shadow health tina jones comprehensive assessment subjective data

Finding: Denies current wheezing (Available)Pro Tip: Patients who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint. Example Question: What is the dose of the pain medication? Finding: Reports maternal grandmother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance. Finding: Asked about review of systems for mouth and jaw. Finding: Asked about patient’s living situation. "I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. "I have a monitor at home, but to be honest I don’t really use it that often." Finding: Reports occasionally taking ibuprofen for cramps (Available)Pro Tip: Finding out about your patient’s use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions. 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. Example Question: Do you lose your balance often? Tina Jones: Some of my friend’s smoke when we go out drinking. Tina Jones: I have a monitor at home, but to be honest I don’t really use it that often. Example Question: Were you wearing shoes when you fell? Finding: Reports last dental visit was several years ago (Available)Pro Tip: Asking about a patient’s dental care is one possible component of a review of systems interview. Finding: Asked if the patient has received a flu vaccine. Student: What are my objectives in this assessment? Finding: Reports ibuprofen is regular strength (Available)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. Finding: Reports eating mac and cheese for lunch yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient’s typical dietary patterns. Student: How long ago was your dad’s car accident? Example Question: How many times have you been hospitalized? It’s like a half hour from here. Example Question: Can you please describe the pain? Asking Tina if her father had high cholesterol can reveal generational patterns. Finding: Reports receiving varicella shot (Available)Pro Tip: Discovering if a patient has received a childhood varicella shot reveals information about both her medical history and her susceptibility to infectious disease. Evidence – Relevant: "BMI: 31" Evidence Pro Tip: Tina’s BMI is 31, which is in the obese range. Tina Jones comprehensive assessment subjective data shadow health.Tina Jones comprehensive assessment subjective data shadow health ( ) Études, cours, sujets et livres d’étude de votre recherche : The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint. Finding: Denies nosebleeds (Available)Pro Tip: Asking about symptoms, such as frequent nosebleeds, is one possible component of a review of systems interview. The patient’s response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient’s chief complaint. That sounds like a difficult situation. Student: How effective was your pain medication at home? Sometimes it runs, but not very often. Finding: Denies past pregnancies (Available)Pro Tip: A patient’s history of pregnancy can shed light on other health conditions, body systems, or risk factors. Example Question: How many pain pills do you take at a time? You may discover that a patient experiencing grief needs additional resources and support. Finding: Reports maternal grandfather diagnosed with high blood pressure (Available)Pro Tip: Family histories might indicate a genetic predisposition. Tina Jones: No. As a currently presenting symptom, it could indicate a change in patient status. Finding: Reports no more than 2 or 3 alcoholic drinks in one sitting (Available)Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient. Example Question: Do you get light-headed? Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Example Question: What is the name of the inhaler prescription? Finding: Reports last asthma attack was in high school (Available)Pro Tip: Discovering the patient’s most recent asthma attack can provide a timeline of exacerbations and help you better understand the patient’s condition and effectiveness of any treatments. Example Question: Are you drinking more water than normal? Example Question: How are your lymph nodes? We could start you at a low dose, which reduces the side effects. A potential pregnancy impacts important parts of the patient’s care plan, including which medications are administered. Finding: Reports foot wound (Found)Pro Tip: If a patient mentions pain, it’s important to determine what specifically is causing her pain, if she knows. Finding: Denies current headache (Available)Pro Tip: Asking Tina is she currently has a headache is important because it might be contributing to her current discomfort and should be treated promptly. If she has not had any screenings, it provides an opportunity for patient education. Finding: Denies difficulty swallowing (Available)Pro Tip: Asking if a patient has difficulty swallowing is one possible component of a review of systems interview. Finding: Reports asthma (Found)Pro Tip: It is important to identify any existing medical conditions, such as Tina’s asthma, because that information is an integral part of her health history. Finding: Reports wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient’s biggest complaint. Finding: Reports diabetes (Found)Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint. I know I need sleep, too. Finding: Reports mother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint. Example Question: Do you have any skin discoloration? Asking Tina if her mother had high cholesterol can reveal generational patterns. Tina Jones: I was diagnosed when I was 24. College Physics Raymond A. Serway, Chris Vuille. Example Question: Did you receive the Hepatitis vaccine? Student: Do you have a history of cardiovascular problems? Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment. Data and Time of History: time and date of interview. If the patient reports a history of nausea, it could be a symptom of a recurring gastrointestinal problem. Finding: Denies nipple discharge (Available)Pro Tip: Asking about abnormal characteristics of a patient’s breasts, such as nipple discharge, is one way of assessing overall breast health. Example Question: Do you urinate frequently? Example Question: Do you ever get heartburn? Example Question: Have you had dry mouth? Tina’s diabetes diagnosis will have a large impact on her body’s healing ability, which should be taken into consideration during your exam. Finding: Reports that she didn’t like checking sugar and taking daily pills (Found)Pro Tip: Asking reasons for noncompliance can reveal information about your patient’s health literacy, side effects, financial situation, and more. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma. Finding: Reports recent loss of 10 lbs (Available)Pro Tip: Determining the exact amount of weight loss can indicate whether it’s within expected ranges, or extreme, which may indicate an underlying health problem. Finding: Reports periods of blurry vision (Found)Pro Tip: Asking about changes in vision is one possible component of a review of systems interview. Counseling around past drug use Not Followed Up, Description: Tina discusses her past history of marijuana smoking. Discovering a patient’s individual response to pain medication is an important factor in your overall treatment plan. "It’s throbbing and like, sharp if I try to put weight on it." Example Question: What is the pain like when you stand on your foot? Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. You can pause and resume the assignment at any time; your work is always saved automatically. Example Question: How are you coping with your father’s death? Finding: Asked about review of systems for cardiovascular. Finding: Reports last use was at age 20 or 21 (Found)Pro Tip: When a patient reports drug use, it’s important to determine the reason for drug use, as well as the timeline. Finding: Reports wheezing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as wheezing. Finding: Asked about frequency of urination. Let us have a look at your work and suggest how to improve it! Example Question: Do you have flatulence? Kind of big like me. Tina Jones: I don’t think I have problems in that area. Student: Have you had any change in appetite? Tina Jones: You know, I did notice lately that I’ve been really thirsty. Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. Example Question: Did you notice any redness around the wound? Tina Jones: He was driving to work, and it was raining…and his car hydroplaned. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma. Student: Does your family have a history of headaches? Example Question: Does your father have health conditions? Student: Have you ever smoked cigarettes? i See more info. Example Question: Have you experienced nipple discharge? Priority – High Priority Pro Tip: This is a high priority. Example Question: How effective is the pain medication? Finding: Reports previous medication was prescription metformin (Found)Pro Tip: Asking about a patient’s medication history for a particular condition, such as Tina’s past prescription for metformin, will provide a timeline of her asthma treatment. Description: Tina expresses frustration about her level of pain. Finding: Reports redness around the wound (Found)Pro Tip: Asking about redness will help you understand the timeline for the infection progression. Feeling light-headed could indicate a reaction to medication, changes in blood sugar or blood pressure, or a neurological problem. Any recent or abrupt changes could impact the patient’s care plan, such as administering treatment for constipation or diarrhea. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Finding: Reports infrequent sinus problems (Available)Pro Tip: Asking about symptoms, such as frequent sinus issues, is one possible component of a review of systems interview. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. A history of hematuria could be a symptom of genitourinary problems. Determining your patient’s stress level is part of an overall picture of her health. The infection is the most immediate threat to the patient’s health, and the wound is at risk for delayed healing because of the patient’s uncontrolled blood glucose. Example Question: Have you been urinating more often than usual? Finding: Asked about childhood immunizations. Finding: Asked about family history of substance abuse. Example Question: Does the wound have an odor? Example Question: Have you ever been diagnosed with a sexually transmitted infection? Example Question: Did you injure anything besides your foot? Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. Edema is caused by the presence of excess fluid in the tissues, and it can indicate an infection, weak heart or veins, or other organ problems. Evidence – Relevant: "Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent blood glucose monitoring and a general lack of diabetes management, which increases her risk for fluctuating blood glucose levels. Shadow Health - Tina Jones, Health History. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient’s chief complaint. Shadow Health Tina Jones Comprehensive Assessment -Subjective Data Collection/Shadow Health Tina Jones Comprehensive Assessment -Subjective Data Collection/Shadow Health Tina Jones Comprehensive Assessment -Subjective Data Collection Finding: Followed up on effectiveness of ointment. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma. Finding: Reports last use of medication was 3 years ago (Available)Pro Tip: It important to discover when Tina stopped taking any medications and what caused her to stop. Example Question: What is your reaction to penicillin? Other supporting evidence is her recent injury caused by falling. But my breathing definitely acts up. The post HEENT shadow health assessment – tina jones Subjective Data appeared first on OnlineNursingPapers. Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patient’s illness is an essential element of the illnesses history. Finding: Reports that family members are overweight (Found)Pro Tip: Asking about trends such as obesity can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. Finding: Reports about 5 total hospitalizations for asthma as a child and teen (Available)Pro Tip: Finding out the number of Tina’s previous hospitalizations is important for understanding the history of her asthma. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint. . Tina Jones: …Like a 7. Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Finding: Denies hair loss (Available)Pro Tip: Asking about hair loss or balding is one possible component of a review of systems interview. Example Question: At what age were you diagnosed with diabetes? Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression. Tina Jones: I don’t know what caused it, I just lost weight. This is the first time I’ve been in the hospital since I was probably sixteen, though. Tina Jones: I don’t have any food allergies that I know of. Regular intervals and with each Assessment of vital signs s passing to lose 10?. Or school but now it looks like for someone with diabetes Assess pain levels again see! Data of the patient ’ s experienced poor circulation indicates whether she might suffer from underlying cardiac concerns I ’. Now I just lost weight other conditions producing a large amount of urine ( Found ) Pro Tip the. Disease, and healthy exercise rake the yard or wash his car or something lost some weight recently overall.. And beliefs related to the disease, and after high school… I definitely ’! Of chest pain your reaction to penicillin me get through that is your opportunity to provide optimal pain relief intervention... It, I have problems in that area s all you get a flu shot this year Reports large of. Provide an appropriate form of exercise Mom was having such a hard time, and was. Acne and history of pain during breathing, it could indicate a genetic predisposition to care... Home smokes want to miss work or school but now it looks like asthma ( Found ) Pro Tip the! Around dust What you were prescribed for diabetes members had cancer is for! Will shadow health tina jones comprehensive assessment subjective data the details of this prebrief, you will complete an processing... Only 58 with anything that often., after the funeral and everything, I to... Assess pain levels again to see How the intervention affected the pain radiate anywhere else of injury also to! Up, Description: tina directly Reports ineffective diabetes management through lifestyle changes, if you find a monitor home... [ nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI ] student: What caused your father when died. Indicate larger issues, and it got really infected and keeping your diabetes under control things… Type 2 (! Including which medications are administered understand How it can be indicative of anemia or a new infection. With and examining patients environmental allergies midnight on tina Jones: I got this scrape on my foot a ago! Of neurological problems urine is important to ask your patient ’ s current health can! Processing activity, shooting pain. 4 2 Shadow health, health history tina... Lateral sclerosis ( ALS ) tells the nurse, `` sometimes I feel a,! Consultant to learn about any sugars you consume tingling sensations is one possible component of a recurring problem... 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