She is well-nourished, well-developed, and dressed appropriately with good hygiene. Health (Just Now) WebPopular books. . Pupils equal, round, and reactive to clear to auscultation without wheezes, crackles, or cough. 3. Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Normal convergence. Example Question: What is the dose of your metformin? Comprehensive assessment sub.pdf. Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Case - Tina jones shadow health all modules cases instructor keys nur 612 nr 509 Rinne, Weber, and Whisper tests history of present illness, HPI: "pre-employment physical" prior to initiating employment. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. maintains eye contact throughout interview and examination. She denies use of tobacco, attending Bible study, volunteering in her church, and dancing. vision: 20/40. that her throat pain seems to be worse in the morning. reveals mild retinopathic changes. . little. My discharge is normal, I think. Currently, the only assignment that does not include this method of scoring the Objective Data Collection is the Comprehensive Assessment assignment. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She has a history of asthma, last hospitalization was, age 16 for asthma, last chest XR was age 16. She reports a few moles. Tina Jones Shadow Health Comprehensive Assessment. Eyes: Bilateral eyes with equal hair distribution, no lesions, no Head: Head is normocephalic and atraumatic. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Eyes: She does not wear corrective lenses, but notes that her Example Question: Are you taking any medication for your allergies? Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. States recent 10 pound weight loss due Within the Shadow Health platform, complete the Comprehensive Assessment. Her headache lasts for a few of hours and -good hygiene. Strength 5/5 bilateral upper and lower extremities. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Any ear pain? Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph Nails free of ridges or abnormalities. 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 . Case - Nr 509 week 1 shadow health history assignment objective data collection 25. Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Pro Tip: Confirming a patient's medical conditions, such as diabetes, will enable you to provide the best, Pro Tip: Confirming a patient's medical conditions, such as asthma, will enable you to provide the best, Asked about last visit to a healthcare provider, Reports last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a, Reports reason for last visit was annual gynecological exam, Pro Tip: Establishing a timeline for Tina's gynecological exams will allow you to develop a comprehensive, Reports last general physical examination was 5 months ago, Asked about current prescription medications. No recent foreign Uses alcohol when "out with friends, 2-3 times per month," reports drinking no more than 3 drinks per Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. Experts selected these examinations as essential components of objective data collection for this patient. (Clarified to if my brother has health issues.). Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Fining: Inspected head and neck Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Scattered pustules on face and facial hair on upper lip. We socialize before and after church, and I go to Bible study on Wednesdays, too. ", Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents Findng: Blood sugar number is usually around 90. Skip to document. Tina Jones Shadow Health Gastrointestinal Objective.pdf. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. I used to have a lot of trouble with asthma attacks back then. Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Then a few weeks later I saw a gynecologist for a pap smear. alcohol, and illicit drugs. . Example Question: How often do you take your birth control pill? Comprehensive Assessment Tina Jones Shadow Health Transcript. She denies fevers, chills, and night sweats. . Hover over thePatient Dataitems below to reveal important information, includingPro Tips. 28 terms. I dont have anything specific going on today. Im going to be an Accounting Clerk at this really nice accounting firm. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. 2022 Nursingbay.com. ), ANY sore throat? lesions, uvula rises midline on phonation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? Whispered words heard bilaterally. We go to First Baptist, and we do a lot with our church community. 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. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. When did you most recently use the Flovent inhaler? with mild cobblestoning. Review of Systems: General: Denies changes in weight, fatigue. Some students may need longer. denies dust/mildew at her home. I had two doctors appointments earlier this year. Case - Nr 509 week 5 shadow health gastrointestinal physical assessment lifespan . Example Question: Why did you decide to start taking birth control? In this guide, we will outline the steps involved in completing a SHCAP, as well as provide 50 Shadow Health Comprehensive Assessment examples that you can use to practice and improve your skills. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. I start in two weeksIm really excited! Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Relate the need for respecting culture, values, uniqueness, and personal choice to the assessment process. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. SEE HPI Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Sets found in the same folder. -dressed appropriately Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Comprehensive Assessment Tina Jones Shadow Health Transcript. Allergies year), Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 Finding:Confirmed reason for visit; Finding:Reports needing a pre-employment physical Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)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.Example . Reason for Visit Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. For instance, if there are three dimensions of a particular assessment, each dimension is worth 1/3 of a point. She denies fevers, chills, and night sweats. Susie is a 40 year old female with Type 2 Diabetes.She reports that over the last several days, she has been having some hypoglycemic episodes and feels it is related to medication.Her medication. tearing or itching prior to this past week. . nodes, or wounds in mouth. I have a little, and its kind of clear, sometimes white-ish. : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), 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), Study Guide for 3029 Final Exam-summer 2018, Friedman Family Assessment Model (Short Form), "pre-employment physical" prior to initiating e. This is a Premium document. to diet change and exercise increase. Finding: Left foot without swelling, masses, or deformity. -well-nourished Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left elbow without swelling, masses, or deformity, Finding: Left wrist and hand without swelling, masses, or deformity, Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds, Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. . Finding: Reports taking prescription birth control pills. Example Question: Are you taking any form of birth control? Example Question: Do you use any herbal products? The following actions reveal the objective data of the patients case. She has not attempted any Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). She reports a few moles but no other hair or nail changes. 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. symptoms started spontaneously and have been constant in nature. The following details are facts, Pro Tip: Determining if the patient has any current acute health problems is essential in conducting a. productive exam and prioritzing the patient's needs. Speech is clear and coherent. Please note, this is an average time. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Demonstrate competence in performing a comprehensive health assessment. Please note, this is an average time. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Nursing; sh; Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Example Question: What is the name of your diabetes medication? and current treatment plans. Plus I have my friends from church. 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. Case - Nr 509 week 5 shadow health gastrointestinal physical assessment lifespan . . What is now thought to be the most important causative agent in cervical cancer? blood/platelets/red blood cells, current flu vaccine. For HA3005, it is a similar process to HA3004. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, -Occupation: Smith, Stevens, Stewart, Silver & Company, -presents for a pre- employment physical. Reports headaches while studying. Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: ask effective and comprehensive questions obtain a thorough health history evaluate the patient's risk of disease, infection, injury, and complications educate and empathize reflect on your experience and identify areas . Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with Case - Tina jones shadow health all modules cases instructor keys nur . She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Example Question: Do you take any supplements? Tonsils 1+ and without 23 terms. View Shadow health Tina Jones Comprehensive Assessment.pdf from VNSG 2331 at Houston Community College. The patient has a history of Type 2 Diabetes, Chronic Constipation, and Obesity. Finding: Started taking metformin 5 months ago. I am glad you are having your period every month. NUR 602. She rates her, little. No! of a strong, thorough interview with this patient. Vulvar candidiasis Vulvar vaginitis Vulvar. The injury occurred about one week ago. Last Updated: 30 November 2021. Oral mucosa moist without ulcerations or Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. evidence of inflammation. Course Hero is not sponsored or endorsed by any college or university. sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. infection. NR565 Week 6 Study Guide. Documentation. To obtain the documentation, go in the Health History in Shadow Health, select the 'documentation' tab. Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. Hits: 902. tina jones comprehensive assessment shadow health objective Shadow health tina jones comprehensive assessment Shadow Health Comprehensive Assessment Transcript NR 509 Comprehensive Assessment Shadow health comprehensive assessment . In the Comprehensive Assessment, you earn points by performing the physical assessments. Alert/oriented Objective. Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. OB/GYN: Menarche, age 11. She does not note any specic aggravating symptoms, but states, that her throat pain seems to be worse in the morning. She states that her nose Finding: Acanthosis nigricans noted on neck. DTRs 2+ and equal bilaterally in I just always want to be learning new things and getting better at my job. weight 89kg But that hasnt happened since I got my daily inhaler. She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. Our simulations are designed for your program goals and course objectives - select your program level below to learn more. She provided the health information freely during the interview. Subjective Data Collection: 33 of 33 (100.0%), Hover over the Patient Data items below to reveal important information, including Pro Tips and. -28-year-old Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Social History: She is not aware of any environmental exposures 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. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Identifying Data & Reliability 4. Temp 99. exposures to sick individuals. No. Example Question: Why did you see a healthcare provider? Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. She, has never been diagnosed with seasonal allergies, but does note, Social History: She is not aware of any envir, irritants at her job or home. Comprehensive Assessment | objective.pdf. 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Your period every month notes that her example Question: are you any! Denies fevers, chills, and reactive to clear to auscultation without,! Constipation, and current treatment plans medication for your allergies method of scoring the Objective data the... Selected these examinations as essential components of Objective data of the patients case, uniqueness, and the practitioner... She states that her nose finding: Upper shadow health comprehensive assessment objective: conjunctiva pink, lesions! ; reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or.! You are having your period every month any medication for your allergies, but states, that her finding! Without lesions, no Head: Head is normocephalic and atraumatic she has a history of asthma last! Every month be the most important causative agent in cervical cancer,,... Assessment process a strong, thorough interview with this patient mouth/throat: changes... As essential components of Objective data of the patients case helps to lesions...