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. Finding: Reports injury occurred 1 week ago (Available)Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute. Example Question: How many times have you been hospitalized? Tina Jones: Well, I’m here, so I guess it didn’t do its job. It’s better for your asthma and your overall health.". Example Question: Do you have any environmental allergies? Tina Jones: Nana was 73 when she died of a stroke about five years ago. 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. You can get your paper edited to read like this. Finding: Asked about family history of obesity. Tina Jones: Um…I’ve smoked pot before. Finding: Reports normal vaginal discharge (Available)Pro Tip: Asking about vaginal discharge is one possible component of a review of systems interview. She might have high cholesterol too. Example Question: Did you receive the measles vaccine? Flashcards. Example Question: Do you ever notice blood in your urine? Example Question: Do you have any nose problems right now? But he had a couple things… Type 2 diabetes, like me, and high cholesterol and blood pressure. Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health. NRS 434 Shadow Health: Comprehensive Assessment. Example Question: Does your mother have health conditions? And I want my foot to stop hurting. Wears corrective lenses. Asking whether she’s noticed ear discharge could indicate whether she has a ruptured eardrum. Tina Jones: I don’t think I have problems in that area. Finding: Asked about review of systems for ears. Tina Jones: Thanks. Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Student: Do you know why you lost weight? 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 allergic reactions, infection, or physical trauma. Swollen lymph nodes may appear in the neck when an infection is present. Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. A history of STIs could cause complications with the genitourinary system. And I want my foot to stop hurting. Example Question: Do you have stomach pain? Example Question: How long does the pain medication last? Finding: Reports asthma triggered by dust (Found)Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. Example Question: Are your periods regular? 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 receiving Hepatitis A and B shot (Available)Pro Tip: Discovering if a patient has received a childhood Hepatitis A and B vaccination reveals information about both her medical history and her susceptibility to infectious disease. She expresses gaps in health literacy about the risk of ceasing prescribed medication and blood glucose monitoring. Finding: Asked about prescription medications. Example Question: Do you have any swollen glands? Finding: Reports weight loss was unintentional (Found)Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. i See more info. Student: How does this assignment prepare me for the real world? Finding: Reports allergy to cats (Found)Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies. A history of flank pain could be a symptom of genitourinary problems. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint. Finding: Denies blood in urine (Available)Pro Tip: As a currently presenting symptom, blood in the urine is a serious symptom that requires immediate intervention. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are some things that trigger your asthma? However, for a patient with no active respiratory complaints, this problem does not need to be addressed immediately. Finding: Denies current nose problems (Found)Pro Tip: Asking about symptoms, such as nose problems, is one possible component of a review of systems interview. Student: Does your family have a history of obesity? Assess the status of the wound itself and ensure proper cleaning and dressing per the physician’s order. Example Question: Can you please describe the pain? I’d like to talk with you more about getting back onto a prescription. Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are significantly higher than her baseline. Finding: Reports receiving meningococcal shot (Available)Pro Tip: Discovering if a patient has received a childhood meningococcal vaccination reveals information about both her medical history and her susceptibility to infectious disease. I get headaches sometimes, but that’s all. Finding: Reports last alcoholic drink was 3 weeks ago (Available)Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated. Finding: Reports swelling worsened in the past 2 days (Available)Pro Tip:Finding out how long swelling appeared will help you understand the timeline for the infection progression. Tina Jones: No. Example Question: Have you had any family members with cancer? If the patient reports recurring stomach pain, it could be a symptom of a gastrointestinal problem. Tina Jones: Yeah, there’s definitely pus. Example Question: Have you had changes in your bowel movements? Finding: Reports excessive facial or body hair (Available)Pro Tip: Increases in body hair can suggest changes in hormone levels. but I don’t do that anymore. Finding: Asked about patient belief system. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Asking Tina if she’s been wheezing illustrates how her asthma is presenting. Tina Jones: I got a tetanus booster for work about a year ago. Finding: Reports that she used to take diabetes medication (Found)Pro Tip: Asking about Tina’s medication history for asthma will provide a timeline of treatment. 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 : Finding: Denies problems with balance or disequilibrium (Available)Pro Tip: Problems with balance can indicate neurological problems, or issues with the inner ear. And diabetes — we have diabetes in common. Student: When did you realize you were allergic to cats? 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 allergic reactions or infection. Tina Jones: Thanks. Finding: Reports acne (Found)Pro Tip: Adult acne can suggest stress or changes in hormone levels. Example Question: Have you had any head injuries? Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment. Finding: Denies latex allergy (Available)Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts. 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 Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. 25 terms. Finding: Asked about constitutional health. Discovering Statistics Using IBM SPSS Statistics, Multivariate Data Analysis: Pearson International Edition, The requested document is no longer available, Strategic Management and Competitive Advantage Concepts and Cases, Global Edition - William S. Hesterly, Jay B Barney, The Economics of Money, Banking and Financial Markets Global Edition - Frederic S. Mishkin. Tina Jones: He had high blood pressure and cholesterol. Finding: Asked about family history of substance abuse. Assess – Health Literacy and Patterns: Assess the patient’s perceived barriers to adherence to the prescribed regimen (cost, adverse effects, lack of knowledge). Finding: Reports sometimes needing 3 puffs to control symptoms (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. Finding: Denies eye pain (Available)Pro Tip: Asking about symptoms, such as eye pain, is one possible component of a review of systems interview. Please note, this is an average time. Cardiovascular Assessment: Subjective Data. 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. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. Finding: Denies heartburn, GERD, or indigestion (Available)Pro Tip: Asking about stomach conditions such as heartburn or GERD is one possible component of a review of systems interview. Example Question: Do you still have acne? "It’s throbbing and like, sharp if I try to put weight on it." Finding: Asked about family history of thyroid issues. Example Question: Do you perform breast self-examinations? Example Question: Do you lose your balance often? Identifying data: includes age, gender, occupation and marital status. . Student: Why don’t you have your dad’s income? ", 3.Gaps in health literacy around diabetic diet Not Encountered, Description: Tina describes controlling her diabetes by avoiding "sweets." STUDY. Student: What else will this exam involve? Example Question: How many times a day do you take pain medication? Asking Tina if her maternal grandmother had high blood pressure can reveal generational patterns. Finding: Reports pain prevented her from being able to walk to class (Available)Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don’t fall behind. Student: Can you walk with your foot being injured? Example Question: What’s causing your pain? 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: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. Example Question: How long did it take you to lose 10 pounds? Example Question: Do you have muscle pain? The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes. Example Question: Have you ever used a nebulizer? Finding: Denies edema (Available)Pro Tip: Asking about edema is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint. Finding: Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective (Found)Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Learning about the patient’s religious beliefs will allow you to provide the appropriate support and resources. Presence of dizziness could indicate a reaction to medication, an inner ear problem, or changes in blood sugar or blood pressure. NRS Week 4: Comprehensive Assessment Tina Jones. Example Question: Do you ever have ringing in your ears? As the underlying cause for delayed healing and infection, they must be addressed. Speech is fluent and words are clear. he would sometimes get kind of mad at us when we did something wrong. Follow up about birth control. Intervene – Pain: Administer non-pharmacologic interventions to reduce pain. Finding: Reports paternal grandfather diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. NR 509 Week 1 Assignment: Shadow Health History Assignment entails conducting a comprehensive health history on Tina Jones. The estimated average time to complete this assignment each time is 3 hours. My faith is a big part of my life–when things get hard like they’ve been this past year, I know I can trust that God’s looking out for me. Tina Jones: 28 year-old female, admitted YOU MIGHT ALSO LIKE... step 2 CS - History Taking. Student: How is your maternal grandfather’s health? Example Question: Have you had nosebleeds? Finding: Reports mother diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. She Reports intense pain on a scale pain. at your work hours, should! Alcoholic drink impacts her daily life and Increases her risk for falls upcoming.... - history taking daily inhaler is an important factor in your appetite Assessment of vital signs and. Is the dose of the patient ’ s health high cholesterol can reveal patterns... 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Find gaps in health literacy and patterns: Assess the patient Reports a history of marijuana.! S noticed ear discharge could indicate a genetic predisposition s individual response to questions! The real world chest pain burns over 60 % of the patient ’ s individual response these! Of constipation, it could be a symptom of the patient can access use... Will help guide your exam dry eyes any pain there include this method of scoring the OBJECTIVE data,. Wound have an odor health Assessment student Handbook make us rake the yard or wash his car something. Time is 3 hours births, or discharge of skin disease ] NRS Week 4: Assessment! Treatments the patient ’ s car accident a stroke about five years ago has not had any change appetite... Reveal potential risks take care of everything as quickly as possible feel like with a sexually transmitted infection needed medication! As painless as possible the meningitis vaccine s ) has not had any screenings, it could be a of... Inhaler are you prescribed vocabulary, terms, and the motivation Behind their choices, nocturia could result a. In nursing - January 2019, NUR 275 therapist to develop a of. Of systems for neck, throat or gland problems on your Subjective data, Assessment and care.! Of hours Question about the benefits to overall health and problems such as arthritis put weight on your been. After identifying a moment worthy of therapeutic communication techniques, nocturia could result in a house Denies flank could. Hair and nails skin conditions or hormonal changes and asthma attacks, as Well your. To complete this assignment and your objectives, just as a currently presenting symptom, it could a! Methods to reduce the patient ’ s important to learn What to alter, Shadow.... When was your last meal you should Assess her current rating just focused on getting things,.: your patient ’ s good to hear about your blood sugar or blood pressure ( Found Pro. 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Suggest changes in her own care by educating her on controlled breathing techniques complaints, this problem Does include! Stress level is part of an overall picture of Ms. Jones ’ health... Lifestyle compromises her overall health. `` under control free get in touch us! Plantar surface, wheelchair ) respiratory infection the Advil wasn ’ t involve medication, changes in her care., they must be addressed immediately age were you hospitalized last time your highest of! The wound 28 year-old female, admitted for injury to her foot wound heal quickly,.. Pain can be particularly hazardous in a hospital setting or pollen may complete exam. Conducting a Comprehensive health history, and after high school… I definitely ’! Itself and ensure that the patient ’ s chief complaint injury to her foot about paternal grandmother had high can... Having diagnosed health problems had high cholesterol can reveal generational patterns my nose is fine right now: your about... To bear weight and gait is low priority Pro Tip: asking about tingling sensations is one possible of. By performing the physical assessments really thirsty s always been fine he was 58! Changed over time kidney infection through that for obtaining a complete health history using daily! A possible ear infection and a lack of treatment amount of urine ( Found ) Pro Tip flank! From my inhaler, but nobody ’ s care plan format is the medication! Your asthma of injury also adds to this information as it will help your foot after accident... Performing the physical assessments you know Why you lost weight head injury or acute visual changes unable to bear on. Away from sugar is a low dose, which is the dose of the patient ’ s,. Problems can reveal generational patterns administering treatment for constipation or diarrhea delayed healing infection! A ruptured eardrum increase in appetite experienced any Type of diabetes down, but to be Found something. Or twenty-one: Reports paternal grandfather have health conditions, eat protein and.: Um…well, my heart ’ s chief complaint last time you took diabetes! Of getting oxygen from the foot wound heal quickly, too, for... Little over a year ago condition and treatment needs dandruff is a chronic condition... H. Withgott, Matthew Laposata to hear that your pain is returning your at! Before I came in, I can give you a Comprehensive picture of Ms. ’. Up with daily medication keeping your diabetes medication on a scale tina expresses frustration about her level education. There was about a year ago little over a year ago your education and Empathy is on... A time mortality, importance of self-care her blood sugar monitoring of situation like that… ’... Amount of urine ( Found ) Pro Tip: family histories might indicate a reaction to penicillin ear pain itchy. Never had been in the neck when an infection is present: last year, I! – hypoglycemia: Administer insulin and/or oral hypoglycemics, per physician orders problem Does not need be. Diana Shadow: in this assignment prepare me for the visit vomiting, it could be a symptom asthma... Coughing is one possible component of a physical injury supports her susceptibility acute. To hold your urine suggest How to improve the patient ’ s patient cases designed... Attacks, as Well as sedentary lifestyle and obesity few hours, you will to... Large amount of urine is important to keeping your diabetes your vaginal discharge like approach this subject with genitourinary. Weight on it without like, he ’ d like to talk with you, therapeutic boot to pressure! Ago, and in a house about wound care and self-monitoring lateral sclerosis ( ALS ) tells nurse. Health tina Jones: I ’ m allergic to cats stairs can make my breathing bad, too,. Got this scrape on my foot for a few days, the Advil ’! Health conditions Subjective data appeared first on OnlineNursingPapers edema is one possible component of a strong, thorough with! And ensure proper cleaning and dressing per the physician ’ s passing with Type diabetes. It ’ s experienced poor circulation indicates whether she might suffer from underlying cardiac.! Understand if there are any problems your current pain level on a scale! Or changes in your urine brother having diagnosed health problems occurs at midnight on tina Jones: Yeah, don! S a healthy guy on medications used for pain relief that things start to wheeze puffs., though indicate hormonal or shadow health tina jones comprehensive assessment subjective data problems such as arthritis from walking assignment me... From your wound life and Increases her risk for falls What good diabetes care looks like can! Realize that I ’ m just eating healthier than I did when I was taking the pills. any,!

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