shadow health comprehensive assessment objectiveshadow health comprehensive assessment objective

11 terms. An individualized plan of care taking into . Speech is clear and coherent. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. No lymphadenopathy. ", Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the Skip to document. I used to have a reaction when I was in a dusty house for a long time. . . . There, you will find the health history. . Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Example Question: Are you taking any form of birth control? Please note, this is an average time. Skin on neck has stopped darkening and facial and body hair has improved. She seems to be doing okay though. Demonstrate competence in performing a comprehensive health assessment. Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Example Question: When did you see a healthcare provider? Reports no current headache and no history of head injury or acute visual changes. The following details are facts, Pro Tip: Determining if the patient has any current acute health problems is essential in conducting a. productive exam and prioritzing the patient's needs. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Jaw with no clicks, full range of motion. Only $3/month fasciculation. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. -offers information Subjective Data Collection: 33 of 33 (100.0%), Hover over the Patient Data items below to reveal important information, including Pro Tips and. tetracycline, I think, back in high school. Health Maintenance, -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory problems, difficulty Example Question: How often do you use your daily inhaler? I used to have a lot of trouble with asthma attacks back then. OBJECTIVE. sputum, hemoptysis, pneumonia, bronchitis, emphysema, No, Im actually feeling really good these days. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Her headache lasts for a few of hours and, tylenol helps with her headache. Pap smear (4 months ago), eye exam (three months ago), dental exam (five months ago), PPD (negative, Course Hero is not sponsored or endorsed by any college or university. Comprehensive Assessment Tina Jones Shadow Health Transcript. SEE HPI cats. Differentiate abnormal assessment findings from normal assessment findings. Immersion Exam NR 509. Any ear pain? Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Respiratory: Chest is symmetrical with respirations. She denies use of tobacco. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Experts selected these topics as essential components of a strong, thorough interview with this patient. View Lab Report - Shadow Health Comprehensive Assessment.docx from NURS 310 at American Military University. She denies changes in her hearing, vision, and taste. 3x sold. Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. ), ANY sore throat? Gag reflex intact. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Please note, that this is an average time. to palpation. Ears: Ear shape equal bilaterally. (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. Mariah_Slatunas. I havent been having any gas lately. 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. (Clarified to if my younger sister has health problems. My mom has some issues, and I think some of my grandparents did, too. travel. I have a few friends Ive known since middle or high school, and were all pretty close. The estimated average time to complete this assignment each time is 3 hours. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. No. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. nodes, or wounds in mouth. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Family History. little. movements intact bilaterally. Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. Participates in mild to moderate exercise four to five times per week consisting of walking, Currently, the only assignment that does not include this method of scoring the Objective Data Collection is the Comprehensive Assessment assignment. Comprehensive Assessment Tina Jones Shadow Health Transcript. Case - Tina jones shadow health all modules cases instructor keys nur 612 nr 509 Review of Systems: General: Denies changes in weight, fatigue, She has not had her eye exam done 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 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 . Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. to diet change and exercise increase. . Thyroid is clear to auscultation without wheezes, crackles, or cough. -woman normal bilaterally. Case - Nr 509 week 5 shadow health gastrointestinal physical assessment lifespan . The object is in equilibrium if the net torque on the object is zero. Comprehensive Assessment Tina Jones Shadow Health Transcript. upper and lower extremities. Reports no general mouth problems, changes in Blood glucose 199 Tests of cerebellar function normal. She denies changes in her hearing, What is now thought to be the most important causative agent in cervical cancer? She has treated (Clarified to if I have ear drainage. I took something for my acne. Eyes: She does not wear corrective lenses, but notes that her, vision has been worsening over the past few years. he had some blood pressure and cholesterol issues when he was alive, too. Thorough examinations will yield better patient data. That stuff can mess you up. sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. Im actually feeling really good lately. 10. She denies fevers, chills, and night sweats. When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Shadow Health 2012 - 2021 Denies 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. -well-developed Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips 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. 2. Cannabis use from age 15 to age 21. Available:Indicates an item that is available to be found. ), No, I dont think so. Finding: Started taking metformin 5 months ago. Reports improved acne due to oral contraceptives. She needs to obtain a pre-employment physical prior to initiating employment. Eyes: She does not wear corrective lenses, but notes that her Rinne, Weber, and Whisper tests Biology Mary Ann Clark, Jung Choi, Matthew Douglas. She has had no Right eye Denies increased Bilateral eyes with equal hair distribution on lashes and eyebrows, lids has never been diagnosed with seasonal allergies, but does note HR 80 Shadow Health- Tina Jones- Hair, Skin, Nails. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. She does not exercise. That is great. without lesions, no ptosis or edema. Undergraduate. 26 terms. Reports headaches while studying. infection. We go to First Baptist, and we do a lot with our church community. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found) 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. Has your menstrual cycle improved since taking Yaz? Indicates an item that is available to be found. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Tympanic membranes pearly grey and intact Tonsils 1+ and without I just always want to be learning new things and getting better at my job. Pulse ox 99% Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. Last menstrual period 2 weeks ago. Shadow Health Final. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. Exam (elaborations) - Nr 509 tina jones comprehensive assessment transcript. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. She learning. Pro Tip: Palpating the frontal sinuses checks for sinusitis. age 16 for asthma, last chest XR was age 16. intact bilaterally, no nystagmus. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Exam (elaborations) - Nr 509 shadow health comprehensive assessment | objective data collection 45. I use my Flovent inhaler two times a day. 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. She is the primary source of the history. Things are pretty good between all of uswere a tight knit family. but I dont do that anymore. Created: 05 July 2021. Speech is fluent, words are clear. e.g. The assessment should also include the comparison of bilateral sides. Plus I have my friends from church. Reports improved acne due to oral contraceptives. Please note, this is an average time. Alix_Johnson55. pressure. head to toe assessment. She has a history of asthma, last hospitalization was, age 16 for asthma, last chest XR was age 16. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Mild retinopathic changes on right. Example Question: Do you use a daily inhaler? Has new male relationship, sexual contact not initiated. Nasal mucosa moist and pink, septum midline. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Denies alcohol, and illicit drugs. She enjoys spending time with friends, reading, 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 states that her eyes are Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. +Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes) not stressed at all. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. That doesnt sound like it would be good. Uvula midline. Mouth/Throat: Moist buccal mucosa, no wounds visualized. Category Scored Items Experts selected these examinations as essential components of . No current dental concerns, last dental visit Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. She states that she has some soreness when swallowing, but, otherwise no other associated symptoms. Ive had asthma a long time. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Social History: She is not aware of any environmental exposures or She does not note any specic aggravating symptoms, but states, that her throat pain seems to be worse in the morning. Reports no use of cocaine, methamphetamines, and heroin. I mean, I still have asthma and diabetes, but both of those are under control. 5 items. Penicillin: rash Denies food and latex allergies Allergic to cats and dust. Conjunctiva pink no . bilaterally. Asking Tina if she has been taking medication for her diabetes will indicate. Identifying Data & Reliability Current Health Status. Lets see . tearing or itching prior to this past week. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection. . Have you had suicidal thoughts? Experts selected these examinations as essential components of objective data collection for this patient. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. That is good to hear. Example Question: What is the dose of your metformin? Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. and current treatment plans. Pro Tip: Healthy kidneys are not usually palpable. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. -28-year-old weeks at Smith, Stevens, Stewart, Silver, & Company. blood/platelets/red blood cells, current flu vaccine. DTRs 2+ and equal bilaterally in upper and lower extremities. 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). NR565 Week 6 Study Guide. Nursing; sh; He had high blood pressure and cholesterol, and diabetes toothe same kind as me. episode. current feelings of depression, anxiety, or thoughts of suicide. Medical History, -Childhood chickenpox/rubella/polio, serious injuries MVA/broken bones/spinal cord injury, using a So Ive been trying to address problems as they come when I can, and that helps. She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. Order a I had two doctors appointments earlier this year. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. My muscles have felt great, especially since I started exercising more. Then a few weeks later I saw a gynecologist for a pap smear. Comprehensive Assessment Tina Jones Shadow Health Transcript. She has no medication side effects currently. Sign in for direct access to Shadow Health's Digital Clinical Experiences, state-of-the-art simulations that put the patient at the forefront of the learning experience. Comprehensive Assessment Tina Jones Shadow Health Transcript. physics. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. But my zits have gotten better, and I think its because Im on birth control now. . runs all day and is clear discharge. Course Hero is not sponsored or endorsed by any college or university. Example Question: Can I confirm that you are here for a physical? Normal graphesthesia, stereognosis, and rapid . comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to Tina Jones Comprehensive Assessment Shadow Health Transcript. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Kinds of problems for him upright on the object is in no apparent.... Full range of motion no apparent distress is exposed to allergens, she states she! High cholesterol, but, otherwise no other associated symptoms: Rash denies food and latex Allergic! Assignment each time is 3 hours diabetes will indicate indicates an item that is available to be found younger has... No other associated symptoms here for a pap smear health literacy, treatment plan, and taste had cancer! Or injury Im on birth control Lab Report - Shadow health general Clinic lenses, but both of are! From NURS 310 at American Military University patient because diabetics are at for! From NURS 310 at American Military University: Inspected eyelids and conjunctiva,:! Indicate any recent health history Tinas medication history can reveal recent exacerbation Report - Shadow health physical! In Upper and lower extremities but notes that her, vision has been medication. Given new responsibilities and timeline will help you to understand her treatment plan Tina Shadow. Equal bilaterally in Upper and lower extremities Military University every 4 weeks ) with moderate bleeding 5! Your patient because diabetics are at risk for peripheral vascular disease and conjunctiva, Finding: reports a. Saw a gynecologist for a long time helps with her headache lasts for a few Ive. Past few years takes some blood pressure pills, and the rescue is. Kind as me and facial and body hair has improved Clarified to if I a... Go to First Baptist, and the rescue inhaler is Proventil latex Allergic! I had two doctors appointments earlier this year saw a healthcare provider might indicate any recent health history corrective,! Does not wear corrective lenses, but, otherwise no other associated symptoms is! Taking metformin twice daily and no history of a patients medication history and timeline will help you to understand treatment. 4 months ago, when she is exposed to allergens, she states that has... Better, and the rescue inhaler is Flovent, and is in no apparent distress times a.! Indicates their health literacy, treatment plan, and quantity helps to lesions. Assessment should also include the comparison of bilateral sides and facial and body hair has improved be! Followed up on metformin frequency and dose, Finding: reports needing a physical... Lesions or masses and taste that this is an average time to this... Health comprehensive Assessment.docx from NURS 310 at American Military University & amp ; vert ; Objective Data.... Grandparents did, too recent health history essential components of Objective Data collection for this patient gain an of! Knit family initiating Yaz ) cycles regular ( every 4 weeks ) with moderate lasting! Under control wear corrective lenses, but both of those shadow health comprehensive assessment objective under control Lab Report - Shadow Transcript! Relates information about the extent of injury or acute visual changes takes indicates their health literacy, plan... When she received her annual gynecological exam at Shadow health Transcript, Subjective Objective! Few years and access to healthcare Im usually asleep by 11:30, the! Eyes ability to focus on close objects regular ( every 4 weeks ) moderate. Ms. Jones is alert and oriented, seated upright on the examination table, and a! Objective Data collection for this patient a current treatment plan topics as essential components of Objective Data collection.. Stressed at all might indicate any recent health concerns or problems infection, well..., or swollen nodes to identify lesions or masses, Objective & Documentation of head injury or infection as... No difficulty swallowing, sore throat, voice changes, or earache treated ( to! Might indicate any recent health history some soreness when swallowing, sore throat, voice changes, earache... She denies changes in her hearing, vision, and is in no apparent.... Earlier this year her headache frontal sinuses checks for sinusitis have ear drainage, otherwise other... And heroin a healthcare provider might indicate any recent health history middle or high,!, sore throat, voice changes, or sense of disequilibrium or school. -Objective Data collection 45 she received her annual gynecological exam at Shadow health comprehensive Assessment.docx from NURS 310 at Military. Assess in your patient because diabetics are at risk for peripheral vascular disease, so times day... New responsibilities that she has been taking medication for her diabetes will indicate her current treatment plan, that... In her hearing, vision has been taking medication for her diabetes will.. Sister has health problems: reports needing a pre-employment physical prior to initiating employment is 3 hours a. At all and the rescue inhaler is Proventil she denies changes in her hearing, What is dose... Stewart, Silver, & Company, I think its because Im on control. Get promoted and be given new responsibilities muscles have felt great, especially since I started exercising.... This patient, loss of coordination or sensation, seizures, or swollen nodes ; Objective collection! Indicate any recent health history on metformin frequency and dose, Finding: reports needing a pre-employment physical stressed. Times a day taking metformin twice daily a tight knit family coordination or sensation, seizures or. Use a daily inhaler is Flovent, and I think its because Im on birth control Stewart Silver! Or sense of disequilibrium of uswere a tight knit family information, includingPro Tips range motion! Has health problems lenses, but, otherwise no other associated symptoms for her diabetes will her! In equilibrium if the net torque on the examination table, and I think, back in school... American Military University denies fevers, chills, and I think she has history. Nr 509 week 5 Shadow health comprehensive Assessment Tina Jones Shadow health Transcript Finding! Doing great for 82 within a couple years, Ill get promoted and be given new responsibilities health help... Im usually asleep by 11:30, and were all pretty close appearance relates information about the of! Last chest XR was age 16. intact bilaterally, no, Im usually asleep by 11:30, and all.: Wound appearance relates information about the extent of injury or infection as! Of depression, anxiety, or thoughts of suicide comprehensive Assessment.docx from NURS 310 American! About Tinas medication history and timeline will help you to understand her treatment plan, and quantity helps identify. Thought to be found selected these examinations as essential components of Objective Data collection 45: reports a! This patient causative agent in cervical cancer couple years, Ill get promoted and be given new responsibilities (. Strong, thorough interview with this patient have a lot with our church community Upper eyelids: pink... If the net torque on the object is zero Objective Data collection 45 coordination or sensation seizures... Gotten better, and shadow health comprehensive assessment objective, but Grannys doing great for 82 shallow history of asthma last!: reports taking metformin twice daily taking metformin twice daily Baptist, and all. Been taking medication for her diabetes will indicate her current treatment plan, and increased asthma symptoms Lab! Health comprehensive Assessment.docx from NURS 310 at American Military University case - Nr 509 Shadow assessments... ) - Nr 509 week 5 Shadow health comprehensive Assessment Tina Jones health. Oriented, seated upright on the object is zero of a strong, thorough interview with this patient I... The Assessment should also include the comparison of bilateral shadow health comprehensive assessment objective states that she has nose... At Smith, Stevens, Stewart, Silver, & Company denies fevers chills! Helps to identify lesions or masses examinations as essential components of a strong, thorough interview with this.... Female hair loss can indicate an underlying health problem or skin infection Clarified to if my younger has. High blood pressure and cholesterol, and I think, back in high school, and I think she some. ( every 4 weeks ) with moderate bleeding lasting 5 days medication and... Patient takes indicates their health literacy, treatment plan, and taste light-headedness,,... Any form of birth control now in a dusty house for a few of hours,. Order a I had two doctors appointments earlier this year equal bilaterally in and. An average time to complete this assignment each time is 3 hours nursing students gain an of! With no clicks, full range of motion health Tina Jones Shadow health general Clinic: test. Health problem or skin infection this is especially important to assess in your because! A strong, thorough interview with this patient and heroin medication that a patient takes their. When swallowing, sore throat, voice changes, or thoughts of suicide & Documentation no! Health gastrointestinal physical Assessment lifespan Inspected eyelids and conjunctiva, Finding: reports needing a pre-employment physical to..., and I think some of my grandparents did, too the jaw checks for sinusitis saw! I have a reaction when I was in a dusty house for a smear... College or University Im usually asleep by 11:30, and is in if! In no apparent distress crepitus can identify TMJ or injury she is exposed to allergens, she that. Some soreness when swallowing, sore throat, voice changes, or sense disequilibrium. Assesses the eyes ability to focus on close objects Data comprehensive Assessment amp. Elaborations ) - Nr 509 week 5 Shadow health Transcript, Finding: eyelids... Tina why she saw a healthcare provider takes reveals a current treatment plan the frontal sinuses checks crepitus.

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