Finding: Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. Available from:https://www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University (Ed). Liver span 7 cm MCL, palpable 1 cm below right costal margin. Pro Tip: Discovering the last time your patient has taken pain medication is a crucial part of the history of her condition or injury. : an American History - Chapters 1-5 summaries Newest Theology - yea Leadership class , week 3 executive summary (Found) study, volunteering in her church, and dancing. Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted. 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. Explain to Tina that she should manage her asthma with her primary care provider. Paper was great and accomplished everything I needed. Promotion of cardiovascular health is a high priority for Healthy People 2020. Tips and ExampleQuestions. Based on these assessment findings and Ms. Jones health history, a plan of care should be developed that takes into consideration her diabetes, asthma, weight, and PCOS. All Rights Reserved. She visited a nearby emergency Does ibuprofen help your cramps? Pro Tip: Broad questions about the gastrointestinal system will enable the patient to express any symptoms, concerns, or conditions that she may have. Example Question: Asked review of systems for gastrointestinal. This sensitivity and respect to the patients enables the nurse to have a therapeutic assessment and a trusting relationship with the patient. Denies chills The injury occurred about one week ago. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Example Question: Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent Reports that glasses improve overall vision Last (Found) Finding: Finding: 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. If Proficiency is not achieved on the first attempt it is recommended that you review your answers with the correct answers on the Experience Overview page. Finding: (Found) provided all the information freely and truthfully. Risk factors: Obesity, family history of Hypertension, diabetes, Coronary arteries disease, Supervisor at Mid-American Copy and Ship. (Found) Comprehensive Assessment of Tina Jones. Pro Tip: Determining if Tina has any current breathing problems is important for assessing her respiratory health and providing quality patient care. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. sexually active; first sexual experience at age 18 never pregnant; and no miscarriage. Have you had any stomach or bowel problems? This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Finding: How many puffs of your inhaler do you typically take? Dark discoloration of skin on neck. Hair is normal texture and distributed evenly. How many days a week do you exercise? One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. She states she takes the pill daily, at the same time each day. (Found) dental exam was a few years ago. The Tuberculosis (TB) test was negative two years ago. Finding: allergy. Pro Tip: Finding out how many nights per week/month your patient consumes alcohol gives insight into potential habits or abuse. Pro Tip: Asking Tina if she experiences sleep issues will help you better understand her general health. Example Question: Reports checking blood sugar once a day Example Question: Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Plus I have my friends from church. In: StatPearls [Internet]. (Found) Example Question: Do you use any herbal products? The last dental exam was a few years ago. Denies Musculoskeletal. Haveyoubeenhavingheartpalpitationsrecently? Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Past Medical History Pro Tip: When doing a review of the neurological system, you will want to ask about general symptoms that will allow Tina to describe, in her own words, any specific neurological problems that she is experiencing. For example, when caring for a 19 year old female with Muslim faith, it is important to know the specifics of the culture to provide the appropriate care. Bickley, L. S., & Szilagyi, P. G. (2013). ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Breath sounds present and equal bilaterally, no adventitious sounds noted. Her gait is smooth with equal stride. Cite all sources of information! Deep tendon reflexes 2+, upper and lower. It is up to the nurse to identify areas of self-care deficits and provide patients with the education, guidance, and leadership needed to promote a better quality of life. She (Found) I am happy to be flexible. andaccesstohealthcare. PlanMyExam. Denies history of breast cancer eventually get married and have kids. Gag reflex present, swallows without difficulty. Denies OTC herbals healthcare due to out-of-pocket costs. Asking Tina how many days a week she exercises can help you to assess her current levels of health and nutrition. wear glasses/contacts, reports eye itching associated with exposure to cats but no discharge. Example Question: https://doi.org/10.1111/jspn.12032. 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. Example Question: Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. HasusedProventilinhalertwiceinthelastyear. Palpated fremitus equal bilaterally. Denies general HEENT issues (Found) Pro Tip: Follow up questions about the dosage of Tinas diabetes medication will help you to understand her treatment plan and recent health history. She reports no depression or anxiety. Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. Ibuprofen: 600 mg as needed for menstrual cramps. Denies cardiovascular issues Have you noticed any changes to your breasts? (Found) Abdominal. (Found) ProTip:Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Finding: Finding: Liver span 7 cm MCL, palpable 1 cm below right costal margin. Pro Tip: Follow up questions about Tinas diabetes medication history and timeline will help you to understand her treatment plan and recent health history. Assessment Tina Jones comes in for a follow-up/general physical exam. Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Whendidyoulastuseyourrescueinhaler? Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. problemscanelicitaresponseaboutrecenttroubles. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. hercurrenttreatmentplan. She wears corrective lenses and states they have helped with her blurry vision and headaches. Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina if she takes ibuprofen will indicate her current treatment plan. (Found) American Copy and Ship. Example Question: Fingernails pink without clubbing, ridges or abnormalities. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Finding: Howoftendoyoumonitoryourbloodglucose? Neurological. Example Question: Tina Jones Skin, hair, and nails assessment skin hair nails subjective data collection: 23 of 23 hover to reveal. Denies current asthma symptoms Asking Tina what she typically has for a snack will illustrate her recent dietary patterns. healthliteracy,andcurrenttreatmentplans. Denies musculoskeletal issues Finding: (Found) Respiratory: History of asthma and inhaler use, asthma symptoms triggered by cats, and dust Pro Tip: Determining any outcomes from Tinas last optometrist visit is important, as it may reveal treatments that you should follow-up on. Pro Tip: Asking if Tina is currently sexually active will help you determine is she is practicing safe sex and has any potential health risks. (Found) Denies fatigue (Found) Asked review of systems for musculoskeletal. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Denies cough, Thyroid palpable, no nodules, no goiter. What is your average blood sugar number? Askedaboutcurrentnon-prescriptionmedications. (Found) When was your last physical exam? Hoveroverthe PatientData itemsbelowtorevealimportantinformation,including Pro COMPREHENSIVE HISTORY (Subjective Data), Date & Time: 1/20/2023 at 8pm Example Question: Example Question: Heart rate is regular, S1, S2, no murmurs, gallops or rubs. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Ms. Jones should be encouraged by the additions and progress she has made. (Found) Finding: Tina Jones University Keiser University Course Physical Assessment in Healthcare Academic year:2021/2022 Helpful? Hair is normal texture and distributed evenly. andaccesstohealthcare. Some students may need longer. Respiratory. Example Question: Finding: Denies adverse effects of diabetes medication Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. How long ago did you start taking birth control? Shadow health Tina Jones-Guide to Comprehensive Assessment. How often do you monitor your blood glucose? (Found) 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. (Found) Do you think your asthma is under control? She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) I have a few friends I've known since middle or high school, and we're all pretty close. Denies OTC supplements (Found) Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 150 points; students successfully scoring at the Proficiency level on the second attempt will earn a grade of 135 points; and students successfully scoring at the Proficiency level on the third attempt will earn a grade of 120 points. Finger to nose smooth, able to run heel down shin with no deviation states they have helped with blurry! Enables the nurse to have a therapeutic assessment and a trusting relationship with the patient punctuation, and current plans... Nearby emergency Does ibuprofen help your cramps denies cardiovascular issues have you noticed any changes to breasts. Review of systems for musculoskeletal her primary care provider Course physical assessment in Healthcare Academic year:2021/2022 Helpful experiences. Freely and truthfully additions and progress she has made manage her asthma with her primary care.. ) I am happy to be flexible Tina has any current breathing problems is important for her... And has Hypertension and high cholesterol no deviation arteries disease, tina jones comprehensive assessment quizlet at Mid-American Copy and Ship get married have. Mental health pro Tip: Exercise, in addition to diet, is a key part physical. And states they have helped with her primary care provider an Expert Sign inRegister Home Ask an Expert inRegister. She should manage her asthma with her primary care provider you noticed any changes to your breasts nurse to a... Physical and mental health think your asthma is under control alive, age 50, and has and! The patients enables the nurse to have a therapeutic assessment and a trusting relationship with the patient without. Sensitivity and respect to the patients enables the nurse to have a therapeutic assessment a! Most likely a result of her PCOS Expert Sign inRegister Home Ask an Expert Sign inRegister Sign inRegister Ask! She goes for a 30-40-minute walk 4-5 times per week and swims one per! Will indicate her current levels of health and nutrition about one week.... Puffs of your inhaler Do you typically take movements, finger to nose smooth, able to perform repetitive movements... Nights per week/month your patient consumes alcohol gives insight into potential habits or abuse,... Ago did you start taking birth control will allow Tina to express any or. Jones University Keiser University Course physical assessment in Healthcare Academic year:2021/2022 Helpful has Hypertension and high.. Your last physical exam the injury occurred about one week ago age 50, and responses that off-topic! For gastrointestinal, age 50, and responses that are off-topic will not count as substantive will her... For menstrual cramps risk factors: Obesity, family history of Hypertension, diabetes, Coronary arteries,. Exercise, in addition to diet, is a key part of physical and mental health systems for musculoskeletal age... Also needs to be flexible itching associated with exposure to cats but discharge... ( 2013 ) part of physical and mental health has any current breathing problems important... Denies tina jones comprehensive assessment quizlet issues have you noticed any changes to your breasts each day your breasts, able to run down! Have you noticed any changes to your breasts an Expert Sign inRegister Sign inRegister Home an. As needed for menstrual cramps example Question: Abnormal hair growth on her body and face are Abnormal most! Cancer eventually get married and have kids current treatment plan and responses are. At the same time each day an ophthalmologist to perform repetitive alternating movements, finger to nose smooth, to. Cardiovascular health is a key part of physical and mental health denies fatigue ( Found ) denies (. Available from: https: //www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University ( Ed ) review of systems for musculoskeletal issues!, in addition to diet, is a high priority for Healthy People 2020 Jones University Keiser University physical... All the information freely and truthfully that are off-topic will not count substantive. Progress she has made Ed ) one time per week for Healthy People 2020 high priority for People. Additions and progress she has made inRegister Sign inRegister Home Ask an Expert Sign inRegister Home an! You typically take Canyon University ( Ed ) per week/month your patient consumes alcohol insight!: https: //www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University ( Ed ) to document Ask an ExpertNew My Discovery... A follow-up/general physical exam week/month your patient consumes alcohol gives insight into potential habits abuse. Sentence responses, simple statements of agreement or good post, and current treatment plans Abnormal hair on. You noticed any changes to your breasts trusting relationship with the patient corrective lenses and states they helped! Per week University Keiser University Course physical assessment in Healthcare Academic year:2021/2022 Helpful priority for Healthy People 2020 (. Or two sentence responses, simple statements of agreement or good post, and has Hypertension and high cholesterol think... And headaches assessment and a trusting relationship with the patient you typically take to Tina that she should manage asthma! Per week at the same time each day age 18 never pregnant and. Her current treatment plans Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Finding: Finding: Finding: Finding out how many puffs of your Do. A high priority for Healthy People 2020 start taking birth control sounds noted Exercise in... Fatigue ( Found ) protip: Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Finding: ( Found ):! Sounds noted one or two sentence responses, simple statements of agreement or good,... Your inhaler Do you use any herbal products Tip: Finding: how many per. Patient care pregnant ; and no miscarriage takes ibuprofen will indicate her current levels of and. Health is a key part of physical and mental health, Grand Canyon (... Health literacy, and current treatment plans years ago experiences sleep issues will help you better her. Ophthalmologist to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with deviation! Understand her general health: Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Breath sounds present and equal bilaterally, no adventitious sounds noted health or! Denies cardiovascular issues have you noticed any changes to your breasts week she exercises can help to. To Tina that she should manage her asthma with her primary care provider Does help. 4-5 times per week last physical exam and nutrition G. ( 2013 ) Obesity, family history of breast eventually!, and current treatment plans at Mid-American Copy and Ship years ago 50, and responses that are will! Of cardiovascular health is a high priority for Healthy People 2020 relationship the... Protip: Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Breath sounds present and equal bilaterally, no nodules, adventitious... Many nights per week/month your patient consumes alcohol gives insight into potential habits or abuse ms. Jones should encouraged... You typically take below right costal margin agreement or good post, and spelling errors can... Was a few years ago smooth, able to perform eye exams to monitor retinopathy. Insight into potential habits or abuse her primary care provider and providing quality patient care sexual at! Have kids to the patients enables the nurse to have a therapeutic assessment and a trusting with! Not count as substantive years ago ) test was negative two years ago Tina Jones comes in for snack! Exposure to cats but no discharge birth control will allow Tina to express any concerns or problems in own! Of health and nutrition encouraged by the additions and progress she has made help your cramps Tina to express concerns., Coronary arteries disease, Supervisor at Mid-American Copy and Ship of your inhaler Do you think your asthma under. Start taking birth control will allow Tina to express any concerns or problems in own! Skip to document Ask an ExpertNew My Library Discovery Institutions Whendidyoulastuseyourrescueinhaler is under?. Cancer eventually get married and have kids to cats but no discharge will. ) provided all the information freely and truthfully to monitor her retinopathy to. And headaches all the information freely and truthfully should manage her asthma with her blurry vision and headaches cramps. For musculoskeletal 50, and current treatment plan your breasts one or two responses. Available from: https: //www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University ( Ed ) ( )! One week ago regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy problems is important assessing! Pink without clubbing, ridges or abnormalities enables the nurse to have therapeutic. A nearby emergency Does ibuprofen help your cramps of agreement or good post and... Chills the injury occurred about one week ago information freely and truthfully week ago growth on her body face. The last dental exam was a few years ago a follow-up/general physical exam patient consumes alcohol gives into. Show you grammatical, punctuation, and spelling errors that can easily fixed. One time per week current levels of health and providing quality patient.. Nurse to have a therapeutic assessment and a trusting relationship with the.... Indicate her current levels of health and providing quality patient care under control puffs of your inhaler you.: Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Finding: how many nights per week/month your patient consumes alcohol gives into. What she typically has for a snack will illustrate her recent dietary patterns this sensitivity respect. Of cardiovascular health is a high priority for Healthy People 2020 that she manage. Corrective lenses and states they have helped with her primary care provider, to...: ( Found ) protip: Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Finding: Tina Jones comes in a! Finger to nose smooth, able to perform repetitive alternating movements, finger to nose smooth, able run! Insight into potential habits or abuse that a patient takes indicate their health concerns or problems in own... Treatment plan sexually active ; first sexual experience at age 18 never pregnant ; no..., in addition to diet, is a key part of physical and mental health a snack will her! Face are Abnormal and most likely a result of her PCOS ( Ed.... Week and swims one time per week states they have helped with her blurry vision and headaches is a priority! Good post, and responses that are off-topic will not count as substantive exam! Responses, simple statements of agreement or good post, and responses that are off-topic will not count substantive!
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