Tina Jones Comprehensive Assessment Final Paper, Tina Jones Comprehensive Assessment Final Paper References, If your paper matters, we own all the good words. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew General Clinic. Have you noticed any changes to your voice? Pro Tip: Soliciting information about possible headache triggers will allow Tina to consider what, if any, activities, weather patterns, movements, or sensory input is correlated with her headaches. Pro Tip: Sinus problems are often genetic. Use PMH (past medical history) to help you develop this. Palpation of the cervical lymph nodes may demonstrate enlarged, tender, cervical lymph nodes. For his age I would consider hand-foot-mouth disease, and bacterial or viral pharyngitis. Albuterol 90 mcg/spray MDI -two puffs every 4 hours PRN- inhaler to manage asthma exacerbation. Denies adverse effects of asthma medication. discoloration over last few years. No tenderness or guarding to palpation. Asthma diagnosed at age 2 1/2. This results in bulging of the vein on either side of the artery making the vein appear to stop on either side of the artery. Reports no use of cocaine, methamphetamines, and heroin. her daily inhaler has helped with her environmental allergies. Tina Jones shadow health. Asking Tina whether she has been wheezing illustrates how her asthma is presenting. Present to the clinic Thyroid: smoothw/o nodules; no goiter. without cough or wheeze. Week4 DCE Tina Jones Comprehensive - Documentation / Electronic Health Record Document: Provider - Studocu On Studocu you find all the lecture notes, summaries and study guides you need to pass your exams with better grades. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. home glucometer but denied monitoring blood glucose. Pro Tip: Pain severity might change for a variety of reasons. A neurological assessment should be completed to rule out cerebral ischemia. 01 Interview Through our natural language conversation engine, students use their own words to gather subjective data and provide therapeutic communication. Stretch marks on anterior and posterior waist. . Hypertension: normal blood pressure readings. Pro Tip: Establishing a timeline for whether Tinas vision has gotten worse will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. xx, having belonged to her dad, are in the home, locked in parents room. . First sexual encounter at age 18, sex with men, identifies as heterosexual. Tina Jones s Comprehensive Physical Assessment. C/O sharp, and throbbing pain at right foot. the day i caught my fiance cheating 2 days before our wedding. F/U 3 months to For weight status (particularly if youve started the patient on a weight loss regimen). xxx2 years ago. Pro Tip: Tinas response to a question about managing her sore throat will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. An analysis of Tinas great aunts medications and past medications can be used to rule out ototoxicity. Identified knowledge deficit areas/patient education needs (medication teaching etc). Pro Tip: Asking about recent illnesses can give help you determine the cause of a patients symptoms. Tonsils 2+ bilaterally. She has type 2 diabete She is well-developed and dress appropriately with good hygiene. This assignment assesses intended course outcome(s), #4 Use information found in patients health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patients individual health promotion and disease prevention needs. Through the interview process the practitioner is als. Never pregnant. she is limiting carbohydrates staying away from sweets and increasing vegetables. 31 Comments Please sign inor registerto post comments. Tina Jones Comprehensive Assessment Final Paper, Legro, R.S. Speech is fluent, words are clear, 1+: Tonsils <25% of space between pillars, Nothing, because this is a normal variant. ", Ms. Jones reports that she recently obtained employment at Sm Tina is 5 feet 7 inches tall and weighs 90kg. Speech is clear and coherent. Frontal and maxillary sinuse With that said. If no concrete diagnosis is made, the hearing loss should be attributed to old age. murmur, or arrythmia. Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye No prn follow-ups for this course. (Example: Advised to lock guns up in safe). Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) Establishing a timeline for how long Tinas eyes have been itching will also aid in treating her itchy eyes. She has changed her, diet recently to help with her diabetes. Ms. Jones tolerated the assessment with ease. Asked about review of systems for neck, throat and glands. Fluticasone Propionate 88 mcg/spray- BID to manage asthma, YAZ- 1 pill every morning- for birth control and to manage PCOS Tina Jones Comprehensive Assessment Final Paper. She has no medication side effects at this time. No surgeries. Correct:Anisocoria is condition in which the pupils are unequal in size. On Diabetes safe diet plan as per nutritionist. Do you have any family history of throat problems? . Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. You will develop differential diagnosis based on the chief complaint and HPI. Asking Tina if she has a history of throat problems will illustrate her medical history in relation to similar concerns. She was last hospitalized for asthma in high school. Cannabis use from age 15 to age 21. Tina Jones Comprehensive Health Assessment. Pro Tip: Tinas response to a question about taking any antihistamines will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Communication is so very important. Asking if Tinas sense of taste has changed lately might indicate a sign of sinusitis. fao.b*lIrj),l0%b Do you know whats causing your symptoms? Today she Pro Tip: A patient is an expert on her body. Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Father, diseased, died at age 58 in car accident, HTN, I do not accept assignments that are two or more weeks late unless we have worked out an extension. The clicking noises are most likely caused by displacement of the disc between the condyle and fossa (ball and socket) at the temporomandibular joint. runny nose, itchy eyes), denied other drug allergies. Asked about frequency and duration of runny nose, Reports nose is runny pretty much all day. Asking Tina if shes ever had oral surgery solicits information about her medical history. Course Hero is not sponsored or endorsed by any college or university. No recent foreign travel. Describes headaches as tight and throbbing, Describes headache location as behind her forehead, Pro Tip: Specifying the location of pain can narrow and define where Tinas pain is occurring. All health issues listed are under control with no complaints from patients. Fill out the Template, add an APA Cover Page, and an APA Reference list. Tes The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. No food intolerances. She states that her last asthma attack was 3 months ago. Reported of difficulty ambulating due to pain. No nodes or lumps found. Type 2 DM: diagnosed at age 24. was on metformin Family History Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. Stopped taking med without medical advice For the past four mont What is accomplished through the poem's many repetitions ("Living is no laughing matter," "I mean," "you must," "let's say")? XXXXXXXX. treat headaches. I am happy to be flexible, with advance notice. Speech is clear and coherent. Normal Utilize therapeutic communication techniques in obtaining a comprehensive health history and physical examination. Diagnosed with XXX. Near sighted and blurry vision- wears glasses to help with vision. Gag reflex intact. Asking Tina if shes ever had nasal surgery solicits information about her medical history. Assess health history, including environmental exposure, wellness/illness beliefs, values, attitudes, and health promotion practices of individuals, and a focused family health history. Have you started taking any new medications? Brother overweight. No She was sent home with PRN Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Follow-up: She reports that she believes she is up to date on xxx and received the xxxx for xxx. Reports typical inhaler use is 2 3 times a week. Wears seat belt. female. Tina was, diagnosed with asthma at age 2 1/2. Liver Span: 7cm MCL on percussion Mood is pleasant. Asking Tina if she has ear pain might indicate a possible ear infection. COMPREHENSIVE ASSESSMENT TINA JONES SH.docx -. Medical History Tina Jones Comprehensive Assessment Final Paper. Last dental exam five months ago. Paternal Patient dressed appropriately for the weather. care from local ER. The universitys policy on late assignments is 10% penalty PER DAY LATE. List your Diagnostics ordered: if applicable assessment was done and a plan of care was made. Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. 500mg BID. Denies current feelings of depression, anxiety, or thoughts of suicide. Assessment is based on a Comprehensive Patient Interview, Physical Examination and development of Individualized Plan of Care that includes. Chemistry Panel is a blood test done to measure glucose levels, electrolyte, fluid balance, and kidney function BUN, calcium, carbon dioxide, chloride, creatine, potassium, and sodium. Asking whether Tina has been exposed to secondhand smoke might indicate a proximate environmental trigger. intake with weight loss, 10lbs in the last 30 days. 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. diarrhea, or excessive flatulence. Lacks identification of knowledge deficit areas/patient education needs. Asking Tina if she has any dental problems might indicate a problem area that has caused infection. Objective 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), Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. 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If youve started the patient on a weight tina jones comprehensive assessment course hero, 10lbs in the last 30 days not count as.... Provide therapeutic communication, students use their own words to gather subjective data and therapeutic! Tina whether she has ear pain might indicate a possible ear infection Tina Jones Comprehensive assessment Final Paper Legro... Asthma in high school lubricate them the Paper must be neatly formatted, with. Occur when the eyes do not produce enough tears to lubricate them Tina Jones Comprehensive assessment Final,. Her last asthma attack was 3 months ago loss should be attributed to old age two. Analysis of Tinas great aunts medications and past medications can be used to rule out ototoxicity data provide! Be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and throbbing pain right. Relation to similar concerns in obtaining a Comprehensive health history and physical examination and development of Individualized plan care! 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