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need a distraction. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. We're available through e-mail, live chat and Facebook. . Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. when do you fall asleep complains of end of day fatigue. How often do you take your birth control pill? 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. 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. The opportunities listed below are those identified by nursing experts to be of particular importance to this. All the materials from our website should be used with proper references. sweats. SOAP Note samples (14) CVS periodically. energy drinks due to her feelings of tiredness. How does interviewing a heathy patient differ from interviewing a patient with a known health condition? Indicates an item that is available to be found. She seems to be doing okay though. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. bilaterally in upper extremities and lower extremities without thrill She has a history of hypertension which normalized when she initiated diet and exercise. The pain sometimes radiates to his left leg. Conduct a comprehensive review of systems to rule out any possible organ dysfunction or disease. The opportunities listed below are Is the Education and Empathy section scored in every patient case assignment? Note that some assignments will not require you to provide education and empathy for a score, but it is encouraged. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. This button will not appear after the due date of the assignment, or if your instructor has chosen to not allow reopening for the assignment. Last updated on November 16, 2021 The score you receive in the Education and Empathy section is based on the timing of your therapeutic statements during critical moments in the patient interview. Do you have any problem with your breasts? 10:22 PM EDT. I just always want to be learning new things and getting better at my job. I have a little, and its kind of clear, sometimes white-ish. This record includes questions asked, statements made, and actions/assessments performed. Description: Tina describes how busy she is with school and work. concern regarding these episodes. Subjective Data Collection: 50 of 50 (100.0%), Objective Data Collection: 70 of 73 (95.9%), Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. what brings you in today Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Clicking on each opportunity will show a description of that opportunity, the lines in the transcript in which you encountered that opportunity, and a model educational or empathetic statement. frequency and duration of pain. The Objective Data Collection page contains the physical assessments you could have performed during this assessment. Thorough examinations will yield better patient data. pumpkin bread, lunch is a sandwich, dinner is a homemade mea Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Experience Overview Page. faster than usual. work and school. -reports pain is same on both sides of back. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Besides nursing care, assess the patients mental health, pain management, dietary habits as well as any social needs. She is a good historian. I would get allergies, like sneezing and stuff, and then my asthma would act up. auscultation without wheezes, crackles, or cough. Pro Tip: Palpating the frontal sinuses checks for sinusitis. Does he have any medical issue? This button will not appear after the due date of an assignment, or if your instructor has set the assignment so that only the first attempt is marked as turned in. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She plans to use condoms with sexual activity. If the Reopening feature is enabled, you can make up the lost point in the education and empathy section by recreating the opportunity. Under the grading explanation, you will see a list of Relevant Diagnoses and how many points you earned for that diagnosis. discomfort of 3/10 which she attributes to associated anxiety The pain sometimes radiates to his left leg. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Popular books. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. OB/GYN: Menarche, age 11. College Physics Raymond A. Serway, Chris Vuille. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. NR 509 Week 7 Shadow Health Comprehensive Health Histor. . How often do you monitor your blood glucose? This will show an outline of your score. $15.00 Add to Cart. Penicillin: rash Denies food and latex allergies Allergic to cats and dust. Mom has high cholesterol and blood pressure, I think. What medical problems did your father have? Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. She denies chest pain during the episodes, but does endorse location of pain. he had some blood pressure and cholesterol issues when he was alive, too. Breakfast is usually a muf Palpitations related to caffeine and/or anxiety, Cardiovascular Completed Shadow Health write out, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Cardiovascular | Completed | Shadow Health, https://app.shadowhealth.com/assignment_attempts/101, Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Psychology (David G. Myers; C. Nathan DeWall), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Good job cleaning it and using Neosporin. Experts selected these topics as essential components of a strong, thorough interview with this patient. ), No. (Clarified to: Do you control your diabetes through, Yeah, I stay away from sugar and watch what I eat, in general. Some of these items may not appear depending on the assignment and the options set by your instructor. Help Desk for further information. . General: Ms. Jones is a pleasant, obese 28-year-old African drinking as much water as her normal. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Exam (elaborations) - Focused exam: hypertension and type 2 diabetes - week 10 results | turned in advanced. Around midnight, I get into Undergraduate Graduate . Shadow health assessments can help nursing students develop an understanding of patient safety issues. That is great. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Speech is clear and coherent. Im glad you came in. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Now that Im on the pill Im getting my period every month. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. . shadow health with Tina Jones. dust, and penicillin. Tina Jones Health History _ Education and Empathy_ Shadow Health.pdf. Well, Im starting my new job in two weeks, and Im really excited about that. I will be conducting an interview and later perform a physical exam. . At the top of this page, you will see a percentage score of how you did on Objective Data Collection. sample picot questions (12) I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. For instance, if there are three dimensions of a particular assessment, each dimension is worth 1/3 of a point. How often do you use your rescue inhaler? This button will Reopen your attempt. DNP (36) No visible abnormal findings Rash Papules, pustules, or comedones Skin growths (freckles, moles, or birthmarks) Excessive hair growth Evidence of skin trauma (scar, laceration, or bruising) Red, chapped nose Inspected eyes and orbital area 1 of 1 point Orbital Area (1/4 point) No visible abnormal findings Ptosis Eyelid edema Lesion Allergic shiners Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Scattered pustules on face and facial hair on upper lip, Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Thyroid smooth without nodules, no goiter, Upper eyelids: conjunctiva pink, no lesions, white sclera, Lower eyelids: conjunctiva pink, no lesions, white sclera, Right pupil: equal, round, reactive to light, Left pupil: equal, round, reactive to light, Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope, Left fundus with sharp disc margins, no hemorrhages, Right upper quadrant: no masses, guarding or rebound, Right lower quadrant: no masses, guarding or rebound, Left upper quadrant: no masses, guarding or rebound, Left lower quadrant: no masses, guarding or rebound, Liver: palpable 1 cm below right costal margin, Neck without swelling, masses, or deformity, Right shoulder without swelling, masses, or deformity, Right arm without swelling, masses, or deformity, Right elbow without swelling, masses, or deformity, Right wrist and hand without swelling, masses, or deformity, Left shoulder without swelling, masses, or deformity, Left arm without swelling, masses, or deformity, Left elbow without swelling, masses, or deformity, Left wrist and hand without swelling, masses, or deformity, Fingernails: no ridges or abnormalities in nails, pink nailbeds, Hips without swelling, masses, or deformity, Right leg without swelling, masses, or deformity, Right knee without swelling, masses, or deformity, Right ankle without swelling, masses, deformity, or discoloration, Right foot without swelling, masses, or deformity, Left leg without swelling, masses, or deformity, Left knee without swelling, masses, or deformity, Left ankle without swelling, masses, or deformity, Left foot without swelling, masses, or deformity, Toenails: no ridges or abnormalities in nails, pink nailbeds, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, The patient is a 28-year-old female who presented for a pre-employment physical exam. 10:23 PM EDT. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. The "fast heartbeat" is lo alized t the left Never pregnant. I can give you some more information, on what a balanced diet looks like for someone with, diabetes. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. pico examples nursing (12) Tina Jones palpitations appear to be related to notable stress and These are your achieved scores for the different activities in the assignment. A fail on the SHCA means that the student has not answered any of the questions correctly. How many times a day do you take metformin? Together we can figure out the, frustration at how being unable to bear weight on, Well, I tried to go in two days ago but I couldn't, walk well enough, so I just went home after a, couple hours. I think she had high blood pressure and cholesterol, too. . I am, sorry it is not getting better, but we will take a, pain is returning. NURS 362 COMPREHENSIVE ASSESSMENT PAPER FINAL DRAFT.docx. JVD. Im taking good care of my health these days. A Model Statement is provided as an example of an Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. 3. all the way asleep for another hour and a half, two hours, usually. specific event, but notes that they usually occur about once per w Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Give Me Liberty! . The assessment should also include the comparison of bilateral sides. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Advanced Health Assessment - Summer 2021, NUR 703, (/site_notice_dismissals?from_ash=true&site_notice_id=, those identied by nursing experts to be of particular importance to this patient. The process of creating your own SHCA can be time-consuming and frustrating. : an American History (Eric Foner), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. 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Terms of Use illicit drugs. Scattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. appropriate response to each opportunity. This button will mark this attempt as Turned In, signaling to your instructor that it is ready to be graded. Are you looking for someone to help with shadow health assignments? She denies Ive had asthma a long time. Thank you for your feedback, it will help us serve you better. Comprehensive assessment documentation. Any medical history for your paternal grandmother? tetracycline, I think, back in high school. Using a, Your document will be more credible. Ms. Jones speech is clear and coherent. Have you tried anything else to treat the scrape? She is well-nourished, well-developed, and dressed appropriately with good hygiene. This button will not appear if your instructor has chosen to not show the Lab Pass for the assignment. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Once three months ago, and before that it had been months, too. Clicking on the diagnosis will expand that item, showing you the priority you selected, the evidence you selected, and your selection for Planning. The SHCA consists of ten multiple-choice questions that test a students comprehension of key health concepts. At last check it was 140/80 or 90. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. s1 and s2 heard without murmurs or additional sounds. I took something for my acne. abnormalities present on chest wall. Question I havent been having any gas lately. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Grand Canyon University University of Massachusetts Lowell I am glad you came in. In the Comprehensive Assessment, you earn points by performing the physical assessments.. "/> Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. but I dont do that anymore. My albuterol. Here are some reasons why you should use a writing service to create your SHCA: Here are 50 Shadow health assessment examples done within the nursingstudy.org system, use them as samples and as guides for your assignments. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. With our premium writing service, you no longer have to spend days and nights meticulously working on your assignment, instead use that time to do other important things. This will show an outline of your score. Ms. Jones visited to have a physical exam for the health insurance at her new workplae, I came in because Im required to have a recent physical exam for the health insurance at my new job., Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. She generally dr Here you will see a verbatim record of every interaction you had with the patient. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. (Clarified to if my younger sister has health problems. 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. -denies neck pain. Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months ago, Reason for last visit was annual gynecological exam, Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler, 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 ago, 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 symptoms, Birth control type is Yaz (drospirenone and ethinyl estradiol), Takes birth control pill at the same time every day, Asked about current non-prescription medications, Reports no recent seasonal allergy symptoms, Reports no current medication for allergies, Reports managing diabetes with diet and exercise in addition to medication.