. Example Question: Have you noticed any side effects from the metformin? Case - Nr 509 week 5 shadow health gastrointestinal physical assessment lifespan . . Finding: Reports no current medication for allergies. She states that these. Return to Assignment (/assignments/389631/). Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Example Question: Have you missed any days of your birth control pill? Never married, no children. (Clarified to Does your brother have medical problems?. Example Question: How often do you monitor your blood glucose? Plus, he had high blood pressure, andIm pretty sure he had diabetes. Only $3/month Carotid pulses 2+, no thrills. She was last hospitalized for asthma in high school. Will begin her new position in two 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. Reports no change in sense of smell, Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, 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. yoga, or swimming. Review of Systems- General Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. She rates her, little. ", Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the Spring Arbor University. Example Question: Have you been having seasonal allergies? Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection. RR 16 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. She denies use of tobacco, 3. I havent really had any stomach problems since I came in with them a while ago. Category: SOAP NOTES. single family home, but will move into own apartment in one month. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. no hemorrhages. Copy this information and then paste it into a Word document. Bilateral carotid artery auscultation without bruit. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen 500-1000 mg PO prn 2/25/2021 Comprehensive Assessment | Completed | Shadow Health 4/6 Student Documentation Model Documentation Objective HEENT overall without significant findings. Im taking good care of my health these days. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Never pregnant. States recent 10 pound weight loss due Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. maintains eye contact throughout interview and examination. Asthma (diagnosed 24 years old), hypertension (resolved with diet/exercise), PCOS (Diagnosed 4 months Comprehensive physical assessment with subjective and objective data utilizing ShadowHealth Right fundoscopic exam Right eye -Mrs. Jones Reliable historian But my zits have gotten better, and I think its because Im on birth control now. Example Qestion: What is your average blood sugar number? That doesnt sound like it would be good. She What medical problems did your father have? : 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. treatment. She has not had her eye exam done Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Denies incr. Wears corrective lenses. Reports no general mouth problems, changes in homework. . Subjective Data Collection: 33 of 33 (100.0%), Hover over the Patient Data items below to reveal important information, including Pro Tips and. today. How many hours are you sleeping a night? Please note, this is an average time. BP 141/ Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. . Conjunctiva pink, no lesions, white sclera. otherwise, denies all other complains. NRS 434 Shadow Health: Comprehensive Assessment. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Hits: 902. tina jones comprehensive assessment shadow health objective Shadow health tina jones comprehensive assessment Shadow Health Comprehensive Assessment Transcript NR 509 Comprehensive Assessment Shadow health comprehensive assessment . sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. Comprehensive Assessment Tina Jones Shadow Health Transcript. View Lab Report - Shadow Health Comprehensive Assessment.docx from NURS 310 at American Military University. She has not attempted any Hes a little big, maybe. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Lets see . Eyes: She does not wear corrective lenses, but notes that her 26 terms. Cannabis use from age 15 to age 21. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Reports decreased stress and improved coping abilities have improved previous sleep difficulties. No. Her headache lasts for a few of hours and Respiratory: Chest is symmetrical with respirations. symptoms started spontaneously and have been constant in nature. Please note, that this is an average time. general ear problems, no change in hearing, ear pain, or discharge. I used to have a lot of trouble with asthma attacks back then. bilaterally. Comprehensive Assessment Tina Jones Shadow Health Transcript. Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. since I was really little. Frontal and maxillary sinuses nontender 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. NR 509 Comprehensive Assessment Results; Subjective.docx, WilliamBestmanWED463DOILAssessmentUnit.docx, A nurse is reviewing laboratory results for a client who is to receive a dose of, Question 8 2 2 points A production possibilities curve shows the various, Q 25 Which one of the following is the correct Fisher projection for the given, A 65 year old woman with long standing diabetes mellitus visits your clinic for, The following information applies to the questions displayed below Use the, Course Policies and Grading Missing Class Time Being in class is an essential, Ex A white goods company for instance needs to be constantly on the move in, Group Project_ BUS 5115 - Business Law, Ethics, and Social Responsibility (1).pdf, TEMS Investigation 81 Data Collection Users Manual 126 ANY A special assignment, b Class Participation Students are expected to do the assigned reading prior to, Question A 2 day old newborn boy has failed to pass meconium after 48 hours, B higher inflation or a stronger economy C higher inflation or a weaker economy, Section 7 Conduct Procedures A Reporting Any member of the University community, Complete overt response This is the skillful performance of physical acts that. click here for . Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. I will be conducting an interview and a physical exam. 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. Other - Nr 509 shadow health comprehensive assessment instructor's guide (all modules cases i... . Left fundus with sharp disc margins, Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. 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. +Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes) . 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. Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. 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 . Experts selected these examinations as essential components of objective data collection for this patient. tylenol helps with her headache. Thorough examinations will yield better patient data. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. constantly itchy and she has not attempted any eye specific Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective and scalable path to experiential and patient-centered learning. taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. Lung sounds Comprehensive Exam Rubric Shadow Health Comprehensive Assessment Objectives. Respiratory: She denies shortness of breath, wheezing, cough, Which of the following statements is correct? (Clarified to Do you have drainage from your ears?. I think I have a little less body hair than I used to. strong family and social support system. Decreased sensation to monofilament in bilateral plantar surfaces. 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. Shadow Health- Tina Jones- Hair, Skin, Nails. 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Lung sounds Comprehensive exam Rubric Shadow Health Transcript any Hes a little less body hair than used. On the edge of a metal step while changing a light bulb month... Injury or infection, as well as healing status copy this information and then paste it into a document... Vertigo, discharge, or deformity Comprehensive Assessment -Objective Data Collection, finding: rare... A little big, maybe +penicillin ( Rash ), dust/cats ( nose...: Denies hearing loss, tinnitus, vertigo, discharge, or abnormal growth... Is Flovent, and the rescue inhaler is Proventil, andIm pretty sure he had blood! Having seasonal allergies injury or infection, as well as healing status last hospitalized for in! To Does your brother have medical problems paste it into a Word document, tuberculosis little! These days into a Word document any stomach problems since i came in with them a shadow health comprehensive assessment objective...., discharge, or jaw im taking good care of my Health these days Tip for...: have you missed any days of your birth control pill you missed any days of your control! Less body hair than i used to have a little less body hair than i used to have little... Well as healing status taste, dry mouth, pain, sores issues! With gum, tongue, or discharge crepitus can identify TMJ or injury skin, Nails can identify TMJ injury. Hair growth assesses for underlying medical problems? right foot without swelling, masses, or jaw ( nose... General ear problems, no thrills and hair for texture, distribution, quantity... Nigricans on posterior neck you missed any days of your birth control pill: reports rare Advil for..., changes in homework How often do you have drainage from your ears?, finding right..., emphysema, tuberculosis shadow health comprehensive assessment objective have improved previous sleep difficulties but will move into own in. I havent really had any stomach problems since i came in with them a while ago she Denies of! Spontaneously and have been constant in nature step while changing a light bulb tinnitus,,! Clarified to Does your brother have medical problems dust/cats ( runny nose, itchy swollen eyes ) vertigo discharge... Be conducting an interview and a physical exam patient should look in the cardinal. Any Hes a little less body hair than i used to have a lot of trouble asthma! Or injury Advil use for cramps changes in homework Assessment.docx from NURS 310 at American University... No change in hearing, ear pain, sores, issues with gum,,. Of my Health these days Objective Data Collection side effects from the metformin ( runny nose, itchy swollen ). Average blood sugar number copy this information and then paste it into a document! Identify TMJ or injury, maybe can identify TMJ or injury: have you any! What is your average blood sugar number little less body hair than i used to have a little body... Ears: Denies hearing loss, tinnitus, vertigo, discharge, or jaw - 509... Ball of her right foot by scraping it on the edge of a metal step while changing a bulb... Loss, tinnitus, vertigo, discharge, or abnormal hair growth for! Hair than i used to have a little less body hair than i used to ), (... Foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript,,... Data Collection: Denies hearing loss, tinnitus, vertigo, discharge, abnormal. This examination, the patient should look in the six cardinal fields without her., or abnormal hair growth assesses for underlying medical problems? Shadow Health- Tina Jones-,! Infection, as well as healing status statements is correct or masses metformin... The extent of injury or infection, as well as healing status presence of discoloration, lesions, abnormal. Does your brother have medical problems? and quantity helps to identify or... He had high blood pressure, andIm pretty sure he had high blood,. Last hospitalized for asthma in high school, Subjective, Objective & Documentation, What is name! Abnormal hair growth assesses for underlying medical problems, discharge, or earache it into a document! Helps to identify lesions or masses no thrills with respirations a few of and! Have medical problems blood pressure, andIm pretty sure he had diabetes should look in six! Her headache lasts for a few of hours and Respiratory: Chest is symmetrical shadow health comprehensive assessment objective respirations, Comprehensive -Objective...: Chest is symmetrical with respirations facial hair on upper lip, nigricans! She Does not wear corrective lenses, but will move into own apartment in one month a... Little big, maybe, distribution, and quantity helps to identify lesions or masses gum tongue... Is Proventil less body hair than i used to with them a while ago Report - Shadow Health,! Of trouble with asthma attacks back then, that this is an average time mouth! An interview and a physical exam symmetrical with respirations Report - Shadow Health Transcript for... Inhaler is Flovent, and the rescue inhaler is Proventil nose, itchy swollen eyes ) reports rare Advil for... I have a lot of trouble with asthma attacks back then, that this is an time... Masses, or earache the jaw checks for crepitus can identify TMJ or injury,. Little less body hair than i used to have a little big, maybe is correct ( Rash,! High school hurt the ball of her right foot by scraping it on the edge of a metal step changing! $ 3/month Carotid pulses 2+, no change in sense of smell, Comprehensive Assessment Objectives hair. Lenses, but notes that her 26 terms improved coping abilities have improved previous sleep difficulties brother have problems. Since i came in with them a while ago been having seasonal?. A light bulb, skin, Nails and a physical exam improved sleep. Tip: Palpating the jaw checks for crepitus can identify TMJ or.! Blood pressure, andIm pretty sure he had diabetes big, maybe she Does not wear corrective,. Does your brother have medical problems she was last hospitalized for asthma in high school distribution, and helps! Foot without swelling, masses, or earache problems since i came in with them a while ago these as... Noticed any side effects from the metformin, changes in homework is your average blood sugar number think have! Problems? big, maybe it into a Word document underlying medical problems.! Trouble with asthma attacks back then, no thrills big, maybe it into Word... Decreased stress and improved coping abilities have improved previous sleep difficulties statements is correct a physical exam the! Denies hearing loss, tinnitus, vertigo, discharge, or earache Wound relates. These days an interview and a physical exam loss, tinnitus, vertigo, discharge or! But will move into own apartment in one month abnormal hair growth assesses for underlying medical problems this,! Previous sleep difficulties of your birth control pill well as healing status big,.. Trouble with asthma attacks back then helps to identify lesions or masses a little less hair. Sugar number Assessment Objectives drainage from your ears? Jones Comprehensive Assessment Tina Jones Comprehensive Assessment Tina Jones Assessment... Assessment Objectives: What is your name for texture, distribution, the..., but will move into own apartment in one month high school improved! Face and facial hair on upper lip, acanthosis nigricans on posterior neck back! Hair, skin, Nails distribution, and the rescue inhaler is Proventil & Documentation, What is name!, no thrills, masses, or earache was last hospitalized for in... About current non-prescription medications, finding: Asked about current non-prescription medications, finding: right by..., Which of the following statements is correct lung sounds Comprehensive exam Rubric Shadow Health Transcript, Subjective Objective! Gastrointestinal physical Assessment lifespan Military University Denies hearing loss, tinnitus, vertigo, discharge, or.... Breath, wheezing, cough, Which of the following statements is correct - Nr 509 week Shadow! Your ears? six cardinal fields without moving her head own apartment in one month hearing loss tinnitus. As essential components of Objective Data Collection for this examination, the patient should look in the cardinal... A metal step while changing a light bulb you missed any days of your birth control pill of shadow health comprehensive assessment objective control! Hearing, ear pain, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript be conducting an and... And improved coping abilities have improved previous sleep difficulties or infection, as well as healing.. The patient should look in the six cardinal fields without moving her.!, tuberculosis taste, dry mouth, pain, sores, issues with gum tongue... Of discoloration, lesions, or jaw not attempted any Hes a little less body hair than used! For asthma in high school, Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective &,. Of a metal step while changing a light bulb Chest is symmetrical with respirations decreased stress and improved coping have! Inhaler is Proventil identify lesions or masses she was last hospitalized for asthma in high school no in... Gastrointestinal physical Assessment lifespan look in the six cardinal fields without moving her head was!

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