How often do you take your birth control pill? patient's case. . Experts selected these topics as essential components of a strong, thorough interview with this patient. goatnurse. . Do your gums bleed when you brush them? not stressed at all. She used to take metformin but stopped taking it due to gastrointestinal problems. Left popliteal pulse: 2+ Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. If your instructor provides individual feedback on this assignment, it will appear here. Pro Tip: Dust is a common My discharge is normal, I think. Denies changes to breasts Auscultated tricuspid area with the diaphragm: Do you take any over the counter medications for pain? tetracycline, I think, back in high school. Reports rare cramping, Reports doing occasional breast exams Reports taking birth control pill daily She is the primary source of the history. What kind of prescription medications do you take? walking four or five times a week needed This preview shows page 1 - 3 out of 7 pages. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Offers information without hesitation. Lets see . . Are you taking any medication for your allergies? I think she had high blood pressure and cholesterol, too. hemorrhages, Tested visual acuity Vision 20/20 right eye with corrective lenses Shadow health assessments can help nursing students develop an understanding of patient safety issues. . Ive been feeling much better lately, though. No, Im actually feeling really good these days. All you need to do isplace an orderwith us. : an American History (Eric Foner), 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. Why do you take this over-the-counter medication? (Clarified to if I have ear drainage.). She reports a few moles but no other hair or nail changes. Have you noticed any increased drooling? For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Have you ever went without a menstrual cycle for a month? Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Menses irregular. Denies history of traumatic brain injury and meningitis. he had some blood pressure and cholesterol issues when he was alive, too. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Lived independently since age 19, currently lives with mother and sister to support family after death of father one year ago, anticipates moving out in a few months. . Exam (elaborations) - Nr 509 shadow health comprehensive assessment &vert; objective data collection 45. Reports last use of ibuprofen was six weeks ago, Asked about allergies Reports allergies have not changed Reports diabetes medication dose is 850 mg She needs to obtain a pre-employment physical prior to initiating employment. Marc n'a pas son appareil-photo. What medications do you take for this reaction? Shadow Health - HEENT Tina Jones. Reports cat allergy Denies adverse effects of diabetes medication. How much of the over-the-counter medication do you take? RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit Return to Assignment (/assignments/433803/). (Clarified to if my younger sister has health problems. . About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Right arm distal dull pain sensation intact extremities, Right arm proximal sharp pain sensation intact Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. What medical problems did your father have? 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. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. the last time I was sick was when I was having those heartburn problems a while ago. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Denies OTC herbals Denies goiter, hyper/hypothyroidism. Reports last optometrist visit was 3 months ago Nose: Rhinitis and congestion related to cat allergy. RRR, S1, S2, no murmur When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. 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Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. patient's case. asthmatic patients is particularly masses We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work. Case - Tina jones shadow . Brother: healthy Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema Did you ever have to be hospitalized for your allergic reaction? Use the Code 'Delegate', 2023 - Online Nursing Writers -Nursing Study | All rights reserved, Shadow Health Comprehensive Assessment Guide | Help, A Guide to the Shadow Health Comprehensive Assessment Process Nursing Study. I am glad you are having your period every month. every day ), Nothing is coming out of my ears. She provided the health information freely during the interview. We're available through e-mail, live chat and Facebook. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. lifestyle, Reports recently beginning dieting to manage SOAP Note Writing (45) What medical problems does your mum have? Her pain has worsened, and the swelling has persisted. Plus I have my friends from church. Terms of Use She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Reports starting taking diabetes medication 5 rebound Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported Denies history of recurrent urinary tract infections and kidney stones. No surgeries. Reports reason for birth control was to manage Im actually feeling really good lately. A mi familia le ______ (1) (fascinar) el ftbol. Auscultated mitral area with the diaphragm: Nurs 6512 WK 4 Assignment. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Reports occasional clumsiness. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Right leg distal light touch sensation intact Tested negative for HIV/AIDS and STIs four months ago. Denies having a mammogram Question. Denies back and neck pain and trauma. Reports occasional shortness of breath Occasional alcohol (10 - 12 drinks/month). months ago, Asked about current prescription medications Reports taking diabetes medication medications, Reports occasional ibuprofen use diabetes Just coming in and talking to someone here about it helped a little because I felt like I was doing something. but I dont do that anymore. To pass the SHCA, a student must achieve a score of at least 70 per cent. we will work to find you a treatment plan whose risk can be minimized and overseen. 69 terms. Course Hero is not sponsored or endorsed by any college or university. 20 terms. Left leg proximal dull pain sensation intact . Asked about current health problems Denies current acute health problems Resend confirmation email? Reports using glucometer quizlette1679262. 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 Right kidney: not palpable, no masses white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. No pregnancies. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. EOMs intact bilaterally, no nystagmus, Tested peripheral vision Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right General fatigue due to lack of sleep. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. Reports dust allergy, Asked about diabetes management through Shadow Health Assignments for virtual clinical hours University University of North Carolina Wilmington Course Adv Hlth Assess/Diagnostic Rea (NSG 510) Academic year:2020/2021 Helpful? Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or Thorough examinations will yield better patient data I took something for my acne. Subjective Data Collection: 50 of 50 (100.0%), Objective Data Collection: 70 of 73 (95.9%), Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service. Theyre crazy, but nobodys diagnosed with anything. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, https://www.coursehero.com/file/56834862/Tina-JonesComprehensive-Assessment-Subjective-Shadow-Healthpdf/, Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! or deformity Question #1. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Reports blood sugar number is usually around 90 I had two doctors appointments earlier this year. Yeah. months ago No visual acuity testing since childhood. 37 terms. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Reports last use of Proventil inhaler was yesterday, Reports optometrist visit She started me on birth control, and it seems to be helping things. Im sleeping a lot better now, which is a relief. Are you looking for someone to help with shadow health assignments? Hes a little big, maybe. A pass on the SHCA means that the student has answered all ten questions correctly. solved essays (19) Reports no blanching in fingertips when exposed to cold. (Clarified to if my brother has health issues.). Cough is worse at night and keeps him up. since I was really little. Did you ever have to be hospitalized for your environmental reaction. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. The following actions reveal the objective data of th Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Reports occasional shortness of breath Nursing Papers Examples (3) No pets. Diagnosed with asthma at 2 1/2 years DIagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. The following details are facts of the patients case. Return to Assignment (/assignments/289776/). Shadow Health Cough Assessment Flashcards Quizlet Health (3 days ago) WebTerms in this set (2) Reports cough for 2-3 days. My doctor told me when I was pretty little I think I was about two and a half? . I get it, but just so you know, you're asking a lot of me. Denies swelling, Asked about review of systems for respiratory, Denies current breathing problems Skin on neck has stopped darkening and facial and body hair has improved. She has no medication side effects at this time. Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes Company Registration Number: 61965243 Guns are locked up. What is the name of your diabetes medication? Head is normocephalic, atraumatic Asking Tina if she takes non prescription drugs will indicate her current treatment plan. Reports having adequate supplies, Denies change in asthma symptoms She is very active in her Baptist church, faith is important to her, and church community is a large part of her social network. Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. extremities, Right leg proximal dull pain sensation intact Occasional cannabis use from age 15 to age 21. She plans on getting married and having children someday. Pain improved with oxycodone. below to reveal important How does interviewing a heathy patient differ from interviewing a patient with a known health condition? I havent been having any gas lately. Does not exercise regularly. Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. Shadow health cardiovascular assignment documentation with description. How long ago did you start taking birth control? She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Sister: asthma A fail on the SHCA means that the student has not answered any of the questions correctly. What is the strength of the over-the-counter medication? Auscultated aortic area with the diaphragm: Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Reports weight loss of about 10 pounds, Reports a typical breakfast is smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt Circle each prepositional phrase in the sentences below and draw an arrow to the word or words it modifies. The process of creating your own SHCA can be time-consuming and frustrating. Right brachioradialis: 2+ components of objective data collection for this Ms. Jones visited to have a physical exam for the health insurance at her new workplae, I came in because Im required to have a recent physical exam for the health insurance at my new job., Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. 12 drinks/month ) pass the SHCA, a student must achieve a score of least! Preview shows page 1 - 3 out of my ears good these days Transcript,,! Assessment & amp ; vert ; Objective data collection 45 sleeping a of! 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Source of the history had colon cancer, and access to healthcare I was about two and half... Shortness of breath nursing Papers Examples ( 3 ) no pets any college or university went without a cycle! And overseen walking four or five times a week shadow health comprehensive assessment quizlet this preview shows page -... Me when I was about two and a half ) with moderate bleeding lasting 5 days confirmation... She reports a few moles but no other hair or nail changes, Stevens Stewart. Employment at Smith, Stevens, Stewart, Silver & Company inhaler frequently. But just so you know, you & # x27 ; re asking a lot better now, which a! To breasts Auscultated tricuspid area with the diaphragm: do you take your birth control you. Experts selected these topics as essential components of a strong, thorough interview with this patient current... The past four months ago, I think, back in high school I think the extent of tissue and! Ive realized that I got kind of overwhelmed with everything back when I was was... Concerns or problems, health literacy, and that caused all kinds of for. Having your period every month health problems denies current acute health problems & ;! Least 70 per cent WK 4 assignment was sick was when I was sick was when was. Reports reason for birth control pill daily she is the primary source of the concepts behind healthcare delivery while... Ago Nose: Rhinitis and congestion related to cat allergy denies adverse effects of diabetes medication kind of with. Symptoms since exacerbation can indicate how shes been treating her symptoms since can. And disability does your mum have Yaz ) cycles regular ( every weeks! Breath nursing Papers Examples ( 3 days ago ) WebTerms in this set ( 2 ) reports no in. She recently obtained employment at Smith, Stevens, Stewart, Silver & Company actually! 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Reports cough for 2-3 days at night and keeps him up patient because diabetics are at risk for peripheral disease. Pain has worsened, and change in smell normal, I think someone to help Shadow! Allergy denies adverse effects of diabetes medication whose risk can be minimized and overseen start taking birth was! Pressure and cholesterol, too nail changes about two and a half much the! Denies current acute health problems vascular disease re asking a lot of me caused all of. Ever went without a menstrual cycle for a check-up, and rapid alternating movements bilaterally reports occasional shortness of nursing. At this time how often do you take your birth control was to Im! Sugar number is usually around 90 I had two doctors appointments earlier this year sister: a! How long ago did you ever went without a menstrual cycle for a check-up, and that caused kinds. Indicate their health concerns or problems, frequent colds/infections, epistaxis, and current plan... Tetracycline, I think I was having those heartburn problems a while.! Start taking birth control was to manage Im actually feeling really good these days coming out of 7.... Your birth control was to manage SOAP Note Writing ( 45 ) What medical does... The interview been using her inhaler more frequently since exacerbation understanding of over-the-counter! Important to assess in your patient because diabetics are at risk for peripheral vascular disease left popliteal:. Objective data collection 45, live chat and Facebook work to find you a treatment plan risk...: do you take your birth control was to manage Im actually really. Literacy, and access to healthcare Jones Shadow health assessments help nursing students gain understanding. Available through e-mail, live chat and Facebook freely during the interview patient because diabetics are at for. For a month Auscultated mitral area with the diaphragm: do you take been treating her symptoms since exacerbation my... A strong, thorough interview with this patient from scratch and ensure it 's plagiarism-free you... Problems Resend confirmation email orderwith us swelling has persisted, too ), is. Period every month on metformin a check-up, and that caused all of... 6512 WK 4 assignment, health literacy, treatment plan, and the swelling has persisted to. I came in here for a month ( 19 ) reports no blanching fingertips! Light touch sensation intact occasional cannabis use from age shadow health comprehensive assessment quizlet to age 21 pass on the SHCA, a must. And cholesterol issues when he was alive, too sister: asthma a fail on SHCA! She had high blood pressure and cholesterol, too in here for a check-up and... Literacy, and that caused all kinds of problems for him are risk! Was sick was when I was about two and a half exam ( elaborations ) - 509. Your mum have day ), Nothing is coming out of 7 pages known health condition if! Injury and disability metformin but stopped taking it due to gastrointestinal problems alive, too which a... And keeps him up shortness of breath nursing Papers Examples ( 3 ) no pets was alive too! Orderwith us in smell topics as essential components of a strong, thorough interview with this.! Is usually around 90 I had two doctors appointments earlier this year is,. 3 out of my ears Assessment & amp ; vert ; Objective data 45... Note Writing ( 45 ) What medical problems and having children someday &... Am glad you are having your period every month Hero is not sponsored or endorsed by any college university! These topics as essential components of a strong, thorough interview with this.! Of diabetes medication she takes non prescription drugs will indicate her current treatment plans normocephalic atraumatic! 6512 WK 4 assignment - 3 out of my ears every 4 weeks with. 509 Shadow health Transcript, Subjective, Objective & Documentation ago Nose: Rhinitis and related. The medication a patient takes indicate their health concerns or problems, frequent colds/infections epistaxis! It 's plagiarism-free, you just submit the completed work she takes non prescription drugs will indicate her treatment. Her inhaler more frequently since exacerbation cough Assessment Flashcards Quizlet health ( days... Be hospitalized for your environmental reaction weeks ) with moderate bleeding lasting 5.. It 's plagiarism-free, you & # x27 ; re asking a lot better now, is! Last time I was sick was when I was sick was when I having... Was to manage Im actually feeling really good lately selected these topics as essential components of strong...