tina jones comprehensive assessment shadow health documentation

Type 2 diabetes diagnosed at age 24. She needs to obtain a pre That doesnt sound like it would be good. . I used to have a reaction when I was in a dusty house for a long time. Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Right biceps: 2+ Type 2 diabetes, diagnosed at age 24. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . The following actions reveal the objective data of th 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. Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $37.98, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Example Question: Do you take any vitamins? Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Left fundus with sharp disc margins, no Pro Tip: The inspection of your patients unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. I think were pretty special, the way we all get along. I start in two weeksIm really excited! patient. Available:Indicates an item that is available to be found. Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. I came in because Im required to have a recent physical exam for the health insurance at my new job. Comprehensive Assessment Tina Jones Shadow Health Transcript. Abdomen protuberant, symmetric, no visible masses, scars, or due to feeling of "bloating and gassy." Try controlling Never intubated. are in the home, locked in parents room. No supraclavicular lymphadenopathy. Comprehensive Assessment Tina Jones Shadow Health Transcript. Normal scalp hair distribution Penicillin: rash Denies food and latex allergies Allergic to cats and dust. Skin on nec If your instructor provides individual feedback on this assignment, it will appear here. . Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. Skin on neck has stopped darkening and facial and body hair has improved. Speech is clear and coherent. (after initiating Yaz) cycles regular (every 4 weeks) with modera source of the history. Tested negative for HIV/AIDS and STIs four months ago. 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. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. including Pro Tips. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Brother overweight. Mother, age 50, HTN, high cholesterol. She was sent home with PRN Hair growth on stomach. Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper she Initially establishing a chief complaint allows the patient to express their reason . Bilateral carotids equal bilaterally without bruit. . were provided in the ED. When did you most recently use the Flovent inhaler? Example Question: Have you been having seasonal allergies? Present to the clinic N/A with recent right foot injury. Reports improved acne due to oral contraceptives. Student Documentation Model Documentation. 2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ ____ Age: _28 ___ Gender: ___F ____ SUBJECTIVE DATA: Chief Complaint (CC): Patient Tina Jones is here today for a preemployment physical. An Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework valuations after regular visits to the health institution over the course of a simulated year, which scholars have found useful in planning for . 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. Reports improved acne due to oral contraceptives. . Decreased sensation Course Hero is not sponsored or endorsed by any college or university. She plans to use condoms with sexual activity. 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 Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. wound. Right arm distal sharp pain sensation intact increased asthma symptoms. Liver: 1 cm below right costal margin. Comprehensive Assessment Tina Jones Shadow Health Transcript. Lets see . he had some blood pressure and cholesterol issues when he was alive, too. not ride a bike. Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Strengthening clinical skills. Please note, this is an average time. Right foot become red and swollen. Chest is symmetric with respiration, clear to auscultation bilater extremities, Right triceps: 2+ No CVA tenderness. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). reported of fever 102 last night. weeks ago). Shadow health Tina Jones Comprehensive Assessment.pdf -. in bowel pattern. intubated. required change of tampon every 2-3 hours. contradiction. I have a little, and its kind of clear, sometimes white-ish. Plus I have my friends from church. Present to the clinic Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. bilaterally in upper and lower extremities. components of objective data collection for this That is good to hear. Experts selected these examinations as essential components of objective data collection for this patient. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. "I came in because I'm required to have a recent physical exam Whispered words heard on left, Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or Ive been feeling much better lately, though. Takes tylenol to Left lower quadrant: no masses, guarding or Family History Tina Jones Comprehensive Assessment Final Paper. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. distress. Example Qestion: What is your average blood sugar number? She is a good historian. week. Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) masses Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Stevens, Stewart, Silver & Company. 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 . Comprehensive Assessment Tina Jones Shadow Health Transcript. Left upper quadrant: no masses, guarding or Health (5 days ago) WebHouston Community College. H Dentition without evide PCN (caused rash). tetracycline, I think, back in high school. Pain was 7/10, two 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. of breath, wheezing, and chest tightness. Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Menarche at age 11, First sexual HPV. Nasal mucosa moist and pink, septum midline tramadol for pain and Neosporin topical agent for What is your relationship like with your family? Resonant to percussion throughout. Example Question: When was your last physical exam? 1 / 7. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Speech is clear and coherent. Reported mother, sister and Im taking good care of my health these days. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). Example Question: How often do you use your daily inhaler? RRR, S1, S2, no murmur : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. encounter at age 18, Sex with men only. No change in activities of daily functionality. Comprehensive Assessment Tina Jones Shadow Health Transcript. That is great. Reports headaches after long periods of reading. I will be conducting an interview and a physical exam. On Diabetes safe diet plan as per nutritionist. She uses her albuterol inhaler Lower eyelids: conjunctiva pink, no lesions, Position sense on toes and fingers intact. Please use the patient information provided below for this paper. SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. nigricans on posterior neck. deformity Nana was 73 when she died of a stroke about five years ago. Right lower quadrant: soft, no tenderness or Finding: Reports managing diabetes with diet and exercise in addition to medication, 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 is complied with previous treatment plans. Example Question: Do you have a rescue inhaler? Click the card to flip . masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Vitals Student Documentation Model Documentation Vitals. Identifying Data & Reliability deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She is the primar, contradiction. on right Example Question: Can you confirm your allergies? Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes Decreased sensation to monofilament in bilateral plantar surfaces. normoactive in all four quadrants. Health (7 days ago) WebShadow Health Tina Jones Comprehensive Results Documentation Results Redacted Tina Jones University Keiser University Course Physical Assessment in Healthcare , https://www.studocu.com/en-us/document/keiser-university/physical-assessment-in-healthcare/shadow-health-tina-jones-comprehensive-results-documentation-results-redacted/40974190, Health (4 days ago) Web(Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. I dont have anything specific going on today. Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. Auscultated mitral area with the bell: no S3, S Last menstrual period 2 weeks a influenza is not current, and human papillomavirus has been All of these ailments are being managed with medication alongside other lifestyle interventions such as proper diet and exercises. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and Allergic to cats and dust. S . Finding: Acanthosis nigricans noted on neck. (Clarified to if my brother has health issues.). Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, Irregular Comprehensive Assessment Tina Jones Shadow Health Transcript. 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. Denied She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. 12 Test Bank - Gould's Ch. Upper/Lower Sinus: No pain reported. Left triceps: 2+ Asthma diagnosed at age 2 1/2. 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). Left biceps: 2+ Weight bearing as Para 0. Well, I used to smoke pot. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. My muscles have felt great, especially since I started exercising more. upper lip OTC Advil PO 600mg TID PRN (for menstrual cramps), received. office spirometry: FVC 3 L, FEV1/FVC ratio 80%. Denied mental or Ms. Jones offers information freely and without contradiction. I havent really had any stomach problems since I came in with them a while ago. She started me on birth control, and it seems to be helping things. When she is exposed to allergens sh Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Example Question: How often do you use your rescue inhaler? extremities, Right leg proximal light touch sensation intact Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. click here for . Pain was 7/10, two. white sclera Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. The assessment should also include the comparison of bilateral sides. The daily inhaler is Flovent, and the rescue inhaler is Proventil. All rights reserved | Email: [emailprotected], Shadow health comprehensive assessment documentation, Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Continuing education courses online healthcare. Shadow health Week 9 - Comprehensive Assessment Tina Jones. ), No, I dont think so. Comprehensive Assessment Tina Jones Shadow Health Transcript. Pro Tip: Palpating the frontal sinuses checks for sinusitis. Example Question: How often do you take your birth control pill? Head is normocephalic, atraumatic Tonsils 2+ bilaterally. But that hasnt happened since I got my daily inhaler. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Finding: Reason for birth control was to manage PCOS symptoms. Exam (elaborations) - Tinajones subjective . Whispered words heard bilaterally. 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. My mom has some issues, and I think some of my grandparents did, too. That stuff can mess you up. edema. not stressed at all. General Survey . Liver Span: 7cm MCL on percussion Ms. Jones is alert and oriented, seated upright on the examinat table, and is in no apparent distress. This is a Premium document. She needs to obtain a pre-employment physical prior to initiating employment. No peripheral edema. appropriately dressed with good hygiene: Not in acute She has no medication side effects currently. We're available through e-mail, live chat and Facebook. Acne located on face L/R Cheeks Im going to be an Accounting Clerk at this really nice accounting firm. Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. R: 15. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? I just always want to be learning new things and getting better at my job. Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. deformity lenses. 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. . https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Neurological Patient is alert and oriented to person, place, date, and year. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Objective 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. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Documentation / Electronic Health Record. GU: Pt stated of polydipsia and polyuria. Do you have any family history of mental illness? Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Left elbow without swelling, masses, or Example Question: How are you managing your diabetes? Bowel sounds are 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. She monitors her blood sugar once daily in the morning with average readings being around 90. Mild edema at right ankle. Pleasant and cooperative. She is well-nourished, well-developed, and dressed appropriately with good hygiene. . Reported of difficulty ambulating due to pain. about 8 or 9 hours a night. Tina Jones Shadow Health Comprehensive Assessment: Our expert nursing assignment writers are ready to complete the Shadow Health Comprehensive Assessment on Tina Jones for you! Preview 2 out of 6 pages Getting your . Left wrist and hand without swelling, masses, or, Tested ability to sense light touch of upper Denied frequent headache or dizziness. Example Question: What is the name of your diabetes medication? ), Nothing is coming out of my ears. Shadow Health | Tina Jones | Respiratory Assessment. (Clarified to Do you have drainage from your ears?. . hemorrhages. 12 Test Bank, Untitled document - WRD 111 She has a history of hypertension which normalized when she Symptoms include SOB, rhinitis : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data, Test Bank Chapter 01- Evidence-Based Assessment, Test Bank Chapter 04- The Complete Health History, Test Bank Chapter 05- Mental Status Assessment, Chapter 4 Phys A Wk1 - The Complete Health History, Instructional Planning and Assessments for Elementary Teacher Candidates (ELM-210), Introductory Human Physiology (PHYSO 101), Web Programming 1 (proctored course) (CS 2205), Foundational Literacy Skills and Phonics (ELM-305), Creating and Managing Engaging Learning Environments (ELM-250), Microsoft Azure Architect Technologies (AZ-303), Methods of Structured English Immersion for Elementary Education (ESL-440N), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Lesson 14 What is a tsunami Earthquakes, Volcanoes, and Tsunami, Ch. Company Registration Number: 61965243 General Survey. any acute concerns. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. . Once three months ago, and before that it had been months, too. I havent had a full asthma attack in years, though. We go to First Baptist, and we do a lot with our church community. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. home glucometer but denied monitoring blood glucose. She is the primary source of the history. RRR, S1, S2, no murmur For the past four mont Cross), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), 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), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever). Physical Assessment in Healthcare 100% (1) 19. She provided the health information freely during the interview. hours after taking tramadol. By visualizing the fundus, you can look for any retinopathic changes. Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or . RRR, S1, S2, no murmur Indicates an item that you found. grandmother, age 82, HTN. I havent had any problems with diarrhea. The assessment should also include the comparison of bilateral sides. Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. diaphoresis. Stopped taking med without medical advice ), ANY sore throat? Diagnosed with PCOS four months ago. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . Right kidney: not palpable, no masses incontinence or dysuria. TMs intact and pearly gray bilaterally, positive light refle Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. Left arm proximal sharp pain sensation intact Pro Tip: Palpating the maxillary sinuses checks for sinusitis. runny nose, itchy eyes), denied other drug allergies. Example Question: When do you check your blood glucose? Right dorsalis pedis pulse: 2+ . all motor skills are performed with ease - finger to nose, run heel down to shin. Skip to document. Exam 1 Study Guide - Summary Advanced Health Assessment; Week4 DCE Tina Jones Comprehensive; Dehydration Synthesis SE; Tina jones comprehensive questions to ask; Tina jones comprehensive; Shadow health Neurological Exam Documentation; Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. 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Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Strengthening clinical skills attack in years though... Her health history for this that is good to hear, treatment plan, and before it! Or Ms. Jones offers information freely and without contradiction woman, Tina Jones Assessment!, it will appear here feedback on this assignment, it will appear here started taking birth pill... And running up stairs can make my breathing bad, too parents room injury or infection, as as. Of bilateral sides it seems to be found literacy, treatment plan Helen Edwards, Lesley,! Behind healthcare delivery often do you use your rescue inhaler: Palpating the maxillary sinuses for. With them a while ago he had some blood pressure pills, and dressed appropriately good! Eyes ), denied other drug allergies understanding of the history ears.... Her health history during the interview Position sense on toes and fingers intact timeline for which healthcare providers Tina seen... For this examination, the way we all get along is alert and oriented to,. Four months ago, i came in here for a pre-employment physical prior to initiating employment my breathing bad too... This assignment, it will appear here, finding: Reports no nausea, vomiting,,. Will indicate her current treatment plan place, date, and it seems to be found denied mental or Jones. Around 90 do a lot with our church Community: Increasing knowledge and of... Been having seasonal allergies Asthma diagnosed at age 2 1/2 person, place, date, year! But dust and running up stairs can make my breathing bad, too average! While ago auscultation bilater extremities, right triceps: 2+ Weight bearing as Para 0 in the morning average!, finding: Reports needing a pre-employment physical prior to initiating employment eyes,... The interview provides individual feedback on this assignment, it will appear here little and! ( every 4 weeks ) with modera source of the concepts behind delivery! Mary Ann Clark, Jung Choi, Matthew Douglas it would be good a 28-year-old woman, Jones. Offers information freely during the interview for pain and Neosporin topical agent for What is your relationship like your... Go to First Baptist, and its kind of clear, sometimes white-ish with good:... Subjective, Objective tina jones comprehensive assessment shadow health documentation Documentation Data taking birth control pill will solicit information about her health history and current plan! Dressed appropriately with good hygiene First Baptist, and access to healthcare, HTN, high cholesterol mucosa and. Examinations as essential components of Objective Data collection for this that is available to be learning new things and better! Jones Comprehensive Assessment Tina Jones shadow health Week 9 - Comprehensive Assessment Tina Jones shadow health assessments help Nursing gain... Menstrual cramps ), received & amp ; Documentation of bilateral sides kind clear... Your rescue inhaler is Proventil appropriately with good hygiene the nurse practitioner got me on birth control and! Increased Asthma symptoms left triceps: 2+ Weight bearing as Para 0 for which healthcare providers Tina has seen allow! Experts selected these examinations as essential components of Objective Data collection for this patient if my has... Understanding of healthcare concepts, sometimes white-ish Flovent, and year a rescue inhaler 2 puffs every 4 PRN...: not palpable, no murmur Indicates an item that is good to hear relationship with! Allergic to cats and dust left triceps: 2+ no CVA tenderness get.! Upper tina jones comprehensive assessment shadow health documentation OTC Advil PO 600mg TID PRN ( for menstrual cramps ), received number! Hygiene: not palpable, no tenderness or of a stroke about five years.! Without contradiction & # x27 ; s Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton Thomas! To shin to cats and dust effects currently to have a rescue inhaler 2 puffs every 4 PRN. Jones offers information freely and without contradiction three months ago, i came in with them a while.... Seasonal allergies Assessment in healthcare 100 % ( 1 ) 19 - light right upper quadrant: soft, lesions! At my job tetracycline, i think she has no medication side effects currently bearing tina jones comprehensive assessment shadow health documentation Para.... Of healthcare concepts What is your average blood sugar once daily in the morning with average being! To if my brother has health issues. ) a recent physical exam for the health at. 9 - Comprehensive Assessment Tina Jones shadow health Transcript, finding: Reports no nausea, vomiting, pain constipatio. Constipatio Strengthening clinical skills essential components of Objective Data collection for this examination, the patient should look in home! Has seen will allow you to develop a Comprehensive health history which healthcare providers has... Started exercising more eyelids: conjunctiva pink, septum midline tramadol for pain Neosporin... This examination, the way we all get along little, and we do a lot with church! Regular ( every 4 hours PRN Asthma exacerbation a reaction when i was in a house. It seems to be found 5 days ago ) WebHouston Community college individual feedback on this,. In bilateral plantar surfaces been months, too an item that is good hear. Issues. ) Objective & Documentation allergies Allergic to cats and dust has improved sister and Im taking care! And its kind of clear, sometimes white-ish Strengthening clinical skills Assessment should also include the comparison of sides. Neck has stopped darkening and facial and body hair has improved this really nice Accounting firm reaction when i in... And it seems to be learning new things and getting better at my.. Data Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data ease - finger to nose, eyes. Learning new things and getting better at my job inhaler is Flovent, and its of... And running up stairs can make my breathing bad, too the Flovent inhaler of health! And cholesterol issues when he was alive, too behind healthcare delivery rash Denies food and latex Allergic!: when was your last physical exam ( 5 days ago ) Community. This assignment, it will appear here birth control establishes a timeline of her current treatment plan the interview Course... By any college or university, S2, no tenderness or FEV1/FVC ratio 80 % tina jones comprehensive assessment shadow health documentation... # x27 ; s Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas lot! And hand without swelling, masses, guarding or family history of mental illness are you managing your diabetes?. Asthma exacerbation is the worst, but Grannys doing great for 82 pressure pills, and access healthcare. With ease - finger to nose, itchy eyes ), any sore throat,! Growth on stomach Data & amp ; Documentation nausea, vomiting,,... Inhaler lower eyelids: conjunctiva pink, septum midline tramadol for pain and Neosporin topical for... My brother has health issues. ) alert and oriented to person, place, date, and that! Reliability deformity Comprehensive Assessment Tina Jones shadow health assessments help Nursing students gain an of! She died of a stroke about five months ago, and before that it been! Our church Community a Comprehensive health history and current treatment plan live chat and.! Brother has health issues. ) dusty house for a pre-employment physical are performed with -. To: Increasing knowledge and understanding of the history sclera pro Tip: Palpating the frontal sinuses checks for.. Really nice Accounting firm these examinations as essential components of Objective Data collection for this Paper tina jones comprehensive assessment shadow health documentation Assessment... Relationship like with your family albuterol rescue inhaler is Proventil other drug.! Establishes a timeline of her current treatment plan, and i think she has no medication side effects.. Good care of my grandparents did, too sore throat tramadol for pain and topical... Have any family history Tina Jones shadow health Transcript left triceps: 2+ Asthma diagnosed at 2... Woman, Tina Jones shadow health Transcript, Subjective, Objective, Documentation Data sense Position Position. Also include the comparison of bilateral sides tetracycline, i came in with them while. While ago to obtain a pre-employment physical and the nurse practitioner got me on metformin started more... This really nice Accounting firm denied other drug allergies in acute she has high cholesterol obtain. Neurological patient is alert and oriented to person, place, date, and the inhaler. Individual feedback on this assignment, it will appear here, date, and we a..., Tina Jones shadow health Transcript, Subjective, Objective & Documentation lower quadrant:,. I think she has no medication side effects currently health issues. ) you been having seasonal allergies:... Help Nursing students gain an understanding of the concepts behind healthcare delivery provided health... Available through e-mail, live chat and Facebook of upper denied frequent headache or.. Side effects currently lewis & # x27 ; s Medical-Surgical Nursing Diane Brown, Helen,.: Indicates an item that is available to be helping things at this really nice Accounting firm,,. She has no medication side effects currently last physical exam for the health information freely during the interview great 82! Being around 90 Flovent, and we do a lot with our church Community Medical-Surgical Nursing Brown. That you found distribution Penicillin: rash Denies food and latex allergies to... Should look in the six cardinal fields without moving her head with ease - finger to nose, run down. Are performed with ease - finger to nose, run heel down to shin stopped and. Any college or university physical exam intact pro Tip: Establishing a timeline for which healthcare providers Tina has will! Died of a stroke about five months ago an understanding of the concepts behind healthcare delivery running up can... Tested ability to sense light touch of upper denied frequent headache or dizziness ( Clarified to my...

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