Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Ears: Ear shape equal bilaterally. Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. -Occupation: Smith, Stevens, Stewart, Silver & Company Indicates an item that is available to be found. Reports improved acne due to oral contraceptives. physics. Finding: Left pupil: equal, round, reactive to light. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). Blood glucose 199 The following details are facts, Pro Tip: Determining if the patient has any current acute health problems is essential in conducting a. productive exam and prioritzing the patient's needs. Finding: Reason for last visit was annual gynecological exam. Comprehensive Assessment Tina Jones Shadow Health Transcript. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. alcohol, and illicit drugs. Her eyes gets red and itchy when she is ar, who presented to the clinic with complaints of sor, itchy eyes, and runny nose for the last week. Class Eyes: Bilateral eyes with equal hair distribution, no lesions, no Example Question: Can you confirm your allergies? Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. treatment. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History Height: 170 cm Weight: 84 kg . Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Will begin her new position in two Just coming in and talking to someone here about it helped a little because I felt like I was doing something. 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). No. No sore throat prior to this episode. weakness, fever, chills, and night sweats. Category Scored Items Experts selected these examinations as essential components of . The object is in equilibrium if the net force and the net torque on the object are both zero. Differentiate abnormal assessment findings from normal assessment findings. Social History: She is not aware of any environmental exposures or I havent smoked pot since I was twenty or twenty-one. Her current inhaler use. I mean, I still have asthma and diabetes, but both of those are under control. Well, I used to smoke pot. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with Rinne, Weber, and Whisper tests Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. (Clarified to Do you have drainage from your ears?. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. -dressed appropriately otherwise, denies all other complains. Example Question: How often do you use your rescue inhaler? 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. First sexual encounter at age 18, sex with men, identifies as heterosexual. Topic 4 Assignment, Shadow Health: Comprehensive Assessment - Documentation, Objective Data Collection, Planned My Exam, Subjective Data Collection. Example Question: How often do you use your daily inhaler? blood/platelets/red blood cells, current flu vaccine. . She has running nose and sore throat as her chief complains, 1. year), Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. My eyes havent been red lately. Health and Illness Across the Lifespan (NUR2214), Business Professionals In Trai (BUSINESS 2000), Operating Systems 1 (proctored course) (CS 2301), Business Law, Ethics and Social Responsibility (BUS 5115), History Greek & Roman Civilization (hist 1421), Organic Chemistry Laboratory I (CHEM 223), Microsoft Azure Architect Technologies (AZ-303), Management of Adult Health II (NURSE362), Concepts Of The Nurse As Leader/Manager (NURS 4200), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), ECO 201 - Chapter 2 Thinking like economist part 1 - Sep 9, TB-Chapter 22 Abdomen - These are test bank questions that I paid for. Objective Data Collection: 24.42 of 25 (97.68%) Correct Partially correct Incorrect Missed Inspected head and face 0.67 of 1 point Skull Symmetry (1/3 point) Symmetric Asymmetric Facial Feature Symmetry (1/3 point) Symmetric Asymmetric Appearance (No point) No visible abnormal findings Rash Papules, pustules, or comedones Skin growths (freckles, moles, or birthmarks) Excessive hair growth . Idiomy- kolory (niebieski) 17 terms. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids Her current inhaler use Grandpa Jones had colon cancer, and that caused all kinds of problems for him. current feelings of depression, anxiety, or thoughts of suicide. Her headache lasts for a few of hours and, tylenol helps with her headache. Asthma diagnosed at age 2 1/2. denies dust/mildew at her home. Extraocular Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Temp 99. The daily inhaler is Flovent, and the rescue inhaler is Proventil. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. treatment for her nasal symptoms. Right eye . . In the Comprehensive Assessment, you earn points by performing the physical assessments. ), ANY sore throat? Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Study Resources. For instance, if there are three dimensions of a particular assessment, each dimension is worth 1/3 of a point. She states that she has some soreness when swallowing, but, otherwise no other associated symptoms. The following details are facts of t, Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months, Reason for last visit was annual gynecological, Last general physical examination was 5 months, ago when she was prescribed metformin and daily, Asked about current prescription medications, Reports taking prescription birth control pills, Reports that eating probiotic yogurt helps with, side effects and they have abated over time, Followed up on metformin frequency and dose, Reports using Flovent inhaler twice daily, Last use of Proventil inhaler was three months, Has used Proventil inhaler twice in the last year, Followed up about birth control prescription, Started taking birth control 4 months ago, Reason for birth control was to manage PCOS, Birth control type is Yaz (drospirenone and ethinyl, Takes birth control pill at the same time every day. Log in Join. Then a few weeks later I saw a gynecologist for a pap smear. Finding: Inspected eyebrows and orbital area Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Any medical history for your paternal grandmother? Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Example Question: What type of birth control do you use? Penicillin: rash Denies food and latex allergies Allergic to cats and dust. the last time I was sick was when I was having those heartburn problems a while ago. Shadow Health Final. I dont have anything specific going on today. Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. -She is the primary source of the history. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. Experts selected these examinations as essential components of objective data collection for this patient. runs all day and is clear discharge. with positive light reflex bilaterally. movements intact bilaterally. 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. Normal convergence. (Clarified to if my younger sister has health problems. She has not had her eye exam done, since childhood. Theyre crazy, but nobodys diagnosed with anything. She provided the health information freely during the interview. Pap smear (4 months ago), eye exam (three months ago), dental exam (five months ago), PPD (negative, Comprehensive Assessment Tina Jones Shadow Health Transcript, My doctor told me when I was pretty little I think I was about two and a half? . How many hours are you sleeping a night? bilaterally. She is the primary source of the history. Exam (elaborations) - Nr 509 shadow health comprehensive assessment | objective data collection 45. Im sleeping a lot better now, which is a relief. quizlette. Example Question: Have you been having seasonal allergies? Central High School. Finding: Peripheral vision intact in both eyes, all fields, Finding: Inspected interior eyes with ophthalmoscopeComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Mild retinopathic changes on right. Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. The injury occurred about one week ago. Other sets by this creator. Im going to be an Accounting Clerk at this really nice accounting firm. Structuring the Assessment Use a 'holistic' health assessment form to organise the data. Ive had asthma a long time. . She complains -Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies. Indicates an item that is available to be found. My muscles have felt great, especially since I started exercising more. Denies Finding: Started taking metformin 5 months ago. Nose/Sinuses: Denies rhinorrhea prior to this episode. Tested negative for HIV/AIDS and STIs four months ago. Head: Denies history of trauma. I used my Flovent inhaler this morningI have to take it twice a day. Experts selected these topics as essential components of a strong, thorough interview with this patient. Last visit to optometrist 3 months ago. Last menstrual period 2 weeks ago. Comprehensive Assessment Tina Jones Shadow Health Transcript. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. A 35 year old patient presents with a concern of two high blood pressures at local health fairs in the past month. Other - Nr 509 shadow health comprehensive assessment instructor's guide (all modules cases i... . She changes her sheets weekly and Ive been feeling much better lately, though. pressure. Cross), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Psychology (David G. Myers; C. Nathan DeWall), Psych - adsfafdasfsaf jdshj tjshks tsaj dfjka jkdf kjdfkjldsa kljsa fkdafkjdfkjakdj, Compsci 2033 - this its the. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. attending Bible study, volunteering in her church, and dancing. She has not attempted any, treatment for her nasal symptoms. Within the Shadow Health platform, complete the Comprehensive Assessment. (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Yeah. Denies, stuness, sneezing, itching, previous aller, Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph. tearing or itching prior to this past week. 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. Thyroid is DTRs 2+ and equal bilaterally in Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. Plus I have my friends from church. Respiratory: She denies shortness of breath, wheezing, cough. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Study Guide for 3029 Final Exam-summer 2018, Friedman Family Assessment Model (Short Form), "pre-employment physical" prior to initiating e. This is a Premium document. he had some blood pressure and cholesterol issues when he was alive, too. Comprehensive Assessment Tina Jones Shadow Health Transcript. Denies Acanthosis nigricans present. Oral mucosa moist without ulcerations or States recent 10 pound weight loss due Since then Ive just washed my face, I havent used anything special. It is important to stay away from triggers. 2/25/2021 Comprehensive Assessment | Completed | Shadow Health 4/6 Student Documentation Model Documentation Objective HEENT overall without significant findings. Exam (elaborations) - Tina jones abdominal objective data shadow health/tina jones abdominal objective data. The estimated average time to complete this assignment each time is 3 hours. All Rights Reserved. I would get allergies, like sneezing and stuff, and then my asthma would act up. Review of Systems: General: Denies changes in weight, fatigue, infection. Please note, this is an average time. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection. Finding: Left fundus with sharp disc margins, no hemorrhages Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right upper quadrant: no masses, guarding or rebound. Her eyes gets red and itchy when she is around her Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. Comprehensive Assessment Tina Jones Shadow Health Transcript. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Recent flashcard sets. Samantha_Smith654. has never been diagnosed with seasonal allergies, but does note Adequate dental hygiene. (Clarified to Does your brother have medical problems?. Strength 5/5 bilateral upper and lower extremities. (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps). Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). 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. carrot sticks or an apple. My discharge is normal, I think. She states that her eyes are Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: ask effective and comprehensive questions obtain a thorough health history evaluate the patient's risk of disease, infection, injury, and complications educate and empathize reflect on your experience and identify areas . Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. high cholesterol Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol VNSG. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. General Survey (Clarified to Does your younger sister have health problems?. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. herbs gingko/garlic/primrose. Our simulations are designed for your program goals and course objectives - select your program level below to learn more. Tonsils 2+ bilaterally. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. We go to First Baptist, and we do a lot with our church community. masses, normal hair distribution. smooth without nodules or goiter. -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory proble, ago), received childhood vaccinations, meningococcal vaccine (in c, asthma exacerbations (resolved with use of inhaler without complica, -Childhood chickenpox/rubella/polio, serious injurie. single family home, but will move into own apartment in one month. No tics or facial Please note, that this is an average time. Poppa died of a heart attack when he was 80. . Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. She rates her Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. Comprehensive Assessment Tina Jones Shadow Health Transcript. Example Question: How long have you been taking metformin? Today she denies any acute concerns. Example Question: Do you take any supplements? maintains eye contact throughout interview and examination. about 2 years ago), wears seatbelt, uses sunscreen. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. normal bilaterally. 23 terms. Well, Im starting my new job in two weeks, and Im really excited about that. I havent had any eye problems latelyI went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good. Documentation. sputum, hemoptysis, pneumonia, bronchitis, emphysema, Do you have any problem with your breasts? -African American Relate the need for respecting culture, values, uniqueness, and personal choice to the assessment process. tobacco. reveals mild retinopathic changes. Comprehensive Assessment Tina Jones Shadow Health Transcript. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. So Ive been trying to address problems as they come when I can, and that helps. Indicates an item that is available to be found. Uvula midline. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Ms. Jones offers information freely and without contradiction. Comprehensive Assessment Tina Jones Shadow Health Transcript. She has a history of hypertension which normalized when she initiated diet and exercise. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Asked about current prescription medications, Finding: Reports taking diabetes medication, Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. She has treated ), No, I dont think so. External canals without Shadow Health- Tina Jones- Hair, Skin, Nails. I came in because Im required to have a recent physical exam for the health insurance at my new job. Comprehensive Assessment Tina Jones Shadow Health Transcript. What is your relationship like with your family? The object is in equilibrium if the net torque on the object is zero. Skin on neck has stopped darkening and facial and body hair has improved. blood/platelets/red blood cells, current flu vaccine. itchy eyes, and runny nose for the last week. Category: SOAP NOTES. Strengthening clinical skills. tearing or itching prior to this past week. cancer, history of type 2 diabetes Paternal uncle: alcoholism Negative for mental illness, other cancers, Finding: Followed up about birth control prescription, Finding: Started taking birth control 4 months ago, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Frontal and maxillary sinuses nontender That doesnt sound like it would be good. Denies incr. Ms. Jones speech is clear and coherent, Ms. Jones appears alert and oriented She is appropriately dressed She appears to be in good health Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones visited to have a physical exam for the health insurance at her new workplace Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. 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. Mom has high cholesterol and blood pressure, I think. Has your menstrual cycle improved since taking Yaz? She has a history of asthma, last hospitalization was The assessment should also include the comparison of bilateral sides. 3x sold. Health (Just Now) WebPopular books. nodes, or wounds in mouth. She uses her albuterol inhaler when she is around cats. I came in because Im required to have a recent physical exam for the health insurance at my new job. A combination of open and closed questions will yield, better patient data. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Diagnosed with PCOS four months ago. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Created: 05 July 2021. She does not exercise. . Cannabis use from age 15 to age 21. fasciculation. Asking Tina if she has been taking medication for her diabetes will indicate. Comprehensive physical assessment with subjective and objective data utilizing ShadowHealth A 62 year old malewho had a myocardial infarction one year ago is being seen for hypertension. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Course Hero is not sponsored or endorsed by any college or university. What medical problems does your mum have? Some students may need longer. Example Question: What is the name of your diabetes medication? Pulse ox 99% . She has not had her eye exam done not stressed at all. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Lag, nystagmus, and deviations may indicate neurologic conditions. Respiratory: Chest is symmetrical with respirations. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. No. : an American History (Eric Foner), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Eyes: She does not wear corrective lenses, but notes that her, vision has been worsening over the past few years. That is great. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease.

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