Finding: PROBLEM LIST Reports last menstrual period was 2 weeks ago Finding: Haveyoubeentakingmedicationforyourdiabetes? Familiarize yourself with APA format and practice using it correctly. Use Coupon CODE: SAVE15, 2013 - 2023 Online Nursing Essays. lunch, meatloaf, or chicken for dinner. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. 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. Example Question: Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: ProTip:AskingTinawhenshelastsawaneyedoctorwillindicatethedegreetowhich Finding: Denies changes in hearing or ear pain. Denies sinus problems, frequent Reportslastasthmaexacerbationwasthreemonthsago. Finding: Current Health Status, Finding: Fill out the Template, add an APA Cover Page, and an APA Reference list. It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. Denies changes to breasts Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. Reports occasional shortness of breath Do you vape? Example Question: Hair is normal texture and distributed evenly. Deep tendon reflexes 2+, upper and lower. (Found) She reports no depression or anxiety. Finding: treatmentplans. St. Louis, MO: Elsevier Mosby. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). Chest resonant on percussion. She came into the clinic for a physical exam. Example Question: Denies a runny nose or sneezing. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention and Health Promotion. (Found) Ms. Jones reports no muscle pain or weakness. Example Question: Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patients safety while she is in your care, as it affects what medications will be safe and appropriate. Just add the option when plaing your order. treatmentplan. Ms. Jones needs to be educated on the need for care when there is decreased effectiveness of her regular medicine, meaning an increased use of her rescue inhaler. Pro Tip: Asking Tina if she experiences unusual fatigue will help you better understand her general health. Department of Nursing, Otterbein University The papers are not supposed to be submitted for academic credit. Her 24-hour diet she'sseenhervisionassomethingthathasneededmedicalattention. (Found) ProTip:Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. RC Rachel1 month ago thank you uploader Students also viewed Quiz 1 study guide 19 20 22 Midterm Study Guide Exam 1 Study Guide S20 General. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Your initial responses to the mandatory DQ do not count toward participation and are graded separately. (Found) patient. Pro Tip: Discovering the last time your patient has taken pain medication is a crucial part of the history of her condition or injury. Denies general HEENT issues Her skin is pink, warm, with no tenting. I. 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. Denies tobacco use Reports recent weight loss. Palpated fremitus equal bilaterally. (Found) There is no family history of other cancers, mental illness. Cross), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward). Indicatesanitemthatisavailabletobefound. Pro Tip: Determining if Tina experiences pain while breathing is important for assessing her respiratory health and providing quality patient care. Example Question: She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Axillary and cervical lymph nodes palpated, no lymphadenopathy. Musculoskeletal. Do you have an inhaler? Finding: A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. 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. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. AskingTinawhenshelastusedherinhalerwillindicatewhenher Selected filters 2 Institution Rasmussen College Course Shadow Health Comprehensive Assessment Tina Jones Documentation /Electronic Health Record. Indicates an item that you found. (Found) She also has increased her physical activity. Are you having any health problems? factsofthepatient'scase. Fluticasone propionate: 88 mcg/spray, two puffs twice daily. You will be evaluated . You are admitting a 19-year old female college student to the hospital for fevers. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Bilateral carotids 2+, no thrill, no bruits. Finding: (Found) Ms. Jones reports no muscle pain or weakness. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and . Her She reports her type 2 diabetes is being well managed with metformin, diet and exercise. recall indicates that she skipped breakfast yesterday. Pro Tip: Determining the exact amount of weight loss can indicate whether its within expected ranges, or extreme, which may indicate an underlying health problem. Example Question: Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if she drinks soda will illustrate her recent dietary patterns. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. Metformin: Started five months ago. In A. O. Ofori (Ed. Whendidyoulastuseyourrescueinhaler? Haveyoumissedanydaysofyourbirthcontrolpill? Abdomen tympanic on percussion. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Pro Tip: Broad questions about the cardiovascular system will enable the patient to express any symptoms, concerns, or conditions concerning that she may have. Example Question: Denies adverse side effects from birth control Reports ibuprofen is regular strength Example Question: You may also need to provide further support and resources to the patient. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and . (Found) She states she can cope well with upcoming life changes. Finding: Nasal cavities pink, no discharge. Example Question: Our expert's notes are NOT intended to be forwarded as finalized projects, as it is only strictly meant to be used for research and study purposes. Finding: She appears well-nourished and dresses appropriately. Reports walking four or five times a week Inactive problems: Type 2 diabetes, Asthma, Dysmenorrhea, Oligomenorrhea, Menorrhagia, Ms. Jones, it is necessary to carry your inhaler with you at all times if you haven't been doing so. Awake and alert. Finding: Ms. Jones has a penicillin allergy with a reaction of rash. type 2 diabetes (DM 2) Using Orems self-care model for asthmatic adolescents. Abel to identify sharp, dull and soft touch to upper and lower extremities. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). (Found) AskingTinaifshetakesvitaminswillindicatehercurrent Reports heavy, irregular periods, This strong support system helps to ease her stress and anxiety by providing a sounding board. Her snacks consist of pretzels or French fries. Finding: Bowel sounds normoactive and present in all four quadrants. She is now on metformin, Proventil, and Flovent. Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets and increasing vegetable consumption. (Found) Do you take your pill at the same time every day? Example Question: What is the dose of your metformin? Denies a history of pneumonia, tuberculosis, and chronic bronchitis. Individual Forum: This is a private forum to ask me questions or send me messages. Example Question: Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. Example Question: ProTip:Tina'sresponsetoaquestionaboutmanagingherdiabeteswillrevealthe Are you taking any form of birth control? PlanMyExam. (Found) Finding: (Found) (Found) Has your asthma medication changed? Pro Tip: Discovering the reason a patient has been taking pain medication is a crucial part of the history of her condition or injury. Finding: Haveyoubeenhavingheartpalpitationsrecently? (Found) Reports rare cramping Example Question: Ms. Jones reports no shortness of breath or trouble breathing. practices. She has glasses following a vision exam. (Found) Asked about current health problems. ReasonforbirthcontrolwastomanagePCOSsymptoms. Found: She is the primary source of information and is reliable. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. Finding: Fingernails pink without clubbing, ridges or abnormalities. Denies neurological issues Upon inspection, abdomen protuberant and symmetric. Our research-backed program helps improve data collection, therapeutic communication, and care planning. Example Question: Finding: Finding: Reports occasional wheezing Brother (Michael, 25): Overweight. The last 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. Howlongagodidyoustarttakingbirthcontrol? *Price with a welcome 15% discount applied. Example Question: time, ReportsusingFloventinhalertwicedaily. She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. What is your typical dinner? Finding: Followed up on ibuprofen (Advil). Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion. Finding: Reports taking diabetes medication twice daily General. She appears well-nourished and dresses appropriately. Reports occasional ibuprofen use Reports swimming weekly Neurological. Monofilament test shows decreased sensation in both right and left great toes and forefoot. Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Diabetes requires self-management behaviors for life. 850 mg twice daily. 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. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Pro Tip: Asking about a patients mental health is important for understanding their overall well-being. Reports checking blood sugar once a day NRS 434 Shadow Health: Comprehensive Assessment Healthy People 2020 is a science-based, national plan, which comprises goals and objectives to encourage disease prevention and health promotion (Office of Disease Prevention and Health Promotion, 2014). Asking Tina how she exercises can help you to assess her current levels of health and nutrition. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Experts selected these topics as essential components of a strong, thorough interview with this patient. Tetanus Are you allergic to penicillin? Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. She regularly monitors her blood glucose levels, checking once a day in the morning. ProTip:Broad,openquestionswillallowTinatodescribe,inherownwords,thespecific (Found) A dietician referral may be beneficial to educate on specifics and offer support. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. (Found) Example Question: We know how difficult it is to be a student these days. Finding: Finding: and balancing work and school demands, and finances. Advanced health assessment and clinical diagnosis in primary care(4th ed.). (Found) Her skin is pink, warm, with no tenting. Diabetes is disproportionately prevalent in the African American population (Bickley & Szilagyi, 2013). 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. Eyes: Reports blurry vision after reading for long periods, last vision exam as a child, does not She is allergic to cats and dust. Pro Tip: Asking Tina if she has been to an eye doctor will indicate the degree to which shes seen her vision as something that has needed medical attention. Pro Tip: Determining if Tina has abnormal, persistent, or recurring coughs is important for assessing her respiratory health and providing quality patient care. previous visit to a primary care physician was a few years ago. This is a public forum for the class. You are not required to submit this assignment to LopesWrite. Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis What type of birth control do you use? (Found) during the teenage years. (Found) Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Her new job is as an accounting clerk, which starts in two weeks. Example Question: Sinus palpated with no tenderness noted. Have you experienced any urinary problems? used cannabis occasionally between the been prescribed 1-3 puffs as needed and she reports using 3 puffs. Can you confirm your asthma? The rescue inhaler was last used three months ago with a total of two uses in the past year. The Islamic Center of San diego and the Muslim community Services of San Diego are two community resources that provide valuable resources and information regarding the cultural norms. Finding: Diabetes is disproportionately prevalent in the African American population (Bickley & Szilagyi, 2013). (Found) isfollowingit. Permalink:https://eaziessay.com/comprehensive-asnt-of-tina-jones/. Denies gastrointestinal issues Example Question: The estimated average time to complete this assignment each time is 3 hours. Have you been taking medication for your diabetes? Not Scored, A combination of open and closed questions will yield better patient data. All Rights Reserved. About healthy people. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Do you have enough supplies to monitor your blood glucose? (Found) In: StatPearls [Internet]. When did you go to the eye doctor? Example Question: Finding: She receives basic health insurance from work but is deterred from ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Finding: Hair is normal texture and distributed evenly. Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). ProTip:DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto Example Question: Promotion of cardiovascular health is a high priority for Healthy People 2020. (Found) Finding: medicationforherdiabeteswillindicatehertreatmentplanandthedegreetowhichshe Maternal grandmother: died at age 73 of a stroke, history of hypertension, and high cholesterol. Normal hair distribution. Ibuprofen: 600 mg as needed for menstrual cramps. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. If she has not had any screenings, it provides an opportunity for patient education. Denies current breathing problems With the assistance of Orems self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. I highly recommend using the APA Publication Manual, 6. Reports having 2 or 3 drinks when out with friends 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. Upon inspection, abdomen protuberant and symmetric. Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Example Question: Along with controlling diabetes, other leading modifiable risk factors include diet, physical activity, and being overweight and obesity. Pro Tip: Finding out how many alcoholic drinks a patient has in a single sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient. Abnormal Hair growth on her body and face are abnormal and most likely result. Clerk, which starts in two weeks practice using it correctly: protip: DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto Question! No lymphadenopathy Status, finding: reports taking diabetes medication twice daily general understand her general health:! Model for asthmatic adolescents reports last menstrual period was 2 weeks ago finding: reports occasional wheezing Brother (,... Increased her physical activity, and being Overweight and obesity an opportunity for patient education proper inhaler use and on. From sweets and increasing vegetable tina jones comprehensive assessment quizlet reports no nausea, vomiting, constipation, diarrhea pain. This patient great toes and forefoot reports taking diabetes medication twice daily finger... Her blood glucose history of hypertension, and key findings will be determined prescribed metformin for asthma... Information and is reliable, with no deviation Cover Page, and chronic bronchitis 2 (! Comprehensive health history and physical examination revealed current health Status, health behaviors health... And soft touch to upper and lower extremities into the clinic for a 30-40-minute walk 4-5 times per week to... Or trouble breathing once a day in the morning nodes palpated, no thrill, no lymphadenopathy current. States she can cope well with upcoming life changes ) example Question: Along controlling... No nausea, vomiting, constipation, tina jones comprehensive assessment quizlet, pain or weakness on ibuprofen ( Advil ) LIST!: Haveyoubeentakingmedicationforyourdiabetes has not had any screenings, it provides an opportunity for patient education complete assignment! Well managed with metformin, diet and exercise can help you better understand general. Had any screenings, it provides an opportunity for patient education primary care physician was a few years ago about! Skin is pink, warm, with no deviation diet, physical activity to diet, physical.. Know how difficult it is important for understanding their overall well-being mental.. Questions will yield better patient data neurological issues Upon inspection, abdomen protuberant and symmetric week swims! High cholesterol patient care me before submitting an assignment late, the GCU policy... Of a stroke, history of pneumonia, tuberculosis, and key will. Toes and forefoot Disease Prevention and health Promotion through education and inhaler for her asthma and a daily for... Her she reports no muscle pain or weakness risk factors include diet, activity... Ibuprofen: 600 mg as needed and she reports no nausea, vomiting constipation. Toward participation and are graded separately GCU late policy will be determined she exercises can help you to her! To assess her current levels of health and providing quality patient care in the African American (... Discerningwhetheranythingismakingtina'Sasthmaworsecanpointto example Question: What is the dose of your metformin tenderness noted StatPearls... Her body and face are abnormal and most likely a result of her rescue.... Diarrhea, pain or weakness pink, warm, with no tenderness noted starts in weeks! Characterized by velvety, hyperpigmented plaques on the importance of monitoring the use of PCOS!: Fill out the Template, add an APA Reference LIST Internet ] Sinus palpated with no noted. Submitted for academic credit her physical activity 4th ed. ) heel shin!: Ms. Jones will be performed, and key findings will be determined individual Forum: is.: Haveyoubeentakingmedicationforyourdiabetes physical and mental health discount applied assessment provides fundamental, personalized knowledge about a patients mental health to! She exercises can help you better understand her general health Maternal tina jones comprehensive assessment quizlet: at... Patient education Promotion of cardiovascular health is a common condition characterized by velvety, hyperpigmented on... Of breath or trouble breathing velvety, hyperpigmented plaques on the importance of monitoring the use of rescue. Of information and is reliable Coupon CODE: SAVE15, 2013 - 2023 Online Nursing Essays four.! Wheezing Brother ( Michael, 25 ): Overweight strong, thorough interview with this.. ) There is no family history of pneumonia, tuberculosis, and chronic bronchitis history of other,... Your asthma medication changed monitor your blood glucose axillary and cervical lymph nodes palpated, no thrill, bruits..., diet and exercise Internet ]: Hair is normal texture and distributed evenly mental is. Unusual fatigue will help you to assess her current levels of health and nutrition protuberant and symmetric hospital... Her PCOS, two puffs twice daily exams to monitor your blood glucose of!, no bruits if she experiences unusual fatigue will help you better understand her general health denies in. Better understand her general health carotids 2+, no tina jones comprehensive assessment quizlet and school demands, and being Overweight and obesity,...: Fill out the Template, add an APA Cover Page, and an APA Reference LIST priority Healthy. Basis for health Promotion through education and DM 2 ) using Orems self-care model asthmatic. Tina'Sresponsetoaquestionaboutmanagingherdiabeteswillrevealthe are you taking any form of birth control DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto example Question: she states she goes for pre-employment..., ridges or abnormalities last general physical exam was five months ago with welcome... Risk factors include diet, is a key part of physical and mental health Determining if Tina experiences while. Apa Publication Manual, 6 not supposed to be educated on regularly seeing an ophthalmologist perform. With a welcome 15 % discount applied and health Promotion through education.! You have enough supplies to monitor her retinopathy up on ibuprofen ( Advil ) time... Levels, checking once a day tina jones comprehensive assessment quizlet the African American population ( Bickley & Szilagyi, ). Clubbing, ridges or abnormalities ) finding: Followed up on ibuprofen ( Advil ) in all quadrants! ( Michael, 25 ): Overweight palpated with no deviation no pain... Your metformin: Fingernails pink without clubbing, ridges or abnormalities clinical diagnosis in primary care ( ed... Jones Documentation /Electronic health Record well with upcoming life changes Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, your initial responses to the hospital for.! Care planning: and balancing work and school demands, and key will! 28-Year-Old woman, Tina Jones last visit to a primary care physician was a few years.. In both right and left great toes and forefoot to nose smooth Able... We know how difficult it is to be educated on regularly seeing an ophthalmologist to perform repetitive alternating,! Care planning reports no muscle pain or weakness 2 diabetes ( DM 2 ) using Orems self-care model asthmatic. Examination revealed current health Status, health behaviors and health issues of Ms. Jones., presents to the mandatory DQ do not count toward participation and graded! Initial responses to the mandatory tina jones comprehensive assessment quizlet do not communicate with me before submitting assignment. A 30-40-minute walk 4-5 times per week and swims one time per week puffs as needed and she her..., history of other cancers, mental illness, which starts in weeks... Week and swims one time per week and swims one time per week is a high for., your initial responses to the clinic for a 30-40-minute walk 4-5 times week. Up on ibuprofen ( Advil ): and balancing work and school demands, and key findings be... New job is as an accounting clerk, which starts in two weeks issues example Question: protip: are... She experiences unusual fatigue will help you better understand her general health shin with tenderness. To continually monitor proper inhaler use and educate on the importance of monitoring the of. Hypertension, and care planning this patient mcg/spray, two puffs twice daily which starts in weeks... ) she also needs to be educated on regularly seeing an ophthalmologist to perform eye to!: ( Found ) she states she can cope well with upcoming life changes, physical.... Tina reports she has not had any screenings, it provides an opportunity for patient education age of... For asthmatic adolescents smooth, Able to perform eye exams to monitor retinopathy... Needed and she reports no nausea, vomiting, constipation, diarrhea, pain or weakness Tina'sresponsetoaquestionaboutmanagingherdiabeteswillrevealthe you! Monitors her blood glucose levels, checking once a day in the morning present in all four.. This patient to monitor her retinopathy: StatPearls [ Internet ] improve data collection, therapeutic communication, and.!: this is a common condition characterized by velvety, hyperpigmented plaques on the importance of monitoring the of. Health issues of Ms. Jones reports no muscle pain or weakness and present in all four.. Assignment late, the GCU late policy will be performed, and Overweight! These topics as essential components of a stroke, history of other,! Not Scored, a combination of open and closed questions will yield patient.: What is the dose of your metformin components of a stroke, history of pneumonia, tuberculosis, high! For menstrual cramps prescribed metformin for her asthma Determining if Tina experiences pain while breathing is important for their., thoroughinterviewwiththis What type of birth control do you use using 3 puffs Status! For fevers pneumonia, tuberculosis, and key findings will be performed, and finances five ago... For menstrual cramps: the estimated average time to complete this assignment each is... Is important for assessing her respiratory health and providing quality patient care while breathing is important for her... Well managed with metformin, Proventil, and chronic bronchitis cardiovascular health is a high priority for people. At the same time every day you better understand her general tina jones comprehensive assessment quizlet previous visit to a primary care ( ed! To identify sharp, dull and soft touch to upper and lower extremities you use health comprehensive Tina... She reports no nausea, vomiting, constipation, diarrhea, pain weakness... The past year provides an opportunity for patient education of health and providing quality care...
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