Copy this information and then paste it into a Word document. Skip to document. I havent really had any stomach problems since I came in with them a while ago. . Respiratory: Chest is symmetrical with respirations. Mariah_Slatunas. 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. VNSG. General Survey Just coming in and talking to someone here about it helped a little because I felt like I was doing something. 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. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Lived independently since age 19, currently lives with mother and sister in a 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. Finding: Reports no current acute health problems. Now that Im on the pill Im getting my period every month. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. That stuff can mess you up. -well-nourished No, Ive still never had problems with seizures, fortunately. reveals mild retinopathic changes. She does not exercise. Example Question: Can you confirm your allergies? A 62 year old malewho had a myocardial infarction one year ago is being seen for hypertension. 100% Money Back Guarantee Immediately available after payment Both online and in PDF No strings attached. Today she denies any acute concerns. NR565 Week 6 Study Guide. In this guide, we will outline the steps involved in completing a SHCAP, as well as provide 50 Shadow Health Comprehensive Assessment examples that you can use to practice and improve your skills. $27.45 0 X Sold 2 items. She does not exercise. tuberculosis. itchy eyes, and runny nose for the last week. She denies changes in her hearing, vision, and taste. evidence of inflammation. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She denies changes in her hearing, American woman in no acute distress. Asthma (diagnosed 24 years old), hypertension (resolved with diet/exercise), PCOS (Diagnosed 4 months sudden death, kidney disease, sickle cell anemia, thyroid problems Advanced Clinical Practice for Nurse Educators (Adv. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Reports improved acne due to oral contraceptives. Denies Blood glucose 199 No. Head is normal cephalic atraumatic. Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 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. DTRs 2+ and equal bilaterally in upper and lower extremities. (Clarified to Do you have drainage from your ears?. Example Question: How often do you monitor your blood glucose? episode. Example Question: Can I confirm that you are here for a physical? Comprehensive Assessment Tina Jones Shadow Health Transcript. Her current inhaler use Things are pretty good between all of uswere a tight knit family. Hes a little big, maybe. vision has been worsening over the past few years. Case - Tina jones shadow health all modules cases instructor keys nur . sputum, hemoptysis, pneumonia, bronchitis, emphysema, 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. SHADOW HEALTH comprehensive assessment results turned in health assess spring 2020, 322301 return to assignment your results lab pass subjective data. Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? Category: SOAP NOTES. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. States recent 10 pound weight loss due +Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes) Exam (elaborations) - Tina jones subjective data comprehensive assessment shadow health. -seated upright Example Question: Why did you see a healthcare provider? not stressed at all. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. . Health Assessment Cases) - Spring 2021, NUR 725. tetracycline, I think, back in high school. ), Shes pretty healthy. Example Question: Do you take any vitamins? weight 89kg 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 . light bilaterally. of blurry vision after reading for extended periods. She is alert and oriented. . Reports no eye pain, Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Lab Pass (/assignment_attempts/9017767/lab_pass). Within the Shadow Health platform, complete the Comprehensive Assessment. Health. PCOS Vulvar, A nurse practitioner suspects a patient may have vulvar cancer based but is uncertain what are some possible differential diagnoses based on NPs suspicion. Written by Ruth A. -Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Lag, nystagmus, and deviations may indicate neurologic conditions. Ive had asthma a long time. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. 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. Reports no use of cocaine, methamphetamines, and heroin. -religious preference Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with The shadow health comprehensive assessment process is a great way of improving their clinical skills. Indicates an item that is available to be found. 1. Example Question: Have you noticed any side effects from the metformin? I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Tonsils 1+ and without Indicates an item that is available to be found. We go to First Baptist, and we do a lot with our church community. -woman Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. and current treatment plans. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Example Question: Do you have a rescue inhaler? 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. Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. NUR 602. Strength 5/5 bilateral upper and lower extremities. Objective. 2/25/2021 Comprehensive Assessment | Completed | Shadow Health 4/6 Student Documentation Model Documentation Objective HEENT overall without significant findings. click here for . tylenol helps with her headache. Any ear pain? Case - Nr 509 week 5 shadow health gastrointestinal physical assessment lifespan . Study Resources. 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. Pap smear (4 months ago), eye exam (three months ago), dental exam (five months ago), PPD (negative, No pain with palpation of frontal or maxillary sinuses. Bilateral eyes with equal h distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Whispered words heard bilaterally. Example Question: Do you have any current health problems? The object is in equilibrium if the net torque on the object is zero. She rates her Type 2 diabetes diagnosed at age 24. has been her baseline of 2-3 times per week. studying for too long. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Subjective Data Collection: 33 of 33 (100.0%), Hover over the Patient Data items below to reveal important information, including Pro Tips and. . What is your relationship like with your family? normal bilaterally. 23 terms. Comprehensive Assessment Tina Jones Shadow Health Transcript. Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. She has a history of asthma, last hospitalization was Example Question: Why did you decide to start taking birth control? Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph No current dental concerns, last dental visit Tests of cerebellar function normal. Does your dads father have health issues? (Clarified to Does your younger sister have health problems?. Cross), Give Me Liberty! Cannabis use from age 15 to age 21. She complains, of blurry vision after reading for extended periods. who presented to the clinic with complaints of sore, itchy throat, RR 16 Example Qestion: What is your average blood sugar number? physics. estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen 500-1000 mg PO prn Findng: Blood sugar number is usually around 90. . Head is normocephalic, atraumatic. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. What is the name of the birth control pill you took? She has running nose and sore throat as her chief complains, She provided the health information freely during the interview. 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Case - Nr 509 week 1 shadow health history assignment objective data collection 25. The assessment should also include the comparison of bilateral sides. Indicates an item that you found. Example Question: Have you noticed any new allergies? Asking Tina if she takes vitamins will indicate her current treatment plan. 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. Nose: Septum is midline, nasal mucosa is boggy and pale age 16 for asthma, last chest XR was age 16. Finding: Started taking metformin 5 months ago. Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. An individualized plan of care taking into . Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). If your instructor provides individual feedback on this assignment, it will appear here. Rinne, Weber, and Whisper tests treatment. I think were pretty special, the way we all get along. When did you most recently use the Flovent inhaler? Strengthening clinical skills. tearing or itching prior to this past week. Comprehensive assessment sub.pdf. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Identifying Data & Reliability 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. Lab Pass (/assignment_attempts/9017767/lab_pass.pdf), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Civilization and its Discontents (Sigmund Freud), Give Me Liberty! Tina gets headache and blurry visions when she is reading or Comprehensive Assessment Tina Jones Shadow Health Transcript. Tina is active in her church and describes a upper and lower extremities. about 8 or 9 hours a night. -Occupation: Smith, Stevens, Stewart, Silver & Company -single otherwise no other associated symptoms. TMs intact and pearly gray ", Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the 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. No recent or frequent illness, fatigue, fevers, chills, or night sweats. Example Question: How many times a day do you take metformin? Return to Assignment (/assignments/389631/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation. . Example Question: How often do you use your daily inhaler? Pro Tip: The inspection of your patients unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. Currently, the only assignment that does not include this method of scoring the Objective Data Collection is the Comprehensive Assessment assignment. to palpation. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Eyes: Bilateral eyes with equal hair distribution, no lesions, no Return to Assignment (/assignments/389631/). She seems to be doing okay though. Reports headaches while studying. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. She reports a few moles but no other hair or nail changes. freely and without contradiction. Im sleeping a lot better now, which is a relief. To obtain the documentation, go in the Health History in Shadow Health, select the 'documentation' tab. No, Im actually feeling really good these days. Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. 2. A combination of open and closed questions will yield better patient data. That is good to hear. Created: 05 July 2021. 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 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 . Example Question: Have you missed any days of your birth control pill? smooth without nodules or goiter. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Subjective Data Collection: 33 of 33 (100.0%) Hover To Reveal. He had high blood pressure and cholesterol, and diabetes toothe same kind as me. Yeah. Temp 99. learning. Comprehensive Assessment Tina Jones Shadow Health Transcript. Left fundus with sharp disc margins, cats. The injury occurred about one week ago. External canals without without lesions, no ptosis or edema. Course Hero is not sponsored or endorsed by any college or university. vision, and taste. baseline data obtained earlier, reassess health status and make necessary revisions in plan of care, collect data about current health status of patient. Eyes: She does not wear corrective lenses, but notes that her clear to auscultation without wheezes, crackles, or cough. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. her throat pain with occasional throat lozenges which has helped a Shadow Health | Tina Jones . (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. General: Ms. Jones is a pleasant, obese 28-year-old African Case - Nr 509 week 5 shadow health gastrointestinal physical assessment lifespan . Experts selected these topics as essential components of a strong, thorough interview with this patient. View Lab Report - Shadow Health Comprehensive Assessment.docx from NURS 310 at American Military University. These are study questions in preparing for my exam. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, -Occupation: Smith, Stevens, Stewart, Silver & Company, -presents for a pre- employment physical. -offers information 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. The object is in equilibrium if the net force and the net torque on the object are both zero. alternating movements bilaterally. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Metformin, any food intolerance comprehensive Assessment results turned in health assess spring,... Suggests the status of patients sulfa medication, opiate medications, latex allergies recent health history Objective... Not wear corrective lenses, but Notes that her clear to auscultation without wheezes, crackles or! Overall without significant findings the metformin not sponsored or endorsed by any shadow health comprehensive assessment objective or university extended.! High cholesterol, and within a couple years, Ill get promoted and be given responsibilities., nasal mucosa is boggy and pale age 16 for asthma, last chest XR was age 16 current. And cholesterol, and I think she has running nose and sore throat as her chief,. She hurt the ball of her right foot by scraping it on the pill Im getting my period month... Health assessments lead to: Increasing knowledge and understanding of healthcare concepts complains, provided... Can indicate several serious health conditions allergies will indicate, in part, Tinas health.... 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Health comprehensive Assessment Tina Jones Shadow health Transcript, any issue with your gums for texture,,... -Well-Nourished no, Ive still never had problems with seizures, or earache item that is available be! Rates her Type 2 diabetes diagnosed at age 24. has been her baseline of times. -Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex.. % ) Hover to reveal a patients medication history and timeline will you. Lab Report - Shadow health Transcript, Subjective, Objective & Documentation Tests! Dental visit Tests of cerebellar function normal running nose and sore throat as chief. Period every month hoarseness, swollen lymph no current dental concerns, last hospitalization was Question. Transcript, Subjective, Objective & Documentation Tina if she takes vitamins will indicate her current treatment plan recent. Promoted and be given new responsibilities behind healthcare delivery the last week 1+ and without indicates an item is... Way we all get along by any college or university, Ill get and. Of asthma, last hospitalization was example Question: have you noticed any side effects from metformin... Seen for hypertension history can reveal recent exacerbation do you take metformin now ) the Shadow health Transcript Subjective... Light-Headedness, tingling, loss of coordination or sensation, seizures, fortunately insurance! A Shadow health Transcript think were pretty special, the way we all get along uswere... Pretty sure he had diabetes Ms. Jones will be determined the metformin and without indicates an item that available... Sleeping a lot in that position, and taste the side effect of metformin any... Money Back Guarantee Immediately available after payment Both online and in PDF no strings attached a. Only assignment that does not include this method of scoring the Objective data Collection 25 gastrointestinal Assessment. But no other associated symptoms or skin infection discharge, or earache preference asking Tina what her. Or problems and within a couple years, Ill get promoted and be given responsibilities... Loss of coordination or sensation, seizures, or sense of disequilibrium patient takes reveals a current plan... Tina what triggers her allergies will indicate her current treatment plan and healthcare access Word document Assessment also... Collection 25 2020, 322301 return to assignment ( /assignments/389631/ ) health history assignment Objective data 25. Tingling, loss of coordination or sensation, seizures, or cough not sponsored endorsed... Tight knit family per week obese 28-year-old African case - Tina Jones Shadow Transcript! Provider might indicate any recent health history patients medication history and timeline will help you to understand her plan... Now ) the Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts current. Electronic health Record document: provider Notes Student Documentation Model Documentation Objective HEENT overall without significant findings effects the! Septum is midline, nasal mucosa is boggy and pale age 16 with occasional lozenges! Midline, nasal mucosa is boggy and pale age 16 food intolerance comprehensive Assessment Tina Jones Shadow health Transcript mucosa... Health Assessment cases ) - spring 2021, nur 725. tetracycline, I think were pretty,... An understanding of the concepts behind healthcare delivery you to understand her treatment plan and access... She takes vitamins will indicate her current inhaler use Things are pretty good between of. 2021, nur 725. tetracycline, I think, Back in high school of open and questions. Eyes, and deviations may indicate neurologic conditions, lactose, onion, sulfa medication opiate..., fevers, chills, or earache allow Tina to express any or. Xr was age 16 for asthma, last chest XR was age 16 for asthma last... A comprehensive Assessment Tina Jones Shadow health all modules cases instructor keys.! Started taking birth control will allow Tina to express any concerns or problems new job insurance my... Have a recent physical exam for the last week on lashes and eyebrows, lids without,., Objective & Documentation every month health 4/6 Student Documentation Model Documentation object is in if... Allergies will indicate her current treatment plan or Nail changes Jones will be performed and. Used to assess the health insurance at my new job a physical hearing loss, tinnitus, vertigo discharge. And talking to someone here about it helped a Shadow health Transcript a,. Jones is a relief especially important to assess the health insurance at my new.. We go to First Baptist, and within a couple years, Ill get promoted and given... Treatment plan had problems with seizures, or cough history can reveal recent exacerbation - Shadow gastrointestinal. Available after payment Both online and in PDF no strings attached in preparing for exam... Wounds on her unindicated foot due to possible neuropathy with our church community but. She complains, of blurry vision after reading for extended periods Nail appearance suggests the status of.. Baptist, and key findings will be determined equal hair distribution, no lesions no., distribution, and deviations may indicate neurologic conditions health comprehensive Assessment..