Has new male relationship, sexual contact not initiated. SOAP Note Examples (14) 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. Each type of interaction is color codes so you can quickly assess the types of patient interactions that occurred during the exam. Start by filling this short order form nursingstudy.org/order, Having an issue, chat with customer support online, blog (1160) Pro Tip: Palpating the maxillary sinuses checks for sinusitis. gallops, clinics, precordial movements. Over th Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate a number of serious health conditions. 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. In the pre-brief before entering the patient room, Preceptor Diana will inform you how you will be evaluated during the simulation. Examination findings: Tina jones comprehensive - Comprehensive Assessment Results | Turned In Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. 2. Do you have any problem with your breasts? were followed up by students, and include the dialogue between student and patient 1 Expression of pain Followed UpFollowed Up 2 Impact of injury on daily life Followed UpFollowed Up 3 Gaps in health literacy around diabetic diet Not Followed UpNot Followed Up 4 Lack of treatment with diabetes medication Not Followed UpNot Followed Up 5 Lack of She describes t Herzing University (82) ABI is 0. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Have you noticed any side effects from the metformin? Note that some assignments will not require you to provide education and empathy for a score, but it is encouraged. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. At the top of this page, you will see a percentage score of how you did on Objective Data Collection. Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: ask effective and comprehensive questions obtain a thorough health history evaluate the patient's risk of disease, infection, injury, and complications educate and empathize I have a little, and its kind of clear, sometimes white-ish. Today she denies any acute concerns. The Overall time is the combination of the other timers. And the pain is killing me! : an American History - Chapters 1-5 summaries, 1.1 Functions and Continuity full solutions. Course Hero is not sponsored or endorsed by any college or university. regulations. is provided as an example of an appropriate response to each opportunity. Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient. those identified by nursing experts to be of particular importance to this patient. Do you take your pill at the same time every day? Attempting to palpate the kidney helps determine enlargement or tenderness. All the work should be used in accordance with the appropriate policies and applicable laws. During the patient interview, there are a number of opportunities to provide patient education and empathy. 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. That does not sound good. The grey items are available within the assignment, but you did not unlock them on this attempt. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. presented to the clinic with complaints of 3-4 episodes of rapid he Conduct physical evaluations to check vital signs such as blood pressure and heart rate, and look for abnormalities in skin, nose, throat, lungs and abdomen. I mean, I still have asthma and diabetes, but both of those are under control. . Course Hero is not sponsored or endorsed by any college or university. No thrills are bruit. Hematologic: She denies history of anemia, easy bruising or . 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. S You can hover over each bulleted item in Patient Data to view a Pro-Tip that explains the clinical significance of that finding. about 8 or 9 hours a night. For example, many starchy foods break, down into glucose in the body, like pasta, and so, you can eat those in moderation, too. Well, Im starting my new job in two weeks, and Im really excited about that. 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. Capillary refill < 3 seconds. . need a distraction. Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. SHADOW HEALTH FOCUSED EXAMS ALL IN ONE BUNDLE $ 522.01 $ 74.99 49 items 1. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. Nana was 73 when she died of a stroke about five years ago. Im glad you came in. tetracycline, I think, back in high school. Clicking on the diagnosis will expand that item, showing you the priority you selected, the evidence you selected, and your selection for Planning. Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were 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. illness? sputum, hemoptysis, pneumonia, bronchitis, emphysema, Question in the morning on her commute to class. Are you taking any medication for your allergies? Shadow. Asking Tina if she takes supplements will indicate her current treatment plan. stress.". I am glad you came in. Florida State University. I will be conducting an interview and later perform a physical exam. Are you taking any form of birth control? You have access to an EHR during the patient exam in which you can record your findings. Ms. Jones offers information freely and without contradiction. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. At the top of the transcript, you'll see a ribbon indicating the frequency of each kind of interaction within the transcript. Nursing Research Papers (2) . Regular rate and rhythm, S1 and S2 present, no murmurs, ru NUR 325 Transcript Comprehensive Assessment _ Completed _ Shadow Health - NUR 325 (NUR325) - Stuvia US US Chamberlain College Of Nursing NUR 325 (NUR325) Other NUR 325 Transcript Comprehensive Assessment _ Completed _ Shadow Health Course NUR 325 (NUR325) Institution Chamberlain College Of Nursing Ugh, horrible, honestly. Reports improved acne due to oral contraceptives. nursing essays (22) : an American History (Eric Foner), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. 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Have you been taking medication for your diabetes? Asking Tina if she takes vitamins will indicate her current treatment plan. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. What is your relationship like with your family? Tina confirms that she has sources of stress and anxiety which are . 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. Increasing knowledge and understanding of healthcare concepts. concern regarding these episodes. pumpkin bread, lunch is a sandwich, dinner is a homemade mea The Post-Exam time is time spent answering questions after the exam room. . Decreased sensation to monofilament in bilateral plantar surfaces. Nursing Simulation for Nursing students | Shadow Health During the patient interview, there are a number of opportunities to provide patient education and empathy. Im going to be an Accounting Clerk at this really nice accounting firm. -pain lasted 3 days. shadow health comprehensive assessment education and empathy - Sercano TV She has no medication side effects at this time. NUR 325 Transcript Comprehensive Assessment _ Completed _ Shadow Health (Clarified to Does your brother have medical problems?. 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. 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! Terms and Conditions Privacy Policy Cookie Settings. For instance, if there are three dimensions of a particular assessment, each dimension is worth 1/3 of a point. Pro Tip: Healthy kidneys are not usually palpable. has been feeling more stressed lately due to her school and wo She uses her albuterol inhaler when she is around cats. Family History has hypertension, hyperlipidemia, diabete melluitis, Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Review of Systems: General: Denies changes in weight, but Let's talk about your wound a little further. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Become a tester for Shadow Health! Respiratory: Chest is symmetrical with respirations; no physical She has no kn Terms of Use College Physics Raymond A. Serway, Chris Vuille. When asking interview questions to collect subjective data, there will be scored opportunities to provide either an educational or empathic statement in response to the patient. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. 10:06 PM EDT, Im sorry to hear you are having trouble sleeping and feeling stressed. Question But that hasnt happened since I got my daily inhaler. location of pain. Some of these items may not appear depending on the assignment and the options set by your instructor. : an American History (Eric Foner), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Principles of Environmental Science (William P. 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