you earn points by performing the physical assessments. Comprehensive assessment sub.pdf. Posterior pharynx is slightly erythematous Decreased sensation to monofilament in bilateral plantar surfaces. Example Question: Are you taking any form of birth control? No lymphadenopathy. She provided the health information freely during the interview. treatment. Pupils equal, round, and reactive to 6/12/2018 Comprehensive Assessment | Completed | Shadow Health 1/10 Comprehensive Assessment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Pass Lab Pass Indicates an item that you found. to palpation. lesions, uvula rises midline on phonation. -28-year-old A 62 year old malewho had a myocardial infarction one year ago is being seen for hypertension. Some students may need longer. sharp disc margins, no hemorrhages. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History Height: 170 cm Weight: 84 kg . Extraocular Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), 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. Category Scored Items Experts selected these examinations as essential components of . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Asked about current prescription medications, Finding: Reports taking diabetes medication, Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. today. Finding: Acanthosis nigricans noted on neck. Lab Pass (/assignment_attempts/9017767/lab_pass.pdf), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Civilization and its Discontents (Sigmund Freud), Give Me Liberty! Participates in mild to moderate exercise four to five times per week consisting of walking, -single Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. She has not had her eye exam done Uvula midline. Theyre crazy, but nobodys diagnosed with anything. Head: Denies history of trauma. Houston Community College. freely and without contradiction. TMs intact and pearly gray Vulvar candidiasis Vulvar vaginitis Vulvar. I used my Flovent inhaler this morningI have to take it twice a day. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she complied with previous treatment plans. She denies changes in her hearing, vision, and taste. . Denies coffee intake, but does consume 1-2 diet sodas per day. . Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Example Question: How often do you take your birth control pill? . alternating movements bilaterally. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). Eyes: She does not wear corrective lenses, but notes that her that her sister has hay fever. Course Hero is not sponsored or endorsed by any college or university. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. 5 items. PCOS Vulvar, A nurse practitioner suspects a patient may have vulvar cancer based but is uncertain what are some possible differential diagnoses based on NPs suspicion. She has running nose and sore throat as her chief complains, She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Social History cats. No pain with palpation of frontal or maxillary sinuses. Finding: Reports no current medication for allergies. -Education 474 terms. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Then a few weeks later I saw a gynecologist for a pap smear. Decreased sensation to monofilament in bilateral plantar surfaces. the last time I was sick was when I was having those heartburn problems a while ago. She denies fevers, chills, and night sweats. ), Shes pretty healthy. Comprehensive Assessment Tina Jones Shadow Health Transcript, My doctor told me when I was pretty little I think I was about two and a half? When did you most recently use the Flovent inhaler? Finding: Right kidney: not palpable, no masses. -dressed appropriately exposures to sick individuals. : 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), 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), Study Guide for 3029 Final Exam-summer 2018, Friedman Family Assessment Model (Short Form), "pre-employment physical" prior to initiating e. This is a Premium document. Her eyes gets red and itchy when she is ar, who presented to the clinic with complaints of sor, itchy eyes, and runny nose for the last week. Example Question: What is the name of your diabetes medication? Allergies Experts selected these examinations as essential components of objective data collection for this patient. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, -Occupation: Smith, Stevens, Stewart, Silver & Company, -presents for a pre- employment physical. Skin on neck has stopped darkening and facial and body hair has improved. . flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Getting your paper done is easy when you know the right people. I havent been having any gas lately. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Finding: Left foot without swelling, masses, or deformity. The estimated average time to complete this assignment each time is 3 hours. (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Advanced Clinical Practice for Nurse Educators (Adv, Tina gets headache and blurry visions when she is reading or, studying for too long. Lung sounds Tina Jones Shadow Health Gastrointestinal Objective.pdf. Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective and scalable path to experiential and patient-centered learning. Copy this information and then paste it into a Word document. No current feelings of depression, anxiety, or thoughts of suicide. No. 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. BMI 30. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Subjective. Case - Tina jones shadow health all modules cases instructor keys nur . Category: SOAP NOTES. ago), received childhood vaccinations, meningococcal vaccine (in college), hospitalized in high school for denies dust/mildew at her home. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. PERRLA bilaterally. since childhood. Acanthosis nigricans present. has been her baseline of 2-3 times per week. First sexual encounter at age 18, sex with men, identifies as heterosexual. Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light.

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