Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. Finding: These announcements are made to ensure you understand everything that is due during the week. Adult Illnesses: severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious Childhood Illnesses: Asthma diagnosed at age two and a half. You can even attach screenshots or add additional instructions later. Reports asthma Are you allergic to penicillin? Normal bronchophony results. changes. AskingTinaifshetakessupplementswillindicatehercurrent Finding: 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. (Found) Askedaboutcurrentnon-prescriptionmedications. Example Question: Her new job is as an accounting clerk, which starts in two weeks. When was your last physical exam? Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. She reports no depression or anxiety. Coarse hair growth noted from pubis to umbilicus. Musculoskeletal. Surgical: No surgeries to date. haveabearingonTina'sbreathing. A dietician referral may be beneficial to educate on specifics and offer support. How are you managing your diabetes? Example Question: (Found) Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. She is now on metformin, Proventil, and Flovent. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Risk factors for diabetes which Ms. Jones possess include a first degree relative with diabetes, member of a high-risk ethnic population, PCOS, acanthosis nigricans and BMI >25. Denies sinus problems, frequent Reports using inhaler no more than 2 times per week Reports taking diabetes medication twice daily Whatisthenameofyourdiabetesmedication? Respiratory. Just add the option when plaing your order. You may also need to provide further support and resources to the patient. Reports last use of ibuprofen was six weeks ago 850 mg twice daily. A few days ago, she was exposed to a cat and had to use her inhaler once. Example Question: Has your asthma medication changed? (Found) Finding: Are you allergic to dust? been cleaning the wound twice a day and applying antibacterial ointment and bandages. AskingifTina'sbeenusingherinhalermorefrequentlysince Finding: Deep tendon reflexes 2+, upper and lower. https://doi.org/10.1111/jspn.12032. Sclera white, conjunctiva pink, PERRLA, EOMs intact. She receives basic health insurance from work but is deterred from What strength ibuprofen do you take? Example Question: Capillary refill <3 seconds. These allergens aggravate her asthma symptoms, so she tries to avoid them. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Finding: Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. She is a part-time student, in her last semester to earn a bachelors Found: Have you been taking medication for your diabetes? Doyoutakeyourpillatthesametimeeveryday? Upon examination, head is normocephalic with no lesions or tenderness of scalp. If something is not clear or missing, the writer will contact you for clarification. Reports that side effects of diabetes medication abated over time Asking Tina if she takes supplements will indicate her current treatment plan. Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. The object cannot be in equilibrium because more than one force acts on it. Finding: What is the dose of your metformin? She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention and Health Promotion. NRS Week 4: Comprehensive Assessment Tina Jones NRS 434 Shadow Health: Comprehensive Assessment Within the Shadow Health platform, complete the Comprehensive Assessment. Example Question: Is there anything unusual about your menstrual cycle? NURS 6830 Advanced Health Assessment This sensitivity and respect to the patients enables the nurse to have a therapeutic assessment and a trusting relationship with the patient. Reports no dizziness, tingling, or loss of sensation. It is used for most writing assignments for your degree. (Found) Finding: Example Question: two times a month when out with friends but no more than three drinks per episode. (Found) Her last Do you take Advil? Take the extra few minutes to review instead of getting counted off for these mistakes. Reports recent weight loss. during the teenage years. (Found) The influenza vaccine is not current, and human papillomavirus has not been received. Although Ms. Jones is not sexually active, she states she probably will be soon. Tina Jones Comprehensive Health Assessment. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. severityofhercondition. Example Question: ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Example Question: degree in accounting. Finding: When in doubt, cite the source. This is a Premium document. Diabetes requires self-management behaviors for life. Her Pro Tip: Determining any outcomes from Tinas last optometrist visit is important, as it may reveal treatments that you should follow-up on. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Nasal cavities pink, no discharge. Finding: Reports ibuprofen is effective Askingaboutbreathing This strong support system helps to ease her stress and anxiety by providing a sounding board. study, volunteering in her church, and dancing. Denies tobacco use Reports belief that asthma is well-controlled Finding: (Found) Example Question: Denies adverse side effects from birth control What is a typical snack? The papers are not supposed to be submitted for academic credit. Tina Jones comes into the clinic for a general physical exam. Reports menstrual cycle is normal Finding: (2018). She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. St. Louis, MO: Elsevier Mosby. An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. It is also good practice to identify the purpose of drug use, such as recreation or pain management. Spirometry: FVC 3.9L, FEV1 3.15L, FEV1/FVC ratio 80.56%. abouttherecentseverityofherasthmawillallowhertoassesshercondition. Substantive responses should be at least 150 words. Pro Tip: Establishing a timeline for Tinas gynecological exams will allow you to develop a comprehensive health history. Reports occasional chest tightness A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Tina does not smoke or use recreational drugs. Pro Tip: It is important to determine any recent changes to breast, such as swelling, rashes, lumps, or nipple discharge, as it could be indicative of a serious underlying condition. Example Question: Reports last visit to a healthcare provider was 4 months ago symptomsmostrecentlyrequiredmedicaltreatment. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand (Found) Finding: (Found) Full ROM of TMJ with no crepitus. Finding: And the pain is killing me! click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew Our research-backed program helps improve data collection, therapeutic communication, and care planning. Example Question: a seatbelt in the car, has smoke alarms in the house, and does not ride a bicycle. Howlongagodidyoustarttakingbirthcontrol? Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. andaccesstohealthcare. History Abdominal. What type of birth control do you use? This is a public forum for the class. Paternal grandmother: still living, age 82, hypertension. She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. When did you see a healthcare provider? Followed up on ibuprofen (Advil). Indicates an item that is available to be found. time, ReportsusingFloventinhalertwicedaily. (Found) Using the patient information provided, choose a culture unfamiliar to you and describe what would be important to remember while you interview this patient. When was the last time you used your inhaler? Last dental visit was five months ago with no concerns. How many drinks do you have in a sitting? The estimated average time to complete this assignment each time is 3 hours. Never married, no children. forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). Pro Tip: Determining the last time Tina used her inhaler will help you gain an up-to-date picture of her condition and determine the efficacy of her current medication. Breath sounds present and equal bilaterally, no adventitious sounds noted. exacerbations from dust or cats she uses her albuterol inhaler, but she never uses it more than Finding: Mouth/throat: Denies any dental problems. Normal hair distribution. Followed up about birth control prescription. Reports recently increased appetite. Whispers heard bilaterally. Cultural competence and cultural awareness is needed in nursing especially when gathering information and assessing a patient to effectively empower and promote health (Grand Canyon University, 2018). Finding: Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). (Found) Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Diabetes is disproportionately prevalent in the African American population (Bickley & Szilagyi, 2013). Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patients safety while she is in your care, as it affects what medications will be safe and appropriate. No current complaints or recent illness. Finding: How many days a week do you exercise? Denies changes in hearing or ear pain. Asked about diabetes management through lifestyle. Example Question: Hover To Reveal. Reports having adequate supplies Patient Data the pain and swelling in her ankles have subsided, but the bottom of her foot is increasingly. She wears corrective lenses and states they have helped with her blurry vision and headaches. She reports a few moles but no other hair or nail Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Advanced health assessment and clinical diagnosis in primary care(4th ed.). HPI Tina Jones Foot-c go by Is sammy alive - in class assignment worth points 10th Amendment Deconstructed Copy of 7.4.1 - Seed Germination Gizmo Hesi fundamentals v1 questions with answers and rationales Summary Give Me Liberty! NRS 434 Shadow Health: Comprehensive Assessment Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. How much weight did you lose? This is a comprehensive H & P. You will be assessing the \"whole\" person. Do you have an inhaler? Stereognosis and graphesthesia normal bilaterally. Finding: Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. AskingTina Example Question: Reports starting taking diabetes medication 5 months ago Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014). Did you get prescription eyeglasses? 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