Spirometry: FVC 3.9L, FEV1 3.15L, FEV1/FVC ratio 80.56%. 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. 472 Comments hertreatmentplanandrecenthealthhistory. Click the card to flip Definition 1 / 18 chief complaint Click the card to flip Flashcards Learn Test Match Created by DINA_CASIMIR-DORCELY Shadow Health Terms in this set (18) How are you feeling? Areyoutakinganymedicationforyourallergies? A week ago the scrape startedand the pain got a lot worse in last few days. Doyoutakeyourpillatthesametimeeveryday? Gastrointestinal: Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. than twice a week, sometimes not at all" Patient drinks alcohol about six drinks per month Does not exercise regularly. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate a number of serious health conditions. Ms. Jones speech is clear and coherent. High BP and high cholesterolon both sides and diabetes. How long ago did you start taking birth control? rises midline on phonation. The last visit to the clinic was four months ago for an annual gynecological exam. job." Ms. Jones reports that she recently obtained PMI nondisplaced, no heaves or lifts. Shadow Health - Comprehensive Assessment: Tina Jones Flashcards | Quizlet Shadow Health - Comprehensive Assessment: Tina Jones Term 1 / 7 Current Health Status Click the card to flip Definition 1 / 7 Click the card to flip Flashcards Learn Test Match Created by Cate_Howe Terms in this set (7) Current Health Status . Metformin: Started five months ago. Topics (15) Retrieved from http://www.uptodate.com. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. ), Does your bother have health issues? Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Cross), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! AskingTinahowlongagoshestartedtakingbirthcontrol Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. AskingTinahowshehasbeentreatingherhypertensionwillindicate 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. Reportsneedingapre-employmentphysical. Chamberlain University (39) HasusedProventilinhalertwiceinthelastyear. andaccesstohealthcare. By visualizing the fundus, you can look for any retinopathic changes. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. My eyes havent been red lately. 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. 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. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. She reports I Today she denies any acute concerns. Indicates an item that is available to be found. she'sseenhervisionassomethingthathasneededmedicalattention. Sometimes drink, once or twice in a week, sometimes less. Arizona State University (10) (Clarified to if my younger sister has health problems. When did you last use your rescue inhaler? AskingTinaaboutthe . 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. Cheap Research Papers and computer essay for sale. Well, I used to smoke pot. She has not been eating much and has been staying in bed the last few days, per patient report. (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. No pets. Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing, Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache, Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps. Howoftendoyouuseyourrescueinhaler? Do you take your pill at the same time every day? Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Tina Jones is a 28-year-old African American female patient who is single and presented to the clinic with a request for a pre-employment physical examination. Shadow Health Comprehensive Assessment: Tina Jones . Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. Assessment Tina Jones comes in for a follow-up/general physical exam. exercise four to five times per week consisting of Case - Tina jones health history narrative 2. Scattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Alert and oriented to person, Three months was her last visit to the optometrist for which she was given prescription eyeglasses. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. She is now on metformin, Proventil, and Flovent. Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use: this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago), Allergic to cats and dust Allergiic to penicillin Denies any food or latex allergy. Although Ms. Jones is not sexually active, she states she probably will be soon. Capella University (56) My discharge is normal, I think. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Yeah. treatmentplans. Nasal mucosa moist and I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. Hello, my name is . It is infected and causing pain(7 out of 10). Solved essays (236) (2018). No foreign travel. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Penicillin: rash Denies food and latex allergies Allergic to cats and dust. Denies myalgias and arthralgias. She drinks four caffeinated drinks/day (diet soda). chief complaint Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. without contradiction. Chest resonant on percussion. Whispered words heard bilaterally. Frontal and Tonsils 2+ bilaterally. Tested negative for HIV/AIDS and STIs four months ago. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: An individualized plan of care taking into . Asthma is a lung condition that affects people of all ages. She is a good historian. Ms. Jones reports no muscle pain or weakness. 37 C. Patient is in no apparent distress. Self-care deficit theory. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. She started me on birth control, and it seems to be helping things. I just always want to be learning new things and getting better at my job. Pro Tip: Your patient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. symptomsmostrecentlyrequiredmedicaltreatment. Skin on neck has stopped darkening and facial and body hair has improved. Ideas (15) haveabearingonTina'sbreathing. The daily inhaler is Flovent, and the rescue inhaler is Proventil. contraceptives. No history of bone trauma or deformity. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention and Health Promotion. 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. changes in hearing your pain or discharge. DTRs 2+ and equal bilaterally in drinking no more than 3 drinks per episode. That doesnt sound like it would be good. No nail deformities. . Nana was 73 when she died of a stroke about five years ago. Her skin is pink, warm, with no tenting. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. The assessment should also include the comparison of bilateral sides. She states foot still hurts, but much better than when she arrived yesterday. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. I will be conducting an interview and a physical exam. Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. Experts selected these examinations as essential components of objective data collection for this patient. diagnosed her with polycystic ovarian syndrome and Reports decreased stress and improved coping Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Asthma diagnosed at age 2 1/2. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. employment at Smith, Stevens, Stewart, Silver & , or abnormal hair growth assesses for underlying medical problems //www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention health! 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