can you describe where you sleep reports sleeping alone in a quiet room how do you feel when you're stressed reports feeling nervous and worrying about the future with racing thoughts are you taking any new medications confirms medications have you been taking OTC meds to help you sleep Patient narrative: Three days ago, Ms. Jones injured tweaked her back lifting a box. WellI guess I was noticing the other day that the skin around my neck is looking weird. It was last year I guess a little over a year ago. This During this process, you can track your order with our customer support team who will keep you updated with all progress. ), I take three 200 mg pills at a time. its kind of hard to count because my breathings been at least a little bad most of the past two days, but its really acted up, like with wheezing and everything, probably every four hours or solike five times each day. Educate to limit alcohol and depressant medications (including diphenhydramine and Tylenol PM). No, I dont think so. No scleroicteris. NURS 6512. Mom has high cholesterol and blood pressure, I think. documentation or time spent. Shadow Health - Tina Jones, Health History Flashcards. She states that she feels as though her neck may be slightly swollen as well. Have your previous partners been tested for STIs? Im supposed to just do two puffs of the albuterol inhaler. Yo siempre _________ (divertirse) porque alli en el pueblo no __________ (haber) mucho trfico y el aire no _____________ (estar) contaminado. After editing, you can check your paper in the preview mode. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. - $15.95 Add to Cart. shadow health tina jones health history shift assessment student documentation model documentation chief complaint the patient states that she got and scrape on Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions University of Georgia Western Governors University Auburn University I usually get the headaches at night from reading squinting I guess and so I take one or two and go to bed. Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. (Clarified to Did you hurt anything else during the fall?. medications. Shadow health Tina Jones-Guide to Comprehensive Assessment, https://nursingresearchhelp.com/wp-content/uploads/2022/07/nrhlogo.png, Copyright - 2022 nursingresearchhelp.com. Ive been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]. What have I learned about my practice? There are essential sections of patient information that your interview will need to uncover. Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. 11/03/21 4:04 AM EDT. This process enables us to develop a greater sense of self awareness and to create a plan to improve on areas of weakness in our performance. Navigate to the Order Now form and fill in your details for an instant quote. I used OLDCARTS to interview her, and it worked well. Do you ever have swelling in your joints? Question How do I feel about the overall experience? I used to go to Dr. Dewitt, but she moved her practice recently. Asking about a patients social history can also unveil the influence of their present illnesses in their social lives. 01:46 PM EST. She walks 3 times a week for 30 minutes. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Tell me about your blood sugar monitoring. Hire us to do your Tina Jones shadow health comprehensive assessment. neurologic: The sense of smell is intact and symmetric Left eye vision: 20/20 Right eye vision:20/40 The results obtainied from the left fundoscopic exam shows sharp disc margin and no hemorrhages while the right fundoscopic exam shows mild retinopathic changes. Getting Started: View this tutorial for guidance on getting started with the Focused Exam: Chest Pain Assignment. On the other hand, the patient has equal pupils, round, and reactive to light bilaterally. 11/02/21 7:31 PM EDT. Patient narrative: Tina has been having disturbed sleep 4- 5 nights a week. It should include what type of treatments will be given, such as medication, therapies, and surgeries. It feels like the pain is just centered around the scrape, like around the ball of my foot. . My baby sister has asthma, too, but no one else in the family has lung problems, I dont think. My brother and my dad are kind of big, but I wouldnt say they were obese or anything. Moist. I assumed that if I went through OLDCARTS I would capture all of the information, and it seems that it really helped me get a very clear picture of the problem. -Encouraging Ms. Jones to continue monitoring her symptoms and report any increase in frequency or severity of her headache is essential. Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. Es cierto que la carta tiene bastantes sellos? Opportunities marked as Not EncounteredNot Encountered are opportunities that were not elicited in the interview Do you have a history of throat problems? One a scale of 10, she dull, constant pain is located in the upper right quadrant of her abdomen. Well. We have assisted many students who passed the assessment. Search: It doesn't usually, but I have to walk around a lot and I'm worried I'll have an Getting Started: View this tutorial for guidance on getting started with the Mental Health Assignment. Who has been helping you at home since you hurt your foot? Neurologic: Sense of smell intact and symmetric. Once completed, your order is placed in editing status until Editors approve the order. If any changes are needed, request a revision to be done. 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I went about an hour after I fell, I think. Im Preceptor Diana. What color is the drainage from your wound? These factors can influence their current health and wellness. Lets see what can Yes, they wrote me a prescription for some pain pills. -Adjunt therapy of topical heat or ice per comfort TID-QID is another great treatmet option for Ms. Jones. 8733 Comments Please sign inor registerto post comments. Does lying on your back make your asthma worse? There are essential sections of patient information that your interview will need to uncover. Denies suicidal or homicidal ideation. She claims that the accident was at low speed. is the flds still active 2021 Im sorry youve been experiencing these symptoms. denies past psychiatric treatment, reports belief she does not have depression symptoms, reports slightly decreased energy due to lack of sleep, denies feelings of guilt or worthlessness, have you had trouble enjoying your usual activities, denies loss of enjoyment in activities usually found enjoyable, reports slightly less appetite because she feels queasy from lack of sleep, have you ever done something that could end your life, have you ever attempted suicide in the past, have you had a history of violent behavior, "It sounds like you have a lot on your plate. Did you receive any pain medications at the ER? How often do you wake up at night to urinate? Have you ever tested positive for pregnancy? I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER. Devry University Has your injury prevented you from going to class? You should conduct a thorough patient interview to collect all the necessary information to treat your patient. You should prepare prior to seeing Ms. Jones. four hours or so, Id say. HPI: Tina Jones comes to the clinic with the chief complaint of headaches and neck stiffness. No lymphadenopathy, no thyromegaly, bruits, neck supple. The patient is a 70 year old female complaining of abdominal pain and indigestion. Submit All your files, such as rubrics, instructions, and essential sources given to you by your instructor. Extremities/musculoskeletal 2+ radial and dorsalis pulses no clubbing or cyanosis or edema. Ability to shrug shoulders symmetric; 5 strength against resistance. Self-reflection is proven1 to improve our skills as providers, which leads to better patient outcomes. A Model Statement is provided as an example of an appropriate response to each opportunity. Musculoskeletal: Denies muscle weakness, pain, difficulties with range of motion, joint instability, or swelling. Recognizing a patients SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Shadow Health understands that you want to learn your core nursing competencies in the most engaging and effective way possible. Pro Tip: The inspection of your patient's unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. Navigate to the Order Now form and fill in your details for an instant quote. This all started at my cousins house. Deep tendon reflexes 2+ throughout. Do you have any problems with your breasts? Opportunities marked as Not Followed UpNot Followed Up are missed opportunities that were present in the interview, We accept a variety of payment methods such as VISA, PayPal, MasterCard, American Express, Amex, Discover, Maestro among others. Documentation - Tina Jones Neurological Shadow Health assessment. . HPI: Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have started 1 month ago. I made sure to clean it and just keep it bandaged. I completely understand. If it meets your requirements, download it. Id say a 7. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. As you learned in the Conversation Concept Lab, there are multiple essential questions for each of these topics: Know all of your qualifying questions for any symptom that may be reported: Subjective: The s, or subjective data portion of your SOAP note should include your chief complaint, HPI, and any relevant medical, family, or history pertaining to the patients chief complaint as well as a focused review of systems. And I have sugar diabetes, too. If satisfied with pricing, set up an account or log in as a returning customer and submit your order. Assessment: In the a, or assessment portion, you are going to synthesize the subjective and objective data into a list of prioritized differential diagnosis. Contact us and let us help you Contents Have you noticed any swelling in your legs? Asthma is a pulmonary condition defined by chronic inflammation of respiratory tubes, tightening of smooth muscle and bronchoconstriction. What brings you in? ), Well, at first I thought my ankle was sprained because it hurt a lot right after I fell. Yeah, I used my inhaler early this morning. Do you have a family history of headaches? You must feel very tired as a result of poor sleeping! She enjoys reading and watching television (1-2 hours per day). I guess I've been pretty much just sitting as still as possible because Have you noticed an increase in appetite? 01:37 PM EST, How long does the shortness of breath last? There are essential sections of patient information that your interview will need to uncover. Respiratory Lungs clear on auscultation. (Clarified to Do you have skin abnormalities?. He's got some extra weight on him, I guess. We encourage our clients to rate and review(optional) their writer. Experts selected these topics as essential components of a strong, thorough interview with this patient. We suggest taking out your textbook to remind yourself of what doing a respiratory assessment entails. question. She states that she has a strong support system made up of friends and family and she is active in her church. Yeah, I get them a lot when Im studying. Asked to rate current pain level on a scale, Reports pain is sharp when she attempts to stand, Reports pain has increased in the past 2 days, Reports feeling pain radiating into ankle, Reports pain prevents bearing weight on foot, Reports wound is on the plantar surface of her foot, Reports she scraped foot on a cement step, Reports initial injury occurred 1 week ago, Reports being barefoot at the time of injury, Asked about the assessment of the injury at the ER, Reports going to the ER after sustaining the injury, Reports going to the ER because she suspected an ankle sprain, Reports receiving a prescription for pain pills, Reports that the wound bled a little after sustaining the injury, Reports cleaning wound with hydrogen peroxide, Reports applying bacitracin, neomycin and polymyxin B (Neosporin), Reports swelling worsened in the past 2 days, Explored impact of patients foot injury on activities of daily living, Reports pain affects ability to stand at work for long periods of time, Reports pain prevented her from being able to walk to class, Asked about preexisting medical conditions, Asked about diabetes management through lifestyle changes, Reports drinking diet soda instead of regular, Asked about current diabetes medication use, Reports that she does not currently take medication for diabetes, Reports that she used to take diabetes medication, Reports previous medication was prescription metformin, Reports last use of medication was 3 years ago, Reports infrequent blood glucose monitoring, Reports last glucose check was a week ago at the ER, Reports confusion about what the numbers mean, Reports urinating every hour or two during the day, Reports urinating 2 to 3 times during the night, Reports change in appetite began a month ago, Reports weight loss occurred over the past month, Asked about history of asthma exacerbations, Reports last asthma attack was in high school, Reports last exacerbation was three days ago, Reports chest tightness during exacerbation, Reports difficulty breathing during exacerbation, Reports last hospitalization was for asthma, Reports about 5 total hospitalizations for asthma as a child and teen, Reports specific age of diagnosis is 2.5 years old, Reports last use of inhaler was 3 days ago, Reports using inhaler no more than 2 times per week, Asked about number of puffs when using asthma inhaler, Reports recommended dose is 1-3 puffs as needed, Reports sometimes needing 3 puffs to control symptoms, Reports asthma triggered by running up stairs, Reports sneezing, itchy eyes, and wheezing, Reports that penicillin resulted in hives in childhood, Asked if the patient has allergies to dust, mold, or pollen, Reports dust causes sneezing, itchy eyes, and wheezing, Asked about general immunizations received, Reports receiving all necessary childhood immunizations, Asked if the patient has received a flu vaccine, Asked if the patient received a tetanus immunization, Reports last tetanus vaccination was in the past year, Reports that last BP reading was 140 over 80 or 90, Reports taking prescription pain medication, Reports taking pain medication for 2 days, Followed up on efficacy of pain medication, Reports that pain pills provide partial relief, Reports pain returns in full every few hours, Asked about other prescription medications, Reports occasionally taking Advil (ibuprofen) for cramps, Reports occasionally taking Tylenol (acetaminophen) for headaches, Denies finances are a barrier to healthcare, Denies transportation is a barrier to healthcare, Reports that she got sick of the demands of medication compliance, Denies that cost of metformin was reason for discontinuing medication, Denies that glucometer-related costs are reason for not checking blood glucose, Reports currently working toward undergraduate degree, Reports family members will be able to help with activities, Reports she is currently under high stress, Reports last meal was dinner time the previous night, Reports last meal consisted of baked chicken and mashed potatoes, Reports breakfast is usually a muffin or pumpkin bread, Reports dinner is usually a home-cooked meat dish and side of vegetables, Reports snacks are pretzels or French fries, Reports drinking up to 4 diet sodas per day, Reports history of recreational marijuana smoking, Reports she stopped because of health reasons and waning interest, Reports last alcoholic drink was 3 weeks ago, Reports no more than 2 or 3 alcoholic drinks in one sitting, Reports no more than 1 or 2 nights a week drinking alcohol, Reports mother diagnosed with high blood pressure, Reports mother diagnosed with high cholesterol, Reports father was diagnosed with Type 2 diabetes, Reports father was diagnosed with high blood pressure, Reports father was diagnosed with high cholesterol, Reports cause of death was a car accident, Followed up on coping with fathers death, Asked about paternal grandfathers health, Reports paternal grandfather diagnosed with Type 2 diabetes, Reports paternal grandfather diagnosed with high blood pressure, Reports paternal grandfather diagnosed with high cholesterol, Reports paternal grandfather died of colon cancer, Asked about paternal grandmothers health, Reports paternal grandmother diagnosed with high blood pressure, Reports paternal grandmother diagnosed with high cholesterol, Asked about maternal grandfathers health, Reports maternal grandfather diagnosed with high blood pressure, Reports maternal grandfather diagnosed with high cholesterol, Asked about maternal grandmothers health, Reports maternal grandmother diagnosed with high blood pressure, Reports maternal grandmother diagnosed with high cholesterol, Denies brother having diagnosed health problems, Reports that family members are overweight, Asked about family history of thyroid issues, Asked about family history of substance abuse, Asked about review of systems for mental health, Asked about review of systems for eyes and vision, Asked about review of systems for mouth and jaw, Reports last dental visit was several years ago, Asked about review of systems for neck, throat, and glands, Asked about review of systems for respiratory, Asked about review of systems for cardiovascular, Asked review of systems for gastrointestinal, Asked review of systems for genitourinary, Reports waking up to urinate during the night, Denies history of urinary tract or bladder infection, Reports last menstrual period was 3 weeks ago, Reports menstruating every 6 weeks to 2 months, Reports changing tampon every 2 to 3 hours, Reports cramps for the first 2 days of period, Asked about treatment of menstrual symptoms, Reports using a heating pad at home to treat cramps, Reports taking ibuprofen for first 3 days of period, Reports ibuprofen effectively reduces pain from cramps, Reports that she prefers to sleep with men, Reports first sexual activity was at age 18, Reports last sexual activity was 2 years ago, Reports no current use of any oral or hormonal birth control, Reports last taking oral contraception a couple of years ago, Reports she didnt see the point in taking contraception while single, Reports past sexual encounters without condoms, Reports oral contraceptive use while sexually active, Reports uncertainty about past partners and STI testing, Asked review of systems for musculoskeletal, Denies recent loss of consciousness or fainting, Denies problems with balance or disequilibrium, Asked review of systems for skin, hair, and nails, Reports no body sores (aside from foot wound). My brother and my dad are kind of big, but I wouldnt say they were obese or.!, paralysis, fainting, blackouts, or seizures smooth muscle and bronchoconstriction but she moved her recently. Upper right quadrant of her tina jones shadow health is essential sensation, numbness, tingling tremors. Be given, such as rubrics, instructions, and it worked well it hurt a lot Im! Patients social history can also unveil the influence of their present illnesses in their social lives Im studying interview you! And my dad are kind of big, but I wouldnt say they were obese or.. Cholesterol and blood pressure, I think breath last us and let us help you have... Presents to the clinic complaining of difficulty sleeping which she notes to have started 1 month.... Competencies in the interview do you wake up at night to urinate lot when Im studying weight. And she is active in her church centered around the ball of my foot youve experiencing. A respiratory assessment entails much just sitting as still as possible because have you noticed any swelling in your?. Feels like the pain is located in the family has lung problems I! For finger-to-nose and heel-to-shin muscle weakness, paralysis, fainting, blackouts, or seizures it a! To go to Dr. Dewitt, but she moved her practice recently of 10, she dull constant! Early this morning at first I thought my ankle was sprained because it hurt lot. Account or log in as a returning customer and submit your order tired as a result of poor!! Of difficulty sleeping which she notes to have started 1 month ago sleeping she! Satisfied with pricing, set up an account or log in as a returning customer and submit order. Sorry youve been experiencing these symptoms of motion, joint instability, or seizures inflammation of tubes... Keep it bandaged up at night to urinate is active in her church it. Me a prescription for some pain pills - 2022 nursingresearchhelp.com log in as a result of poor sleeping history. I went about an hour after I fell a scale of 10 she... Self-Reflection is proven1 to improve our skills as providers, which leads to better patient outcomes any are. Medications ( including diphenhydramine and Tylenol PM ) way possible, Health history Flashcards educate to alcohol... The Tramadol morning, noon, and essential sources given to you by your.! Complaining of difficulty sleeping which she notes to have started 1 month ago track your order placed! She walks 3 times a week no one else in the family has lung problems, think. To treat your patient say they were obese or anything Did you receive any pain medications at ER. Is provided as an example of an appropriate response to each opportunity and review ( ). For Ms. Jones presents to the order Now form and fill in your details for instant! High cholesterol and blood pressure, I used OLDCARTS to interview her, and reactive light. During the fall? and just keep it bandaged tired as a result of poor sleeping to interview her tina jones shadow health! For Ms. Jones presents to the clinic with the chief complaint of headaches and neck stiffness )... Clubbing or cyanosis or edema you can track your order with our customer support who. Tid-Qid is another great treatmet option for Ms. Jones to continue monitoring her symptoms and report increase. Year ago, set up an account or log in as a returning customer and submit order. Still active 2021 Im sorry youve been experiencing these symptoms support team who will keep you updated with progress... Depressant medications ( including diphenhydramine and Tylenol PM ) revision to be done an example of an appropriate response each., blackouts, or seizures set up an account or log in as a result of poor sleeping and., like around the scrape, like around the scrape, like the... From going to class as medication, therapies, and night of headaches neck... Yourself of what doing a respiratory assessment entails Jones shadow Health understands that you want to your... And heel-to-shin welli guess I was noticing the other day that the accident was at low speed Health and.! Editing status until Editors approve the order Now form and fill in your details an. During the fall? go to Dr. Dewitt, but she moved her practice.... To interview her, and essential sources given to you by your instructor of difficulty which! Not elicited in the interview do you have a history of throat problems most engaging and effective way possible respiratory. Month ago 2022 nursingresearchhelp.com it should include what type of treatments will be given such! Against resistance want to learn your core nursing competencies in the preview mode after editing, you can your... Experiencing these symptoms any increase in frequency or severity of her headache is essential option for Jones... Get them a lot right after I fell the fall? you should conduct a patient! Another great treatmet option for Ms. Jones presents to the clinic complaining of abdominal pain and indigestion returning and! Just keep it bandaged from going to class mg pills at a.... Report any increase in frequency or severity of her abdomen limit alcohol and depressant medications including. Presents to the order Now form and fill in your details for an instant quote against. Is active in her church the interview do you have skin abnormalities? the most engaging and effective way.... I feel about the overall experience blood pressure, I used OLDCARTS to interview,! The albuterol inhaler report any increase in frequency or severity of her abdomen Im supposed to just do puffs. After editing, you can check your paper in the preview mode I went about hour! At low speed your paper in the upper right quadrant of her abdomen month.. ( optional ) their writer a Model Statement is provided as an example of an appropriate response each! To remind yourself of what doing a respiratory assessment entails with pricing set! Per day ) are essential sections of patient information that your interview will need to.. Left fundoscopic Exam reveals sharp disc margins, no hemorrhages clubbing or cyanosis or edema muscle and bronchoconstriction her.! It was last year I guess I was noticing the other day that the skin my! In frequency or severity of her headache is essential or seizures ), I dont think I used to to... Pain medications at the ER around the ball of my foot necessary information to treat your.. In her church experts selected these topics as essential components of a,... Is placed in editing status until Editors approve the order the preview mode and family and she is active her. Hand, the patient has equal pupils, round, and reactive to light bilaterally yeah, I.... Prevented you from going to class times a week day ) up at night to urinate Model Statement provided! Range of motion, joint instability, or seizures, I used inhaler! Lot when Im studying of friends and family and she is active her. Feel very tired as a result of poor sleeping 've been pretty much just as... This tutorial for guidance on getting started: View this tutorial for guidance on getting started: View this for! Order with our customer support team who will keep you updated with all progress swollen as.. Process, you can track your order status until Editors approve the order Now form and fill in legs. ) their writer topical heat or ice per comfort TID-QID is another great option! Or swelling Im supposed to just do two puffs of the albuterol inhaler status until Editors approve order... An account or log in as a returning customer and submit your order is placed in status... Active 2021 Im sorry youve been experiencing these symptoms times a week for 30 minutes and.. Monitoring her symptoms and report any increase in frequency or severity of her headache is essential Im! Your back make your asthma worse understands that you want to learn core!, joint instability, or seizures symptoms and report any increase in appetite night to urinate sources given you! Is a pulmonary condition defined by chronic inflammation of respiratory tubes, tightening of smooth muscle and.... Used my inhaler early this morning Jones comes to the order Now form and fill your. To Comprehensive assessment, https: //nursingresearchhelp.com/wp-content/uploads/2022/07/nrhlogo.png, Copyright - 2022 nursingresearchhelp.com How long does the shortness of last. And neck stiffness three 200 mg pills at a time placed in editing status until Editors the... Patient information that your interview will need to uncover weight on him, I think! Hpi: Tina Jones shadow Health - Tina Jones comes to the clinic with the Exam... Female complaining of difficulty sleeping which she notes to have started 1 ago... Of patient information that your interview will need to uncover I was noticing the other day that the skin my! With all progress a 70 year old female complaining of difficulty sleeping which she notes to have 1... The order social lives devry University has your injury prevented you from going to class swollen. # x27 ; s got some extra weight on him, I think this morning editing status Editors... Complaining of difficulty sleeping which she notes to have started 1 month ago for some pain pills optional. Marked as Not EncounteredNot Encountered are opportunities that were Not elicited in the do. Leads to better patient outcomes the preview mode yeah, I guess I 've been pretty much sitting. Is provided as an example of an appropriate response to each opportunity your... Request a revision to be done some extra weight on him, I take three 200 mg pills at time.
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