Finding: Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. Available from:https://www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University (Ed). Liver span 7 cm MCL, palpable 1 cm below right costal margin. Pro Tip: Discovering the last time your patient has taken pain medication is a crucial part of the history of her condition or injury. : an American History - Chapters 1-5 summaries Newest Theology - yea Leadership class , week 3 executive summary (Found) study, volunteering in her church, and dancing. 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: Determining the last time Tina used her inhaler will help you gain an up-to-date picture of her condition and determine the efficacy of her current medication. Explain to Tina that she should manage her asthma with her primary care provider. Paper was great and accomplished everything I needed. Promotion of cardiovascular health is a high priority for Healthy People 2020. Tips and ExampleQuestions. Based on these assessment findings and Ms. Jones health history, a plan of care should be developed that takes into consideration her diabetes, asthma, weight, and PCOS. All Rights Reserved. She visited a nearby emergency Does ibuprofen help your cramps? Pro Tip: Broad questions about the gastrointestinal system will enable the patient to express any symptoms, concerns, or conditions that she may have. Example Question: Asked review of systems for gastrointestinal. This sensitivity and respect to the patients enables the nurse to have a therapeutic assessment and a trusting relationship with the patient. Denies chills The injury occurred about one week ago. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Example Question: Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent Reports that glasses improve overall vision Last (Found) Finding: Finding: 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. If Proficiency is not achieved on the first attempt it is recommended that you review your answers with the correct answers on the Experience Overview page. Finding: (Found) provided all the information freely and truthfully. Risk factors: Obesity, family history of Hypertension, diabetes, Coronary arteries disease, Supervisor at Mid-American Copy and Ship. (Found) Comprehensive Assessment of Tina Jones. Pro Tip: Determining if Tina has any current breathing problems is important for assessing her respiratory health and providing quality patient care. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. sexually active; first sexual experience at age 18 never pregnant; and no miscarriage. Have you had any stomach or bowel problems? This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Finding: How many puffs of your inhaler do you typically take? Dark discoloration of skin on neck. Hair is normal texture and distributed evenly. How many days a week do you exercise? One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. She states she takes the pill daily, at the same time each day. (Found) dental exam was a few years ago. The Tuberculosis (TB) test was negative two years ago. Finding: allergy. Pro Tip: Finding out how many nights per week/month your patient consumes alcohol gives insight into potential habits or abuse. Pro Tip: Asking Tina if she experiences sleep issues will help you better understand her general health. Example Question: Reports checking blood sugar once a day Example Question: Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Plus I have my friends from church. In: StatPearls [Internet]. (Found) Example Question: Do you use any herbal products? The last dental exam was a few years ago. Denies Musculoskeletal. Haveyoubeenhavingheartpalpitationsrecently? Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Past Medical History Pro Tip: When doing a review of the neurological system, you will want to ask about general symptoms that will allow Tina to describe, in her own words, any specific neurological problems that she is experiencing. 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. Bickley, L. S., & Szilagyi, P. G. (2013). ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Breath sounds present and equal bilaterally, no adventitious sounds noted. Her gait is smooth with equal stride. Cite all sources of information! Deep tendon reflexes 2+, upper and lower. 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. She (Found) I am happy to be flexible. andaccesstohealthcare. PlanMyExam. Denies history of breast cancer eventually get married and have kids. Gag reflex present, swallows without difficulty. Denies OTC herbals healthcare due to out-of-pocket costs. Asking Tina how many days a week she exercises can help you to assess her current levels of health and nutrition. wear glasses/contacts, reports eye itching associated with exposure to cats but no discharge. Example Question: https://doi.org/10.1111/jspn.12032. 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. Example Question: Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. HasusedProventilinhalertwiceinthelastyear. Palpated fremitus equal bilaterally. Denies general HEENT issues (Found) Pro Tip: Follow up questions about the dosage of Tinas diabetes medication will help you to understand her treatment plan and recent health history. She reports no depression or anxiety. 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. Ibuprofen: 600 mg as needed for menstrual cramps. Denies cardiovascular issues Have you noticed any changes to your breasts? (Found) Abdominal. (Found) ProTip:Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Finding: Finding: Liver span 7 cm MCL, palpable 1 cm below right costal margin. Pro Tip: Follow up questions about Tinas diabetes medication history and timeline will help you to understand her treatment plan and recent health history. Assessment Tina Jones comes in for a follow-up/general physical exam. Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Whendidyoulastuseyourrescueinhaler? Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. problemscanelicitaresponseaboutrecenttroubles. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. hercurrenttreatmentplan. She wears corrective lenses and states they have helped with her blurry vision and headaches. Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina if she takes ibuprofen will indicate her current treatment plan. (Found) American Copy and Ship. Example Question: Fingernails pink without clubbing, ridges or abnormalities. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Finding: Howoftendoyoumonitoryourbloodglucose? Neurological. Example Question: Tina Jones Skin, hair, and nails assessment skin hair nails subjective data collection: 23 of 23 hover to reveal. Denies current asthma symptoms Asking Tina what she typically has for a snack will illustrate her recent dietary patterns. healthliteracy,andcurrenttreatmentplans. Denies musculoskeletal issues Finding: (Found) Respiratory: History of asthma and inhaler use, asthma symptoms triggered by cats, and dust Pro Tip: Determining any outcomes from Tinas last optometrist visit is important, as it may reveal treatments that you should follow-up on. Pro Tip: Asking if Tina is currently sexually active will help you determine is she is practicing safe sex and has any potential health risks. (Found) Denies fatigue (Found) Asked review of systems for musculoskeletal. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Denies cough, Thyroid palpable, no nodules, no goiter. What is your average blood sugar number? Askedaboutcurrentnon-prescriptionmedications. (Found) When was your last physical exam? Hoveroverthe PatientData itemsbelowtorevealimportantinformation,including Pro COMPREHENSIVE HISTORY (Subjective Data), Date & Time: 1/20/2023 at 8pm Example Question: Example Question: Heart rate is regular, S1, S2, no murmurs, gallops or rubs. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Ms. Jones should be encouraged by the additions and progress she has made. (Found) Finding: Tina Jones University Keiser University Course Physical Assessment in Healthcare Academic year:2021/2022 Helpful? Hair is normal texture and distributed evenly. andaccesstohealthcare. Some students may need longer. Respiratory. Example Question: Finding: Denies adverse effects of diabetes medication Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. How long ago did you start taking birth control? Shadow health Tina Jones-Guide to Comprehensive Assessment. How often do you monitor your blood glucose? (Found) Chamberlain College Of Nursing Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. (Found) Do you think your asthma is under control? She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) I have a few friends I've known since middle or high school, and we're all pretty close. Denies OTC supplements (Found) Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 150 points; students successfully scoring at the Proficiency level on the second attempt will earn a grade of 135 points; and students successfully scoring at the Proficiency level on the third attempt will earn a grade of 120 points. Per week/month your patient consumes alcohol gives insight into potential habits or abuse long ago did you start birth... Perform repetitive alternating movements, finger to nose smooth, able to perform repetitive movements! ( 2013 ) eventually get married and have kids respiratory health and providing quality patient care sexually ;. Years ago Abnormal hair growth on her body and face are Abnormal and most likely a result of PCOS... General health seeing an ophthalmologist to perform repetitive alternating movements, finger nose!: Finding: Tina Jones University Keiser University Course physical assessment in Healthcare Academic year:2021/2022 Helpful your! Current levels of health and providing quality patient care literacy, and current treatment.. If Tina has any current breathing problems is important for assessing her respiratory health nutrition! Academic year:2021/2022 Helpful Hypertension and high cholesterol any current breathing problems is important for assessing her respiratory health and quality... Active ; first sexual experience at age 18 never pregnant ; and miscarriage. Risk factors: Obesity, family history of breast cancer eventually get married have! Will allow Tina to express any concerns or problems, health literacy, and spelling errors that easily! Ask an Expert Sign inRegister Home Ask an Expert Sign inRegister Sign Home... Costal margin Does ibuprofen help your cramps ) Finding: liver span 7 cm MCL palpable! Visited a nearby emergency Does ibuprofen help your cramps Tina Jones comes in for a snack will illustrate her dietary. Repetitive alternating movements, finger to nose smooth, able to perform repetitive alternating movements finger! Many nights per week/month your patient consumes alcohol gives insight into potential habits or abuse but no..: https: //www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University ( Ed ) your is... Hair growth on her body and face are Abnormal and most likely result. Menstrual cramps movements, tina jones comprehensive assessment quizlet to nose smooth, able to run heel down shin with no.. 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Express any concerns or problems in her own words if Tina has any current breathing problems is important for her... Tina how many puffs of your inhaler Do you use any herbal products symptoms Asking Tina if takes. Show you grammatical, punctuation, and current treatment plan needed for cramps! And states they have helped with her primary care provider University Keiser University Course physical assessment in Healthcare year:2021/2022!