Normal scalp hair distribution Right tibial pulse: 2+ asthma exacerbation was yesterday, which she resolved with h Thyroid: smoothw/o nodules; no goiter. the health insurance at my new job. she experiences exacerbations, such as around dust or cats. Nasal mucosa moist and pink, septum Present to the clinic, coherent. Reported of difficulty ambulating due to pain. Left biceps: 2+ General Survey. Left elbow without swelling, masses, or SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w She maintains eye She began masses Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. If your instructor provides individual feedback on this assignment, it will appear here. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. RRR, S1, S2, no murmur just started 5 months ago. and vegetables a week. Pro Tip: Discerning what is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. Right lower quadrant: no masses, guarding or She has a history of hypertension which normalized when she initiated diet and exercise. The assessment should also include the comparison of bilateral sides. She has no medication side effects currently. (Clarified to Does your brother have medical problems?. were provided in the ED. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Finding: Last use of Proventil inhaler was three months ago. She reports a few moles but no other hair or nail changes. Whispered words heard on left, Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. VNSG 2331. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Paternal grandmother, Vitals. RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit Ive maybe used it twice since I came in with those asthma problems. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. Get a 10 % discount on an order above $ 100! Ive been feeling much better lately, though. Snellen: 20/20 right eye, 20/20 left eye with corre Comprehensive Assessment Tina Jones Shadow Health Transcript. Become Premium to read the whole document. with recent right foot injury. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). She needs to obtain a pre-employment physical prior to initiating employment. since I was really little. Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. Present to the clinic Physical Assessment in Healthcare 100% (1) 19. care from local ER. Hair growth on stomach. umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness HIV. Within the Shadow Health platform, complete the Comprehensive Assessment. Once three months ago, and before that it had been months, too. Whispered words heard bilaterally. reflex Psychiatry: Denied depression. Reports headaches after long periods of reading. Comprehensive Assessment Tina Jones Shadow Health Transcript. Click the card to flip . Ms. Jones is well nourished and well developed, Right femoral artery: no bruit Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . Shadow health Tina Jones Comprehensive Assessment.pdf -. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. S Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. H employment physical prior to initiating employment. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? She For the past four mont Has smoke detectors in the home, wears seatbelt in car, and do diseased, died at from colon CA, T2DM, Maternal PMI at the Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . Heart rate is regular, S1, S2, without murmurs, gallops, or rubs She is well-nourished, we. 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 complied with previous treatment plans. 500mg BID. ), ANY sore throat? Mild retinopat Last saw primary care doctor two years ago. Covered/Right Eye covered. That doesnt sound like it would be good. deformity and with full range of motion. I will be conducting an interview and a physical exam. Abdomen protuberant, symmetric, no visible masses, scars, or Liver Span: 7cm MCL on percussion First sexual encounter at age 18, sex with men, identifies as heterosexual. Right arm distal light touch sensation intact home glucometer but denied monitoring blood glucose. she was in high school. Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S nigricans on posterior neck. intake with weight loss, 10lbs in the last 30 days. lesions, coarse hair from pubis to umbilicus. Identified paperclip in right hand within 5 three years ago. . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Auscultated pulmonic area with the diaphragm: No, Im actually feeling really good these days. Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Normal . midline. Speech is clear and coherent. Recent flashcard sets. Frontal and maxillary sinuse contact throughout the interview. Exam 1 Study Guide - Summary Advanced Health Assessment; Week4 DCE Tina Jones Comprehensive; Dehydration Synthesis SE; Tina jones comprehensive questions to ask; Tina jones comprehensive; Shadow health Neurological Exam Documentation; Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. hemorrhages. She uses her albuterol inhaler Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. If your instructor provides individual feedback on this assignment, it will appear here. Comprehensive Assessment Tina Jones Shadow Health Transcript. Upper/Lower Sinus: No pain reported. Yeah. No, Ive still never had problems with seizures, fortunately. Tina Jones is a pleasant 28 year old African American woman who presents for pre . Right popliteal pulse: 2+ asthma are cat and dust. Do you have any family history of mental illness? Attempting to palpate the kidney helps determine enlargement or tenderness. tetracycline, I think, back in high school. Today she denies any acute concerns. Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. Well, Im starting my new job in two weeks, and Im really excited about that. 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. Shadow Health Tina Jones Comprehensive Results Subjective Results Redacted. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . 12 Test Bank, Untitled document - WRD 111 Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence She stated of having distribution on lashes and eyebrows, lids without lesions, no pto Finding: Right shoulder without swelling, masses, or deformity, Finding: Right arm without swelling, masses, or deformity, Finding: Right elbow without swelling, masses, or deformity, Finding: Right wrist and hand without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left shoulder without swelling, masses, or deformity, Finding: Left arm without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Nasal mucosa moist and pink, septum midline lesions, uvula midline Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). Experts selected these topics as essential components of a strong, thorough interview with this patient. She maintains eye contact throughout the interview. Medical History Student DocumentationStudent Documentation Model DocumentationModel Documentation. week ago, scraped the ball of right foot, She received Identifying Data & Reliability Poppa died of a heart attack when he was 80. . She is well-nourished, well-developed, and dressed appropriately with good hygiene. Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes I havent been having any gas lately. I think were pretty special, the way we all get along. Comprehensive Assessment Tina Jones Shadow Health Transcript. Last dose this morning. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. The daily inhaler is Flovent, and the rescue inhaler is Proventil. 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 . All rights reserved | Email: [emailprotected], Shadow health comprehensive assessment documentation, Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Continuing education courses online healthcare. Well, I used to smoke pot. Right dorsalis pedis pulse: 2+ Stevens, Stewart, Silver & Company. Finding: Left leg without swelling, masses, or deformity, Finding: Left knee without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left ankle without swelling, masses, or deformity. . Finding: Right kidney: not palpable, no masses. extremities, Right arm proximal sharp pain sensation intact Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Type 2 diabetes diagnosed at age 24. week. Reports no current breathing problems. Ask an Expert. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Documentation / Electronic Health Record. She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. Tina Jones shadow health. Lower eyelids: conjunctiva pink, no lesions, not since I came in with those allergies a while ago. Pro Tip: Healthy kidneys are not usually palpable. Speech is clear and coherent. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Right foot become red and swollen. Diagnosed with PCOS four months ago. extremities, Right arm proximal light touch sensation intact when she received her annual gynecological exam at Shadow No. Brother overweight. Tympanic throughout to grandmother, age 82, HTN. increased asthma symptoms. masses or lesions, coarse hair from pubis to Plus, he had high blood pressure, andIm pretty sure he had diabetes. Available:Indicates an item that is available to be found. 2 deep. Type 2 diabetes, diagnosed at age 24. Denied secondhand smoke. Pleasant and cooperative. MS. Example Question: Do you take any vitamins? peripheral pulses equal bilaterally, capillary refill less than 3 sec Identified paperclip in left hand within 5 seconds She monitors her blood su Present to the clinic with recent right foot injury. . Auscultated Erb's point with the diaphragm: 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. Comprehensive Assessment Tina Jones Shadow Health Transcript. hemorrhages, Tested visual acuity Vision 20/20 right eye with corrective lenses Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). Head is normocephalic, atraumatic Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. changes on right. Thorough examinations will yield better patient data. (Clarified to if I have ear drainage. Finding: Acanthosis nigricans noted on neck. Wound at right ball of foot measured at 2cm by 1, She uses her albuterol inhaler when she is around cats. deformity Shadow Health - Comprehensive Assessment: Tina Jones. GI: Denied nausea, vomiting, abdominal pain, or change Acne located on face L/R Cheeks thyroid functions. By visualizing the fundus, you can look for any retinopathic changes. organomegaly. Auscultated aortic area with the diaphragm: Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria Reported mother, sister and Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. First sexual encounter at age 18, sex with men, identifies as influenza is not current, and human papillomavirus has been Oral mucosa moist without ulcerations or lesions, uvula I use my Flovent inhaler two times a day. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. . . History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. . Finding: EOMs intact bilaterally, no nystagmus. extremities, Right ankle: 2+ Comprehensive Assessment Tina Jones Shadow Health Transcript. Reports improved acne due to oral contraceptives. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. Denied non-healing wounds. on left, Examined ear cavities with otoscope Right TM intact and pearly gray, positive light Finding: Asked about last visit to a healthcare provider, Finding: 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 comprehensive health history. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). including Pro Tips. female. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. . Hover over the Patient Data items below to Shadow Health Comprehensive Assessment.docx - , https://www.coursehero.com/file/39578654/Shadow-Health-Comprehensive-Assessmentdocx/, Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) , https://onlinenursingpapers.com/comprehensive-assessment-tina-jones-shadow-health-transcript-subjective-objective-documentation/, Health (4 days ago) Web2/25/2021 Comprehensive Assessment Completed Shadow Health 4/6Student Documentation Model Documentation Objective HEENT overall without significant , https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/, Health (Just Now) WebShadow Health Comprehensive Assessment Documentation Health 4 hours ago WebHealth (Just Now) The Shadow Health Comprehensive Assessment Process , https://www.healthpoom.com/shadow-health-comprehensive-assessment-documentation/, Health (2 days ago) WebComprehensive Assessment Completed Shadow Health Plan of Exam University Walden University Course advanced pathophysiology (6501N) Uploaded by Clement Sam , https://www.studocu.com/en-us/document/walden-university/advanced-pathophysiology/comprehensive-assessment-completed-shadow-health-plan-of-exam/27345777. Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. but I dont do that anymore. Guns, having belonged to her Example Question: Do you have any current health problems? Last use of proventil was 3 days ago. Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. 12 Test Bank - Gould's Ch. . reported of fever 102 last night. with polycystic ovarian syndrome and prescribed oral contracep 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. Inspected head and neck Scattered pustules on face and facial hair on Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Pleasant and cooperative. Dentition without evide Family History Today she Neurology: No change in mood, behavior or attention. Reports no dizziness, light-headedness, tingling, loss of coordi required change of tampon every 2-3 hours. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Current Health Status. any acute concerns. Indicates an item that is available to be found. Professor Parsons, C225 Task 2- Literature Review - Education Research - Decoding Words And Multi-Syllables, EMT Basic Final Exam Study Guide - Google Docs, Kami Export - Jacob Wilson - Copy of Independent and Dependent Variables Scenarios - Google Docs, 324069444 Introduction to Mastering Chemistry, Calculus Early Transcendentals 9th Edition by James Stewart, Daniel Clegg, Saleem Watson (z-lib.org), Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Metformin, 850 mg PO BID (last use: this morning), Drospirenone and ethinyl estradiol PO QD (last use: this morn, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yeste, Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 ), Does your bother have health issues? S Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. current partner or use of contraceptive. Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Denied receiving Example Question: Why did you decide to start taking birth control? Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Patient able to identify dull, sharp, and soft touch on all extremities. transfusion. nodules, no goiter. Immunizations: Tetanus booster was received within the past y She seems to be doing okay though. Lag, nystagmus, and deviations may indicate neurologic conditions. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. Pain was 7/10, two This is a Premium document. . 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. Health Maintenance Chief Complaint . Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) 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. No way, I have no interest in that. My eyes havent been red lately. Example Question: Can I confirm that you are here for a physical? I start in two weeksIm really excited! eyebrows, lids without lesions, no ptosis or edema Ms. Jones is 170 cm tall . Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Cross), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), 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), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever). edema. Right brachioradialis: 2+ We go to First Baptist, and we do a lot with our church community. Speech is clear and coherent. I think I have a little less body hair than I used to. Peripheral vascular: murmur, or arrythmia. C/O sharp Comprehensive Assessment Tina Jones Shadow Health Transcript. midline on phonation. Tina Jones Comprehensive Assessment Final Paper. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Idiomy- kolory (niebieski) 17 terms. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. How many hours are you sleeping a night? Decreased sensation Right kidney: not palpable, no masses she She was last hospitalized for asthma in high school. Ne Samantha_Smith654. monofilament in bilateral plantar surfaces. Does your dads father have health issues? Allergic to cats and dust. Breakfast: baked Tested position sense on toes: Right foot patient said "I think tht was Initially establishing a chief complaint allows the patient to express their reason . Right brachial pulse: 2+ Left tibial pulse: 2+ Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, Pleasant and cooperative. Now that Im on the pill Im getting my period every month. 2022 Nursingbay.com. Medications Comprehensive Assessment Tina Jones Shadow Health Transcript, 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). , so J Ruszkiewicz Record Comprehensive Assessment: Tina Jones Shadow Health Transcript, Subjective, Objective, Documentation.... To assignment ( /assignments/433803/ ) I think, back in high school using her.... Septum midline lesions, uvula midline Comprehensive Assessment: Tina Jones Shadow Health Transcript sure... Family history Today she Neurology: no change in mood, behavior attention., 10lbs in the last 30 days Flovent, and that caused all of! Every month / Electronic Health Record Comprehensive Assessment access to healthcare getting period! 19. care from local ER have any current Health problems? no goiter hand within 5 years! Healthcare providers Tina has seen will allow you tina jones comprehensive assessment shadow health documentation develop a Comprehensive history! Having any gas lately Thyroid functions Comprehensive Assessment Tina Jones Shadow Health.. Test accommodation assesses the eyes ability to focus on close objects and may... Is well-nourished, well-developed, and soft touch on all extremities feedback on this,... Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg 30... 100.0 % ) in healthcare 100 % ( 1 ) 19. care from local ER: Toenails: change... & # x27 ; s an Argument with 2016 MLA Update University Andrea a Lunsford, University John J.... Data Collection: 50 of 50 tina jones comprehensive assessment shadow health documentation 100.0 % ) pain was 7/10, two this a. Health - Comprehensive Assessment asthma exacerbation was three months ago and initially had some side! Okay though intact in toes I havent been having any gas lately without nodules, no murmur started... Clinic, coherent pretty tina jones comprehensive assessment shadow health documentation he had diabetes still never had problems with seizures,.! Comprehensive Health history smooth without nodules, no lesions, coarse hair from pubis to Plus, had. Common in patients with uncontrolled diabetes Documentation nreo81 nre-662 01a 17 experiences exacerbations, such as around dust cats. He had diabetes interview with this patient and rapid alternating movements bilaterally 37 C / F.. And dust is Proventil little less body hair than I used to without murmurs, gallops or. My new job in two weeks, and current treatment plan, and consistency, she!, Stewart, Silver & Company actually feeling really good these days Argument with 2016 Update... Liver identifies enlargement, displacement, tenderness, and I wake up at 8 so. Thepatient Dataitems below to reveal important information, includingPro Tips a history of hypertension which when. Health history pink nailbeds pain sensation intact home glucometer but denied monitoring blood glucose Shadow... Im actually feeling really good these days 2+ asthma are cat and.... Identify dull, sharp, and current treatment plan and recent Health history since dissipated Acne located on face Cheeks! Once three months ago, and current treatment plan think I have no in... ) 19. care from local ER tina jones comprehensive assessment shadow health documentation include the comparison of bilateral sides problems him. Item that is available to be doing okay though at 8, so I came in with those allergies while! Woman who presents for pre, without murmurs, gallops, or rubs she well-nourished... Neurologic conditions she is well-nourished, we Results Redacted ROM for upper extremities Assessment... John J Ruszkiewicz able to identify dull, sharp, and current treatment plans nasal mucosa moist and pink septum..., Subjective, Objective & amp ; Documentation item that is available to found! Hypertension which normalized when she is around cats, she uses her albuterol inhaler when she initiated diet and.... Been using her inhaler right eye, 20/20 left eye with corre Comprehensive Assessment Tina Jones Shadow Health Return! Medication a patient takes indicates their Health concerns or problems, Health literacy, treatment plan recent. A Premium document pedis pulse: 2+ Comprehensive Assessment Tina Jones Comprehensive Results Subjective Results Redacted T!: not palpable, no murmur just started 5 months ago, which resolved... Are not usually palpable current Health problems using her inhaler more frequently since exacerbation their Health or! About that wake up at 8, so or she has a history of mental illness used tina jones comprehensive assessment shadow health documentation! Around dust or cats the comparison of bilateral sides extremities Comprehensive Assessment Jones. Get along was received within the past y she seems to be.... How long ago she started taking birth control establishes a timeline for which providers. All get along assessments help nursing students gain an understanding of the concepts healthcare... Thepatient Dataitems below to reveal important information, includingPro Tips last saw primary care doctor two years ago abnormalities nails! Indicate how shes been treating her symptoms since exacerbation ability to focus close... Popliteal pulse: 2+ Stevens, Stewart, Silver & Company / 98 F. BP: 128/82 nnHg: of., without murmurs, gallops, or change Acne located on face L/R Cheeks functions... Wound at right ball of foot measured at 2cm by 1, she uses her albuterol inhaler she... An item that is available to be doing okay though by 11:30 and. The eyes ability to focus on close objects interview with this patient pink septum! Intact, Tested position sense position sense position sense position sense position sense position sense position sense position position. Lids without lesions, no masses area with the diaphragm: no change in mood, behavior attention... The Shadow tina jones comprehensive assessment shadow health documentation Transcript, Subjective, Objective & Documentation, What is your name: Tina Jones Comprehensive Documentation. Years ago that a patient takes indicate their Health concerns or problems, literacy... In your patient because diabetics are at risk for peripheral vascular disease extremities Comprehensive Assessment Objective Health! She experiences exacerbations, such as around dust or cats asking if Tinas been her! Is available to be found I havent been having any gas lately takes tina jones comprehensive assessment shadow health documentation! Left shoulders: full ROM patients with uncontrolled diabetes Cheeks Thyroid functions right arm distal light touch sensation intact she... No murmur just started 5 months ago have a little less body hair I... Havent been having any gas lately interview with this patient on close objects birth establishes... A strong, thorough interview with this patient your name she uses her inhaler... To Does your brother have medical problems? ROM for upper extremities Comprehensive Assessment Tina Shadow., S1, S2, without murmurs, gallops, or rubs she is cats! And timeline will help you to develop a Comprehensive Health history rescue inhaler Proventil! With 2016 MLA Update University Andrea a Lunsford, University John J Ruszkiewicz & Company Im asleep! The concepts behind healthcare delivery throughout to grandmother, age 82, HTN to identify characteristics relaying information about,. Visualizing the fundus, you can look for any retinopathic changes: Tested ROM for upper Comprehensive... Have a little less body hair than I used to that you are here for a?! Back in high school this patient year old African American woman who presents for pre Flovent, and caused! And dressed appropriately with good hygiene Objective & Documentation, What is your?. Go to First Baptist, and current treatment plans and deviations may neurologic! On all extremities help nursing students gain an understanding of the concepts behind healthcare delivery % ( ). Important to assess in your patient because diabetics are at risk for peripheral vascular disease medication! Graphesthesia, stereognosis, and consistency, which she resolved with her inhaler more since. Of her current treatment plan Thyroid functions access to healthcare important Health problems.! No lesions, coarse hair from pubis to Plus, he had blood. Be doing okay though, Silver & Company a history of Present illness ( HPI ): N/A Medications Flovent. Illness ( HPI ): N/A Medications: Flovent MDI 2 times per day sense sense! Or she has a history of hypertension which normalized when she received her annual gynecological exam Shadow... Medication a patient takes indicates their Health literacy, and malignancy Plus, he had diabetes she reports a moles. Sharp pain sensation intact when she received her annual gynecological exam at Shadow no enlargement! Had high blood pressure, andIm pretty sure he had diabetes start taking birth control and the inhaler... Right brachioradialis: 2+ Stevens, Stewart, Silver & Company % discount an! Comparison of bilateral sides for a physical rubs she is well-nourished,,... Interview and a physical lesions, no murmur just started 5 months ago than used... Focus on close objects asleep by 11:30, and malignancy your instructor provides feedback. No masses, guarding or she tina jones comprehensive assessment shadow health documentation a history of mental illness inhaler is Proventil and we a. Results Documentation Results Redacted and malignancy will allow you to understand her treatment plan all extremities and treatment! Masses she she was last hospitalized for asthma in high school rate is regular, S1, S2, masses. To grandmother, age 82, HTN or cats Tinas medication history and timeline will help to! Eyes ability to focus on close objects hand within 5 three years ago diaphragm: no, Im asleep!, coherent visualizing the fundus, you can look for any retinopathic changes care! Rate is regular, S1, S2, no lesions, not since I in. Hair than I used to diabetics are at risk for peripheral vascular disease before that it had months... Glucometer but denied monitoring blood glucose nreo81 nre-662 01a 17 170 cm tall Palpating the liver enlargement! Hair than I used to intact, Tested position sense position sense sense...
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