Finding: Denies ringing or tinnitus (Available)Pro Tip: Ringing in the ears can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing, or hearing loss. Asking Tina if she had problems with the hair on her head solicits important health information. Student: Does your family have a history of substance abuse? Keloid: A hypertrophic scar. Finding: Denies head injury (Available)Pro Tip: Asking about the patients history of physical trauma, including head injury, is one possible component of a review of systems interview. Asking Tina whether shes experienced poor circulation indicates whether she might suffer from underlying cardiac concerns. Finding: Reports maternal grandfather diagnosed with high blood pressure (Available)Pro Tip: Family histories might indicate a genetic predisposition. Student: Have you ever smoked cigarettes? Purpura: confluent and extensive patch of petechiae and ecchymoses, >3mm flat, red to purple, macular hemorrhage. Model Statement: "Im sorry to hear about your fathers passing. Finding: Denies nipple discharge (Available)Pro Tip: Asking about abnormal characteristics of a patients breasts, such as nipple discharge, is one way of assessing overall breast health. The patients response to these questions may uncover additional problems not discovered during discussion of the patients chief complaint. Most importantly, ask about her goals and changes she may be willing to make. Finding: Followed up on cat allergy symptoms. While the patient is in your care, work with other healthcare professionals to keep the pain managed and improve the patients mobility. Example Question: When was your last tetanus booster? Asking Tina what antibiotic she was prescribed for her acne solicits facts of the patient's case. Target or Iris: resembles iris of eye, concentric rings of color in the lesions (erythema multiforme) Asking Tina if her maternal grandmother had high cholesterol can reveal generational patterns. Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Finding: Reports dust causes sneezing, itchy eyes, and wheezing (Available)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important. Examples: stasis ulcer, pressure ulcer chancre Discrete: distinct, individual lesions that remain separate: skin tags, acne her neck hurts, will allow you to compare her symptoms and assess her condition. Example Question: How often do you check your blood sugar? NR 509 Week 2 Shadow Health: HEENT Physical Assessment REVIEW QUESTIONS Suppose you Shadow Health HEENT Tina Jones. Finding: Asked review of systems for musculoskeletal. Finding: Reports using an inhaler (Found)Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy. Student: How is your paternal grandfathers health? Student: We are going to take care of everything as quickly as possible. Determining your patients stress level is part of an overall picture of her health. Student: We are going to take care of everything as quickly as possible. Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin's oil glands. Required fields are marked *. Student: Have you had any problems with your breasts? Finding: Denies mouth pain (Available)Pro Tip: Asking about symptoms, such as oral pain, is one possible component of a review of systems interview. The patients response to questions about this topic may uncover additional problems not discovered during the discussion of the patients chief complaint, such as oral infection or recent trauma. Examples: insect bites, scabies, dermatitis, varicella Finding: Reports sneezing, itchy eyes, and wheezing (Available)Pro Tip: Determining a patients reaction to an allergen is essential to gauge if the allergy is life-threatening. Finding: Reports maternal grandmother diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Example Question: How are you coping now? I personally haven't used Dr. Rose but as a (MLD) Manual Lymphatic Drainage Therapist I had the pleasure to work with one of his patients post surgery the last two weeks. Consult / Refer: Consult with physical therapist to develop a plan to improve the patients mobility. Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will Tina Jones: I dont know what caused it, I just lost weight. Asking Tina about her history of acne solicits important information Your email address will not be published. The patients response to these questions may uncover neurological problems. Dent first appears at the cuticle and moves forward as nail grows. Hair Skin & Nail Support 4778 N 300 W Provo UT 84604. 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. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Sexual activity without condoms increases a patients risk of STIs, and can be an indicator of a patients health literacy. Example Question: When was your last asthma attack? important health information. Tina Jones: Whatever pain medication the ER gave me is helping. . Student: Have you used drugs other than marijuana? Well do our best to get you feeling better and, on your way, home as soon as possible. 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. Student: What medication allergies do you have? important information about her health history and any treatment plan she was following. Asking Tina if she has a history of slow healing wounds specifies the symptoms she is experiencing. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! Finding: Reports father was diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Finding: Asked about the effectiveness of pain medication at home. Example Question: Have you been hospitalized in the past? Anywhere. 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. Example Question: Have you had gum problems? Seen in generalized disorders such as thrombocytopenia, and scurvy. Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care. Finding: Reports infrequent eye redness (Available)Pro Tip: Asking about symptoms, such as eye redness, is one possible component of a review of systems interview. Fissure Example Question: Do you take any supplements? Finding: Denies problems with balance or disequilibrium (Available)Pro Tip: Problems with balance can indicate neurological problems, or issues with the inner ear. Her past history of injury also adds to this risk. Finding: Reports history of recreational marijuana smoking (Found)Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted. Fell free get in touch with us via phone or send us a message. Example Question: Have you had any family members with cancer? Asking Tina if her paternal grandfather had diabetes can reveal generational patterns. Examples: mole, wart She lives down the street from us, and she gets around okay. Finding: Denies dry mouth (Available)Pro Tip: Asking about symptoms, such as dry mouth, is one possible component of a review of systems interview. I cant put any weight on it without like, shooting pain." Finding: Reports only prescription is an inhaler (Available)Pro Tip: Determining what, if any, prescription medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions. Student: What preexisting medical conditions do you have? Educate Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. I've worked with many clients post surgery and have NEVER had a single client who's surgeon paid such attention to detail or the recovery process. Intervene Pain: Administer non-pharmacologic interventions to reduce pain. Example Question: Have you had breast cancer? Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patients illness is an essential element of the illnesses history. Tina Jones: I have a monitor at home, but to be honest I dont really use it that often. Finding: Reports right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patients safety. Example Question: Do you have constipation? Shadow Health Skin, Hair, and Nails Tina Jones Objective Data (SHADOWHEALTHSKIN,HAIR,ANDNAILSTINAJONESOBJECTIVEDATA) Exam (elaborations) Shadow Health: Hair, Skin and Nails . She might have high cholesterol too. Finding: Reports last hospitalization was for asthma (Available)Pro Tip: Finding out if Tina has any past hospitalizations is the first step in understanding any past serious medical issues. She expresses gaps in health literacy about the risk of ceasing prescribed medication and blood glucose monitoring. I was pleasantly surprised by the massage chair I was seated in while each foot was pampered with nail trimming, sugar scrubbed, lotioned, and oiled. Examples: chronic lung inflammation, bronchial tumors, heart defects with right to left shunts. 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. You can pause and resume the assignment at any time; your work is always saved automatically. Risk for ineffective respiratory function. Uncovering the age of death can help you assess the patients current risks. Koilonychia: is a nail disease that can be a sign of hypochromic anemia, especially iron-deficiency anemia. Atrophic Scar: the resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Example Question: Do you urinate frequently? patient. 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. Lumps have a range of severity, as they could be the result of breast injury or cancerous growths, but any abnormalities should be handled with the highest level of concern. Malignant melanoma, Primary contact dermatitis Asking Tina if she has scalp problems solicits important health information. In anticipation of Ms. Jones being discharged from the hospital, your role in this . Example Question: Have you been coughing? Finding: Reports excessive facial or body hair (Available)Pro Tip: Increases in body hair can suggest changes in hormone levels. Finding: Reports cause of death was a car accident (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patients case. The patients response to these questions may uncover additional problems, such as nerve damage. I've had multiple girls cut my hair and they do a great job every time!more. ", 6. Tina Jones: Some of my friends smoke when we go out drinking. Past 24 Hours Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. Finding: Reports living in a house (Available)Pro Tip: Learning about your patients living situation helps develop rapport and gives you a broad picture of her lifestyle. Measure the patients blood glucose and provide medication as per the physicians orders. Scale need. This is a review for laser hair removal in Provo, UT: "Highly recommend! Example Question: How many times a day do you take pain medication? 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. A history of incontinence could be a symptom of genitourinary or pelvic problems. Intervene Diet: Provide the patient a diet without concentrated sweets. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Example Question: Do you wear glasses or contacts? Onycholysis: A slow, persistent fungal infection of fingernails and, more often, toe nails, common in older adults, Fungus causes change in color (green where nail plate separates from bed), texture, thickness, with nail breaking or crumbling and loosening of the nail plate, usually beginning at the distal edge and progressing proximally. Finding: Reports maternal grandfather diagnosed with high cholesterol (Available)Pro Tip: Family histories might indicate a genetic predisposition. Example Question: Have you had jaw problems? Example Question: Are you able to hold your urine? Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will need. Example Question: Have you ever taken medication for your diabetes? Finding: Asked about drainage from the foot wound. Student: How effective was the Neosporin? Finding: Denies muscle weakness (Available)Pro Tip: Asking about muscle weakness is one possible component of a review of systems interview. Example Question: Do you have any nose problems right now? Occurs with any trauma that temporarily impairs nail formation, such as acute illness, toxic reaction or local trauma. The patients response to questions about this topic may uncover additional problems not discovered during the discussion of the patients chief complaint. Example Question: How did your injury happen? A history of hematuria could be a symptom of genitourinary problems. Shadow Health. hover over the patient data Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions University of California Los Angeles Keiser University Example Question: Do you have any food allergies? Finding: Reports eating a bowl of cereal for breakfast yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patients typical dietary patterns. Pro Tip: Sun exposure can directly affect a patient's skin. Asking Tina if her skin has been dry solicits important health history information. Every hour or two when Im awake? Finding: Asked review of systems for gastrointestinal. This patient had a compression body suit, drains for the lymph fluid, and compression half boots. This record provides necessary information for healthcare professionals who will continue patient care. Student: Did your father die from any disease? Finding: Denies difficulty swallowing (Available)Pro Tip: Asking if a patient has difficulty swallowing is one possible component of a review of systems interview. Confluent: lesions run together: Urticaria, hives Presence of dizziness could indicate a reaction to medication, an inner ear problem, or changes in blood sugar or blood pressure. Example Question: Did the metformin cause any side effects? Existing conditions can also inform your treatment and understanding of the patients current health issues. Please let cashiers know when check-out.more, PhenomeNails isnt just a nail salon, its an absolute beauty and relaxing experience. Examples: mosquito bite, allergic reaction While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. Example Question: Has your hearing changed? Diana Shadow: Hi. Koilonychia literally means "spoon nails." Shadow Health- Tina Jones- Hair, Skin, Nails. http://www.yelp.com/search?find_desc=Nail+Salons&find_loc=Salt+Lake+City%2C+UT&ns=1, Hmmm, I got a pedi today. Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patients blood sugar monitoring habits are an important part of her health literacy and home treatment. Example Question: What pain medication have you been taking? Example Question: Have you had a runny nose? Example Question: What is your highest level of education? The patients response to questions about this topic may uncover additional problems not discovered during the discussion of the patients chief complaint, such as vision loss. Has 10 years experience. An athlete should not lose more than 3 percent of his or her body weight during any practice session. Student: Do you currently take medicine for your diabetes? Student: What are my objectives in this assessment? Model Statement: "I understand how it can feel like a frustrating chore to check your sugar every day. She reports intense pain on a numerical scale and describes pain characteristics. Finding: Denies chills (Available)Pro Tip: Asking about additional symptoms, such as chills, is one possible component of a review of systems interview. Evidence Relevant: "I mean, its all red and swollen, and theres pus, it feels hot, it hurts like hell Its got all that going on." Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment. Finding: Reports last tetanus vaccination was in the past year (Found)Pro Tip: For a patient with a recent scrape on a metal surface, confirming the last date of a tetanus shot is essential to prevent any diseases from contact. Symptoms like these could indicate a yeast or sexually transmitted infection. Asking Tina where her moles are located solicits important information about her skin. Student: So that you understand if there are any problems related to their chief complaint. Example Question: How many times have you been hospitalized? Finding: Denies circulation problems (Available)Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. The patients response to these questions may uncover additional problems not discovered during discussion of the patients chief complaint. Student: Does your family have a history thyroid issue? It's 4 p.m. on Tina Jones' second day as a patient here at Shadow General Hospital. 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 patients risk of disease, infection, injury, and complications educate and empathize reflect on your experience and identify areas to improve identify and prioritize nursing diagnoses and develop a plan to address nursing diagnoses. As a currently presenting symptom, it could impact the patients care plan. If the patient reports a history of constipation, it could be a symptom of dietary or gastrointestinal problems. Finding: Reports last dental visit was several years ago (Available)Pro Tip: Asking about a patients dental care is one possible component of a review of systems interview. Example Question: How long does the pain medication last? Finding: Denies painful or difficult urination (Available)Pro Tip: Asking about pain during urination is one possible component of a review of systems interview. Example Question: Do you have a headache? Example Question: Can you please describe the pain? Example Question: What is your reaction to penicillin? We could start you at a low dose, which reduces the side effects. Example Question: Do you have a family history of thyroid problems? Texture: smooth, firm and even surface Thickness: uniformly thin over most of the body Edema Mobility and turgor: ease of rising and ability to promptly return Vascularity or bruising: Cherry (senile) angiomas Edema: edema is fluid accumulating in the intercellular spaces. Auscultate the lungs to listen for abnormal sounds. After obtaining Ms. Jones health history, you will complete an information processing activity. I would hands down choose his clinic. Pro Tip: Establishing information about the character of Tina's skin, like whether the skin on her neck hurts, will allow you to compare her symptoms and assess her condition. Asking Tina if her wound is warm to the touch specifies the symptoms she is experiencing. Asking Tina if her father had high cholesterol can reveal generational patterns. Example Question: Do you lose your balance often? Let us have a look at your work and suggest how to improve it! Finding: Denies corrective lenses (Available)Pro Tip: Asking about the patients use of corrective lenses is one possible component of a review of systems interview. 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 dont fall behind. Example Question: Whats causing your pain? Tina Jones: Well, Im here, so I guess it didnt do its job. Pro Tip: Establishing information about the character of Tina's skin, like when she noticed the skin on her neck changing, will allow you to compare her symptoms and assess her condition. Finding: Reports she is currently under high stress (Found)Pro Tip: Stress can cause both physical and mental health problems and complications. Finding: Reports taking 2 pills each time (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. Example Question: Do you have stomach pain? Finding: Denies ear pain (Available)Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has nail fungus solicits important First, gain a deep understanding of your patients situation. patient. Finding: Denies history of urinary tract or bladder infection (Available)Pro Tip: Asking about a history of bladder or urinary tract infections is one possible component of a review of systems interview. Finding: Reports last penicillin reaction was in childhood (Available)Pro Tip: Determining a patients last reaction to penicillin is part of gathering thorough information about her allergy. her neck is tingly, will allow you to compare her symptoms and assess her condition. Student: Do you currently take medicine for your diabetes? Student: Do you monitor your blood glucose? Wheal Example Question: Are you drinking more water than normal? Pro Tip: Establishing information about the character of Tina's skin, like whether the skin on her neck is itchy, will allow you to compare her symptoms and assess her condition. Bulla: Larger than 1cm diameter; usually single chambered; superficial in epidermis, it is thin walled, so it ruptures easily. Tina Jones: UmIve smoked pot before. As a currently presenting symptom, flank pain could result in a change to the patients care plan. Example Question: Does your paternal grandfather have health conditions? Finding: Asked about patients living situation. Also seen with pneumococcal meningitis, Basal cell carcinoma Scar: after a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). Lichenification Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Student: What additional symptoms have you experienced? The patients response to questions about this topic may uncover additional problems not discovered during the discussion of the patients chief complaint, such as unspecified allergies. Before the use of systematic names, many compounds had common names. Learn. Student: Do you have any problems with your head? Home Flashcards Shadow Health Tina Jones, Health History. Tina Jones: No, I dont think so. Jones Shadow Health Respiratory Physical assessment Assignment Latest shadow Health on the findings in the Shadow Health Skin Hair Nails assessment. Tina Jones: I made sure to clean it and keep it bandaged. Asking Tina if she has dry eyes solicits information about one particular symptom. Every day ER gave me is helping health skin hair Nails assessment about the risk ceasing. Quickly as possible has shadow health tina jones skin, hair and nails quizlet dry solicits important first, gain a deep understanding of the 's! 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