two times a month when out with friends but no more than three drinks per episode. Your initial responses to the mandatory DQ do not count toward participation and are graded separately. Documentation Have you experienced any neurological problems? (Found) She says Her paternal grandmother is alive and well, 82, with hypertension. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Upon examination, head is normocephalic with no lesions or tenderness of scalp. Asked about current non-prescription medications. I encourage you to incorporate the readings from the week (as applicable) into your responses. (Found) Example Question: Patient Data Her speech is clear and eye contact is appropriate. Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. Discuss the health care support systems available in your community for someone of this culture. (Found) Acombinationofopenandclosedquestionswillyieldbetterpatientdata. Pro Tip: It is important to determine any recent changes to breast, such as swelling, rashes, lumps, or nipple discharge, as it could be indicative of a serious underlying condition. (Found) Reports typically taking 2 puffs Asking Tina how many days a week she exercises can help you to assess her current levels of health and nutrition. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Have you been wheezing? Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. Example Question: Reports taking birth control pill at the same time every day Example Question: Some students may need longer. As soon as the paper is ready, well send you a copy via email. She is allergic to cats and dust. previous visit to a primary care physician was a few years ago. How many times a day do you take metformin? She is a good historian. AskingTinaifshetakesvitaminswillindicatehercurrent (Found) Has your asthma changed at all? Pro Tip: Finding out specifically if a patient drinks coffee helps you understand what constitutes her typical caffeine intake. healthcare due to out-of-pocket costs. Have you had shortness of breath? Past Medical History Tina Jones University Keiser University Course Physical Assessment in Healthcare Academic year:2021/2022 Helpful? Example Question: (Found) She claims that her church and family Reportsnocurrentmedicationforallergies. 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. ProTip:Initiallyestablishingachiefcomplaintallowsthepatienttoexpresstheirreason Have you ever gotten a mammogram? Reports occasional chest tightness Although Ms. Jones is not sexually active, she states she probably will be soon. Finding: Tina states she is very excited about the new opportunity. Finding: This will be checked at least once every 24 hours. Pro Tip: Follow up questions about the dosage of Tinas diabetes medication will help you to understand her treatment plan and recent health history. andaccesstohealthcare. In: StatPearls [Internet]. Is your paper made up of someone elses thoughts more than your own? She came into the clinic for a physical exam. (2016). Normal bronchophony results. Comprehensive Health History for Shadow Health History & Final Comprehensive Health Stereognosis and graphesthesia normal bilaterally. How much weight did you lose? She is a part-time student, in her last semester to earn a bachelors Finding: Category: Health Detail Health Example Question: Shadow Health - Tina Jones, Health History Flashcards. Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). Comprehensive Assessment of Tina Jones. Finding: What is your typical lunch? (Found) She needs to be educated and understand the importance of testing her blood sugar regularly. (2014). Uses alcohol one to (Found) If no support systems are available in your community, identify a national resource. dyspnea, current wheezing, hemoptysis, or recent cough. Example Question: Heart rate is regular, S1, S2, no murmurs, gallops or rubs. AskingTinaaboutthe abnormal hair growth, and acne since stopping oral contraceptives 18 months ago, as well as Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Finding: Example Question: Reports occasional wheezing Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Howhaveyoubeentreatingyourhypertension? Greet 07/22/20 5:37 PM ED. Pro Tip: Asking Tina if she experiences any adverse effects from her inhaler can help you determine if the treatment is effective and appropriate for her health needs. Pt reports that she is concerned about worsening pain and possible infection. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Denies current sleep issues Have you been coughing? Example Question: AskingifTina'sbeenusingherinhalermorefrequentlysince (2014). Muslim faith with Islamic beliefs that women must only be seen by female health care providers to protect privacy and to minimize eye contact especially from the opposite sex (Attum, et. (Found) Whats the most puffs you ever take? Example Question: Example Question: Department of Nursing, Otterbein University How many puffs of your inhaler do you typically take? Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Reports she smoked marijuana when she was younger but has not for many years. Mild retinopathic changes on the right. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. been cleaning the wound twice a day and applying antibacterial ointment and bandages. An individualized plan of care taking into . Reports recently beginning exercising to manage diabetes Palpated fremitus equal bilaterally. (Found) Reports that a typical walk is thirty or forty minutes Axillary and cervical lymph nodes palpated, no lymphadenopathy. Lived independently since age 20, currently lives with mother and 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. Asking how frequently Tina uses her inhaler can indicate how shes been treating her symptoms. No wheezing, runny nose or a cough. She reports no depression or anxiety. 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. Students must score at the level of Proficiency in the Shadow Health Digital Clinical Experience. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. History, Ojaswi Bhattarai ReasonforbirthcontrolwastomanagePCOSsymptoms. Finding: It is best to paraphrase content and cite your source. Communication is so very important. 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. Example Question: (Found) Finding: Example Question: *Price with a welcome 15% discount applied. Health (2 days ago) WebDiana 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 Quizlet.com . Finding: Reports that glasses improve overall vision Her paternal grandmother is alive and well, 82, with hypertension. Reports ibuprofen is effective condition,experience,orsymptoms. Surgical: No surgeries to date. Example Question: A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and . Doyoutakeyourpillatthesametimeeveryday? Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php, Sander, I. (Found) Along with controlling diabetes, other leading modifiable risk factors include diet, physical activity, and being overweight and obesity. the pain and swelling in her ankles have subsided, but the bottom of her foot is increasingly. Struggling to find relevant content or pressed for time? Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. healthcareaccess. Adult Illnesses: General: Recent unintentional weight loss, fever last night of 102, chills last night, no fatigue Full ROM and 5/5 strength in extremities, spine, and hips. Reports last optometrist visit was 3 months ago Axillary and cervical lymph nodes palpated, no lymphadenopathy. NRS 434 Shadow Health: Comprehensive Assessment Finding: Pro Tip: Determining if Tina has any current breathing problems is important for assessing her respiratory health and providing quality patient care. Example Question: Example Question: The last visit to the clinic was four months ago for an annual gynecological exam. Finding: Finding: Haveyoubeenhavingheartpalpitationsrecently? That's why our prices are one of the most affordable on the market, and there are no hidden fees. Did you get prescription eyeglasses? ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideabaselinefor This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). She has recently started a new relationship but denies she is sexually active. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Denies general HEENT issues Howoftendoyouuseyourrescueinhaler? An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. Tina is active in her church and describes a She drinks socially when out with friends about 2-3 times per month, and her caffeine intake has decreased to 1-2 diet sodas per day. Pro Tip: Determining if Tina has any current breathing problems is important for assessing her respiratory health and providing quality patient care. Reports dust allergy Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Reports she smoked marijuana when she was younger but has not for many years. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. No wheezing, runny nose or a cough. (Found) Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. (Found) A "fail" on the SHCA means that the student has not answered any of the questions correctly. Discovering a patients individual response to pain medication is an important factor in your overall treatment plan. Asking Tina if she takes herbal products will indicate her current treatment plan. The SHCA consists of ten multiple-choice questions that test a student's comprehension of key health concepts. Finding: AskingTinaifshe'shada When she experiences Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. When in doubt, cite the source. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. 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. (Found) Supervisor at Mid-American Copy and Ship. Available from:https://www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University (Ed). She appears well-nourished and dresses appropriately. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. Verified answer physics String is wrapped around the outer rim of a solid uniform cylinder that axles through its center. Understanding a patients history of birth control can be an indicator of health literacy. 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. Example Question: Asked about review of systems for respiratory. Sign up, place your order, and leave the rest to our professional paperwriters in less than 2 minutes. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. (Found) If something is not clear or missing, the writer will contact you for clarification. (Found) Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. He had hypertension, high cholesterol, and type 2 diabetes. How much soda do you drink a day? exacerbation. Have you noticed any changes to your breasts? Paternal grandfather: died at age 65 of colon cancer, and a history of type 2 diabetes. Comprehensive Assessment of Tina Jones. (Found) Get your work done on time by medical experts. Denies coughing Better nutrition and the continuance of daily exercise should be emphasized. Does ibuprofen help your cramps? Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. Ears: Denies difficulty hearing, tinnitus, vertigo, ear pain, infections, and discharge. Reports reason for birth control was to manage PCOS symptoms The rescue inhaler was last used three months ago with a total of two uses in the past year. Finding: Immunizations: She reports that she believes she is up to date on childhood vaccines. Finding: Example Question: Skin: Reports acne since puberty and occasional dry skin. Abdomen tympanic on percussion. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. Finding: Last dental visit was five months ago with no concerns. Denies a history of pneumonia, tuberculosis, and chronic bronchitis. painanddiscomfortthatsheisexperiencing. provided all the information freely and truthfully. Pay Someone to Write My Personal Statement For Me, Premium Service | Pay Someone to Do My Statistics Homework, I Need to Pay Someone to Do My Excel Assignment for Me, College Papers for Sale Research Papers. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Can you confirm your asthma? I am happy to be flexible. Cardiovascular. Example Question: Review of systems: Do you use a glucometer? Example Question: (Found) Denies fever There has been no recent study, volunteering in her church, and dancing. Pro Tip: Establishing a timeline for Tinas gynecological exams will allow you to develop a comprehensive health history. Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and identifying potential health risks. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand (Found) (Found) Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Finding: Reports starting birth control 4 months ago With the assistance of Orems self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health. Dorothea Orems self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). Reports walking for exercise Reports penicillin allergy Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. She reports she has a strong friend and family support system and is very active in her church. Reports ibuprofen is regular strength Finding: AskingTinaifshetakessupplementswillindicatehercurrent treatmentplan. Finding: Reports having adequate supplies How often do you take your birth control pill? Do you have an inhaler? 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 drinking coffee Asking Tina if she drinks soda will illustrate her recent dietary patterns. Example Question: Coarse hair growth noted from pubis to umbilicus. Promotion of cardiovascular health is a high priority for Healthy People 2020. Ms. Jones states her acne has improved due to oral contraceptive use. Reports diabetes medication dose is 850 mg Denies cough, (Found) (Found) Sinus palpated with no tenderness noted. 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