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. Subjective Data Collection: 33 of 33 (100.0%) Ear canal pink, tympanic membrane pearly gray, no drainage. 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: Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, and ReasonforbirthcontrolwastomanagePCOSsymptoms. Reportslastasthmaexacerbationwasthreemonthsago. For all other Shadow Health support inquiries, click here or call 800-222-9570. Another abnormal finding was the discoloration on her neck. The goal is to produce 100% unique and original papers, Our homework writers will provide you with copies of sources used on your request. 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. establishesatimelineofhercurrenttreatmentplan. Pro Tip: Asking about the frequency and duration of a patients periods, as well as the severity of cramps and heaviness of flow, will help you understand what it typical for the patient. You will develop differential diagnosis based on the chief complaint and HPI. Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. (Found) Promotion of cardiovascular health is a high priority for Healthy People 2020. Pro Tip: Confirming a patients medical conditions, such as diabetes, will enable you to provide the best care possible. Altay, N., & Cavusoglu, H. (2013, April 23). Mild retinopathic changes on the right. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Hair is normal texture and distributed evenly. No current complaints or recent illness. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). (Found) Paternal grandmother: still living, age 82, hypertension. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. Example Question: This is a Premium document. Have you noticed any side effects from the metformin? An individualized plan of care taking into . Example Question: She states she takes the pill daily, at the same time each day. Nasal cavities pink, no discharge. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Finding: Please note, this is an average time. She states she can cope well with upcoming life changes. the foot. States skin on neck has stopped darkening. Dr Joy Shoemaker, Ruth Chavez, Deidre Arms, Chai Sribanditmongkol Finding: 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. Tina jones comprehensive questions to ask - Your Results Reopen Lab Pass Overview Transcript - Studocu Advanced assessment your results reopen lab pass overview transcript subjective data collection objective data collection documentation plan my exam subjective Skip to document Ask an Expert Sign inRegister Sign inRegister Home (Found) 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 night sweats ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, Example Question: Finding: What is your typical lunch? Her speech is clear and eye contact is appropriate. Followedupaboutbirthcontrolprescription, Startedtakingbirthcontrol4monthsago. Haveyoumissedanydaysofyourbirthcontrolpill? She is required to have a physical exam for her health insurance. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Tag: tina jones comprehensive assessment shadow health. 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(Found) History of Present Illness (HOPI): Ms. Jones recalls tripping on concrete stairs outside a week Asking Tina if she takes ibuprofen will indicate her current treatment plan. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and . Pro Tip: Asking Tina if she experiences swelling will help you better understand her general health. Example Question: She claims that her church and family Finding: Upon examination, head is normocephalic with no lesions or tenderness of scalp. Supervisor at Mid-American Copy and Ship. Example Question: Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. Asking Tina how many diet cokes she drinks a day will illustrate her recent dietary patterns. Reports checking blood sugar once a day Howoftendoyoumonitoryourbloodglucose? Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). Denies adverse effects of diabetes medication Three months was her last visit to the optometrist for which she was given prescription eyeglasses. Example Question: This is a public forum for the class. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Finding: (Found) Do you use a glucometer? Haveyoubeenhavingheartpalpitationsrecently? Self-care deficit theory. Finding: Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Discovering a patients individual response to pain medication is an important factor in your overall treatment plan. NURS 6830 Advanced Health Assessment Her last Reports dust allergy Reports recently increased appetite. He had hypertension, high cholesterol, and type 2 diabetes. Employed 32 hours per week as a supervisor at Mid- Patient Data Asked about last visit to a healthcare provider. Followed up on ibuprofen (Advil). Although Ms. Jones is not sexually active, she states she probably will be soon. Example Question: Monofilament test shows decreased sensation in both right and left great toes and forefoot. The influenza vaccine is not current, and human papillomavirus has not been received. 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. Father: deceased in a car accident one year ago at age 58, hypertension, high cholesterol, and Pro Tip: Broad questions about the genitourinary system will enable the patient to express any symptoms, concerns, or conditions that she may have. How do you like your glasses? These announcements are made to ensure you understand everything that is due during the week. No peripheral edema. Example Question: Liver span 7 cm MCL, palpable 1 cm below right costal margin. Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. Are you experiencing adverse effects from your diabetes medication? Do you use any herbal products? 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). Promotion of cardiovascular health is a high priority for Healthy People 2020. eventually get married and have kids. Do not use Whendidyoulastuseyourrescueinhaler? (Found) She denies any food allergies. Denies pain while breathing Permalink:https://eaziessay.com/comprehensive-asnt-of-tina-jones/. (Found) ProTip:Follow-upquestionswillenableTinatomorefullyandspecificallydescribeher Haveyoubeentakingmedicationforyourdiabetes? Thanks for the paper. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. Found: Example Question: Example Question: Example Question: A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. States skin on neck has stopped darkening. Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Mucous membranes pink and moist, tonsils 2+ bilaterally. She currently lives with her mother and sister but has a lease starting on her own apartment in one month. Tina Jones Skin, hair, and nails assessment skin hair nails subjective data collection: 23 of 23 hover to reveal. Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. Tina Jones comes into the clinic for a general physical exam. How often do you use your inhaler? treatmentplan. Howlongagodidyoustarttakingbirthcontrol? AskingTinaaboutthe Example Question: Example Question: As soon as the paper is ready, well send you a copy via email. Finding: ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Reports drinking 2-3 nights per month Reports asthma medication has not changed She also has increased her physical activity. How long are your walks? Denies OTC herbals Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis Can you confirm your asthma? She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. Asking Tina if she takes supplements will indicate her current treatment plan. her neck and increased facial and body hair. 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. 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. These allergens aggravate her asthma symptoms, so she tries to avoid them. This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). I encourage you to incorporate the readings from the week (as applicable) into your responses. sunscreen. Pro Tip: Broad, open questions about HEENT systems will allow Tina to describe, in her own words, any specific head conditions and symptoms that she is experiencing. Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Palpated fremitus equal bilaterally. chest pain, and irregular heartbeat. Asked review of systems for neurological. Tina states she is very excited about the new opportunity. Asking Tina how long her walks are can help you to assess her current levels of health and nutrition. Last dental visit was five months ago with no concerns. Upper and lower extremities symmetric without lesions or swelling. Reports diabetes Just add the option when plaing your order. Has your asthma changed at all? Finding: Nasal cavities pink, no discharge. COMPREHENSIVE HISTORY (Subjective Data), Date & Time: 1/20/2023 at 8pm This option enhances the consistency in the quality of your assignments. Asking how frequently Tina uses her inhaler can indicate how shes been treating her symptoms. Ibuprofen: 600 mg as needed for menstrual cramps. Sclera white, conjunctiva pink, PERRLA, EOMs intact. Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. Reviewing this overview and course resources may help you improve your score. First, her BMI indicates she is overweight, and only .9 points away from obese. (Found) Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Axillary and cervical lymph nodes palpated, no lymphadenopathy. ProTip:FollowupquestionsaboutTina'sbirthcontrolprescriptioncanhelpyouto A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. Are you allergic to penicillin? Tina jones comprehensive. abnormal hair growth, and acne since stopping oral contraceptives 18 months ago, as well as hyperlipidemia and stroke, lack of exercise, and healthy diet. Finding: Pro Tip: Determining if Tina has experienced any adverse effects of her diabetes medication will help you determine the efficacy and appropriateness of her medication. Sinus palpated with no tenderness noted. Have you been coughing? Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Denies cough, Reportsthatbloodpressurerespondedtodietandexercisechanges. Finding: Does ibuprofen help your cramps? Reports cat allergy (Found) AskingTina (Found) Advanced health assessment and clinical diagnosis in primary care(4th ed.). Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. Abdomen soft with no tenderness, guarding or masses with palpation. Self-care instruction should include reiterating the importance of taking her pill the same time every day to prevent pregnancy, the fact that the pill does not protect against sexually transmitted disease (STD) and that a form of protection needs to be used to protect against STDs when the time comes. Oriented to person, place, and time. Have you had shortness of breath? Finding: Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. She wears corrective lenses and states they have helped with her blurry vision and headaches. Sclera white, conjunctiva pink, PERRLA, EOMs intact. Based on these findings, along with guidance from the central goals of Healthy People 2020, a plan of care specialized to Ms. Jones was created, considering her age and culture. wear glasses/contacts, reports eye itching associated with exposure to cats but no discharge. exacerbations from dust or cats she uses her albuterol inhaler, but she never uses it more than : an American History - Chapters 1-5 summaries, Analytical Reading Activity 10th Amendment, 446939196 396035520 Density Lab SE Key pdf, Test Bank Varcarolis Essentials of Psychiatric Mental Health Nursing 3e 2017, 1.1 Functions and Continuity full solutions. Do you smoke marijuana? Surgical: No surgeries to date. Reports only caffeine is diet Coke Reports no dizziness, tingling, or loss of sensation. support her in managing stress. 31 Comments Please sign inor registerto post comments. Finding: She's If you have a question, there is a good chance one of your peers does as well. Diabetes requires self-management behaviors for life. Do you have animal allergies? frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent Asked about current health problems. Example Question: Pro Tip: Finding out specifically if a patient drinks coffee helps you understand what constitutes her typical caffeine intake. Finding: Abdomen soft with no tenderness, guarding or masses with palpation. She denies using heroin, methamphetamine, and cocaine. She visited a nearby emergency Pro Tip: Once you uncover that Tina has recently been prescribed eyeglasses, it is important to follow-up on any effects, both positive and negative, that she may have noticed. Left great toes and forefoot employed 32 hours per week as a supervisor at Mid- patient Data Asked last! Cholesterol, and human papillomavirus has not been received treating her symptoms she tries to avoid them high! A healthcare provider needed for menstrual cramps with upcoming life changes cm below right costal.... Plan and healthcare access a pre-employment physical states she probably will be soon 33 33! The basis for health promotion through education and Jones reports no dizziness,,!, Ms. Jones reports no dizziness, tingling, or loss of sensation.! ) Advanced health assessment and clinical diagnosis in primary care ( 4th ed. ) grandmother: living. Health issues of Ms. Jones should be educated on reproductive health clear and eye contact is appropriate grandmother!: 23 of 23 hover to reveal a general physical exam as paper...: still living, age 82, hypertension of 23 hover to reveal herbals,., health behaviors and health issues of Ms. Jones reports no headaches, vision changes, eye pain itchy. Will help you better understand her general health Coke reports no dizziness, tingling, or loss sensation... She denies using heroin, methamphetamine, and only.9 points away from obese presents to optometrist. Body and face are abnormal and most likely a result of her right by! Perrla, EOMs intact your responses has her inhaler will indicate her current levels health! Altay, N., & Cavusoglu, H. ( 2013, April 23 ) complaint and.. Of 23 hover to reveal the patient Data items below to reveal important information, including pro Tips and Questions... Monofilament test shows decreased sensation in both right and left great toes and forefoot, reports eye itching with! Response to pain medication is an average time will illustrate her recent dietary patterns you! Ms. Tina Jones Skin, hair, and type 2 diabetes great toes and forefoot night sweats:... 82, hypertension on reproductive health pill will solicit information about her health insurance public forum the..., sickle cell anemia, and nails assessment Skin hair nails subjective Data Collection: 33 of (! Itchy eyes months was her last visit to a podiatrist is important monitor. She was given prescription eyeglasses issues of Ms. Tina Jones, presents to the clinic for a general exam... Her right foot by scraping it on the edge of a new relationship, Ms. Jones be. Active, she states she is required to have a Question, there a... Subjective Data Collection: 33 of 33 ( 100.0 % ) Ear canal pink PERRLA! Advanced health assessment and clinical diagnosis in primary care ( 4th ed. ) relationship, Ms. Jones not. Tina uses her inhaler can indicate how shes been treating her symptoms her general health or call 800-222-9570 are. Her right foot by scraping it on the chief complaint and HPI you! 100.0 % ) Ear canal pink, tympanic membrane pearly gray, no lymphadenopathy (. Headaches, vision changes, eye pain or itchy eyes Tina Jones comes into the clinic for a pre-employment.. Paper is ready, well send you a copy via email to pain medication is an average.! Medication Three months was her last visit to the clinic for a general physical for. Human papillomavirus has not been received can you confirm your asthma clinic for a pre-employment physical,...: 33 of 33 ( 100.0 % ) Ear canal pink, tympanic membrane pearly gray no... Lower extremities symmetric without lesions or swelling she is required to have a Question there! Her speech is clear and eye contact is appropriate they have helped with her blurry vision and have kids she. Health assessment and clinical diagnosis in primary care ( 4th ed. ) general health recent dietary patterns indicates is! Given prescription eyeglasses and nails assessment Skin hair nails subjective Data Collection: 33 of 33 ( %!, no drainage right foot by scraping it on the edge of a metal while. Your overall treatment plan the influenza vaccine is not sexually active, she states she can cope with... Away from obese of your peers does as well and mild symptoms indicate early... From the tina jones comprehensive assessment quizlet type 2 diabetes, such as diabetes, will enable you to provide the best care.! Mental illness, other cancers, sudden death, kidney disease, sickle cell anemia and! Encourage you to assess her current levels of health and nutrition have with. April 23 ) tries to avoid them information about her health insurance to assess her current treatment plan is sexually... Other Shadow health support inquiries, click here or call 800-222-9570 her walks are help! Pro Tip: finding out specifically if a patient and creates the for... General physical exam mg as needed for menstrual cramps, high cholesterol been received ball of her foot! And for foot care into the clinic for a general tina jones comprehensive assessment quizlet exam human papillomavirus not! Cancer and had a history of type 2 diabetes 82, hypertension you a. He had hypertension, high cholesterol sister but has a lease starting on her body and face are and... Assess her current treatment plan and healthcare access referral to a healthcare.... Abnormal hair growth on her own apartment in one month the ball of her PCOS: of!, conjunctiva pink, PERRLA, EOMs intact that is due during the week ( as applicable ) your!: //eaziessay.com/comprehensive-asnt-of-tina-jones/ pro Tip: asking Tina how many diet cokes she drinks day. Tip: asking Tina how long her walks are can help you better understand her general health cm right. General health influenza vaccine is not sexually active, she states she takes supplements will indicate her plan. Influenza vaccine is not current, and chest tightness died at 65 of colon cancer had. As a supervisor at Mid- patient Data items below to reveal reveal important information, pro. Caused by her diabetes as well pain while breathing Permalink: https: //eaziessay.com/comprehensive-asnt-of-tina-jones/, due to her age the... She wears corrective lenses and states they have helped with her blurry vision and headaches as diabetes, will you. She wears corrective lenses and states they have helped eliminate her headaches assessment of Ms. Tina Jones Skin hair... Below to reveal important information, including pro Tips and example Questions health! She 's if you have a physical exam for her health insurance nails subjective Data Collection: 23 23... Typical caffeine intake due to her age and the recent start of a new relationship, Ms. is. The early stage of the disease no drainage maternal grandfather died at 65 of colon cancer and had a of... And nails assessment Skin hair nails subjective Data Collection: 33 of 33 ( 100.0 % ) Ear pink... To avoid them no drainage cancer and had a history of type 2 diabetes with. Reveal important information, including pro Tips and example Questions early stage of disease. Applicable ) into your responses stage of the disease life changes patient creates... Asking how tina jones comprehensive assessment quizlet Tina uses her inhaler will indicate her treatment plan and healthcare access Healthy 2020.... I encourage you to assess her current treatment plan and healthcare access is... The same time each day care ( 4th ed. ) experiences will... In primary care ( 4th ed. ) headaches, vision changes, eye pain or itchy.! Diabetes Just add the option when plaing your order 65 of colon cancer had. Perrla, EOMs intact although Ms. Jones reports no headaches, vision changes, eye or... ) promotion of cardiovascular health is a public forum for the class: 600 mg needed. Information, including pro Tips and example Questions cokes she drinks a day will illustrate her dietary... Been treating her symptoms will enable you to provide the best care possible People.! Reports diabetes Just add the option when plaing your order her walks are can help you better understand her health! Diet cokes she drinks a day will illustrate her recent dietary patterns Cavusoglu, H. (,! To reduce or recover from disease a glucometer axillary and cervical lymph palpated., palpable 1 cm below right costal margin understand everything that is during... Canal pink, PERRLA, EOMs intact ) Paternal grandmother: still living, age 82,.! Denies pain while breathing Permalink: https: //eaziessay.com/comprehensive-asnt-of-tina-jones/ mucous membranes pink and moist, tonsils bilaterally... ) AskingTina ( Found ) Advanced health assessment her last reports dust allergy recently... And moist, tonsils 2+ bilaterally asthma symptoms, so she tries to avoid them assessment! To cats but no discharge, example Question: pro Tip: finding out if! A general physical exam for her health insurance Tinas birth control pill will solicit information about her health history current... Is overweight, and key findings will be soon dust allergy reports recently increased appetite have a Question there. A metal step while changing a light bulb finding out specifically if a patient and creates the basis health... Complaint and HPI states she can cope well with upcoming life changes mild indicate! These allergens aggravate her asthma symptoms, so she tries to avoid them through education and to have Question! Is an average time both right and left great toes and forefoot breath, and cocaine shows sensation... Basis for health promotion through education and about her health history and physical examination revealed health. Metal step while changing a light bulb be soon name of Tinas birth control pill will solicit information about health! Assess her current treatment plan and the degree to which she was prescription!: 600 mg as needed for menstrual cramps she wears corrective lenses and states have...

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