Week 9 NURS 6512 SHADOW HEALTH DOCUMENTATION

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Week 9 NURS 6512 SHADOW HEALTH DOCUMENTATION

Week 9 NURS 6512 SHADOW HEALTH DOCUMENTATION

Review of Systems – General General: Tina denies fatigue, fever, or chills HEENT: patient denies hearing issues, double vision, sneezing/rhinitis, denies issues with swallowing/eating, denies tenderness to neck and has full ROM. Skin: denies any rashes, itchiness, dry skin, wounds, scars, Respiratory: patient denies SOB, wheezing, asthma excaerbations, cough. Cardiovascular: Tina denis palpitations, chest pain, tightness, discomfort, or edema Gastrointestinal: denies nausea, vomiting, diarrhea, constipation, heartburn, gas Genitourinary: Denies frequency, urgency, polyuria, urine yellow straw-colored, denies heavy period flow, irregular menses, or cramping. Neurological: denies any numbness, tingling, dizzyness, headaches, or change in bowel/bladder control. Musculoskeletal: denies weakness, pain, verbalizes steady gait, Hematologic/Endocrin: denies any easy bruising, blood clots, denies issues iwth diabetes (in good control), denies heat/cold intolerance Psychiatric: denies depression, anxeity, mood swings, stress.

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HEENT Student DocumentationStudent Documentation Model DModel D

This study source was downloaded by 100000822789681 from CourseHero.com on 04-30-2021 17:00:07 GMT -05:00 Week 9 NURS 6512 SHADOW HEALTH DOCUMENTATION

https://www.coursehero.com/file/54062835/Tina-Comprehensive-Assessment-Shadow-Health-Documentationpdf/

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https://www.coursehero.com/file/54062835/Tina-Comprehensive-Assessment-Shadow-Health-Documentationpdf/
1/29/2020 Blackboard Learn

https://class.waldenu.edu/webapps/blackboard/content/contentWrapper.jsp?course_id=_16633159_1&displayName=Shadow+Health+NURS6512&hr… 4/7

Student DocumentationStudent Documentation Model DModel DSubjective Patient verbalizes use of glasses, no problems with hearing, swallowing, mourht, or neck problems.

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Objective Head: head supples, no masses noted, no tenderness Eyes: no limitations to vision, extraoccular movemnts intact, sclera white and conjunctiva pink/moist, field of vision intact. Ears: hearing normal, passed whisper test, all structures intact and WNL Nose: membranes moist/pink, no inflammation, drainage noted. Mouth: teeth intact, gums pink/intact, toungue pink without defect Neck: no tenderness, no masses palpaable, full ROM, thyroid normal size

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Respiratory Student DocumentationStudent Documentation Model DModel D Subjective No complaints of SOB, wheezing, cough, pain upon inspiration/expiration, uses inhalers as prescribed.

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Objective Inspection of chest anteriorly and posteriorly WNL, no tactile fremitus throughout, chest expansion equal/symmetrical and without difficulty, all areas posteriorly resonant, and anteriorly as well, lung sounds clear throughout without any crackles, or wheezes, or rubs noted. Week 9 NURS 6512 SHADOW HEALTH DOCUMENTATION

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Cardiovascular

Student DocumentationStudent Documentation Model DModel D This study source was downloaded by 100000822789681 from CourseHero.com on 04-30-2021 17:00:07 GMT -05:00

https://www.coursehero.com/file/54062835/Tina-Comprehensive-Assessment-Shadow-Health-Documentationpdf/

Th is

stu dy

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ur ce

w as

sh ar

ed v

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ou rs

eH er

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https://www.coursehero.com/file/54062835/Tina-Comprehensive-Assessment-Shadow-Health-Documentationpdf/
1/29/2020 Blackboard Learn

https://class.waldenu.edu/webapps/blackboard/content/contentWrapper.jsp?course_id=_16633159_1&displayName=Shadow+Health+NURS6512&hr… 5/7

Student DocumentationStudent Documentation Model DModel DSubjective Patient denies palpitations, chest pain.

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Objective S1, S2, no murmurs, all pulses 2+ throughout with no bruits/thrills, PMI nondisplaced with no heaves or lifts, capillary refill in both hands and feet <2 sec/brisk.

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Abdominal Student DocumentationStudent Documentation Model DModel D Subjective No complaints of reflux, gas, pain, diarrhea, constipation, bleeding in stools, daily bowel movements with no difficulties.

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Objective Bowel sound normoactive all quadrants, no masses palpable, soft and non-tender, liver palpable 1cm below right costal margin, spleen not palpable, kidneys not palpable and no masses, absence of CVA tenderness,

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Musculoskeletal Student DocumentationStudent Documentation Model DModel D Subjective No complaints of weakness, pain, or difficulty walking, or picking up, or bending/twisting. Week 9 NURS 6512 SHADOW HEALTH DOCUMENTATION

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This study source was downloaded by 100000822789681 from CourseHero.com on 04-30-2021 17:00:07 GMT -05:00

https://www.coursehero.com/file/54062835/Tina-Comprehensive-Assessment-Shadow-Health-Documentationpdf/

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