Shadow Health Comprehensive Health Assessment Latest Update 2024 2025 Already PASSED | Exams Nursing | Docsity (2024)

Download Shadow Health Comprehensive Health Assessment Latest Update 2024 2025 Already PASSED and more Exams Nursing in PDF only on Docsity! lOMoAR cPSD|37147900 Shadow Health Comprehensive Health Assessment Latest Update 2024-2025 Already PASSED Example Question: Are you up to date on your immunizations? Finding: Denies history of illness Pro Tip: Inquiring into the client's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the client's existing health conditions and a timeline of diagnosis, symptoms, and allergies can indicate where you should follow up to support further care and treatment. Example Question: Have you ever had a serious illness? Finding: Reports diagnosis of gender dysphoria 3 years and 6 months ago Pro Tip: Inquiring into the client's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the client's existing health conditions and a timeline of diagnosis, symptoms, and allergies can indicate where you should follow up to support further care and treatment. Example Question: Have you had any major diagnoses? -Asked about past surgical history Finding: Denies surgeries Pro Tip: Inquiring into the client's relevant history can reveal past diagnoses and previous conditions or concerns. It is important to determine if the client has received any surgeries that could impact their options for current care. Example Question: Have you ever had any surgeries? -Asked about last visit to a healthcare provider Finding: Reports last seeing a provider three months ago Pro Tip: Establishing a timeline for the client's provider visits will allow you to develop a comprehensive health history. Example Question: When did you last visit your primary care provider? Finding: Reports seeing provider for regular hormone therapy follow-up Pro Tip: Establishing a timeline for the client's provider visits will allow you to develop a comprehensive health history. Example Question: What was the purpose of your last visit with your provider? -Asked about current prescription medications Finding: Reports currently taking testosterone enanthate for gender-affirmation therapy Pro Tip: The medications that a client takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking the client about their current prescription medications will indicate their recent health history and any conditions or problems they might be experiencing. Example Question: What are your current prescription medications? -Followed up on testosterone therapy Finding: Reports taking testosterone once per week Pro Tip: Follow-up questions about a client's prescription medication will help you to understand their treatment plan and recent health history. Example Question: How often do you take testosterone? Finding: Reports testosterone is in injection form Pro Tip: Follow-up questions about a client's prescription medication will help you to understand their treatment plan and recent health history. Example Question: How do you administer the testosterone? Finding: Reports having taken testosterone for 3 years and 6 months Pro Tip: Follow-up questions about a client's prescription medication will help you to understand their treatment plan and recent health history. Example Question: How long have you been taking testosterone? Finding: Reports dosage is 100 milligrams Pro Tip: Follow-up questions about a client's prescription medication will help you to understand their treatment plan and recent health history. Example Question: What dosage is your testosterone? Finding: Reports the last dose of testosterone was two days ago Pro Tip: Follow-up questions about a client's prescription medication will help you to understand their treatment plan and recent health history. Example Question: When was your last dose of testosterone? -Asked about current over-the-counter medications Finding: Denies over-the-counter medications Pro Tip: The medication a client takes indicates their health literacy, treatment plan, and access to healthcare. Asking the client if they take non-prescription drugs will indicate their current treatment plan. Finding: Reports snacking on nuts, raisins, or crackers after workouts at the gym Pro Tip: Asking questions about the client's diet can be particularly informative. Discovering what the client typically has for a snack will illustrate their recent dietary patterns. Example Question: What do you normally have for a snack? Finding: Reports drinking eight to ten glasses of water a day Pro Tip: Asking questions about the client's diet can be particularly informative. Discovering a client's hydration habits will help to give you a fuller picture of their recent health history. Example Question: How many glasses of water do you drink each day? Finding: Denies following a diet Pro Tip: Asking questions about the client's diet can be particularly informative. Discovering if the client has any dietary restrictions will help to give you a fuller picture of their nutrition intake. Example Question: Do you have any dietary restrictions? -Asked about caffeine intake Finding: Reports drinking one to two cups of coffee per day 6. Social History -Asked about alcohol intake Finding: Reports drinking once or twice a month Pro Tip: Discovering the details of any client's alcohol intake is important, as alcohol use can have a significant impact on bodily systems, as well as exacerbate health conditions. Example Question: How often do you drink alcohol? Finding: Reports drinking 2 shot glasses of whiskey in a sitting Pro Tip: Discovering the details of any client's alcohol intake is important, as alcohol use can have a significant impact on bodily systems, as well as exacerbate health conditions. Example Question: How many alcoholic drinks do you typically have in a sitting? -Asked about tobacco use Finding: Denies smoking Pro Tip: Finding out if a client uses tobacco products is important to understanding their overall health and identifying potential health risks. Example Question: Do you smoke? Finding: Denies vaping Pro Tip: Finding out if a client uses tobacco products is important to understanding their overall health and identifying potential health risks. Example Question: Do you vape? Finding: Denies hookah use Pro Tip: Finding out if a client uses tobacco products is important to understanding their overall health and identifying potential health risks. Example Question: Do you use a hookah? -Asked about marijuana use Finding: Denies marijuana use Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues. It is also good practice to identify the purpose of drug use, such as recreation or pain management. Example Question: Do you use marijuana? -Asked about recreational drugs Finding: Denies recreational drug use Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues. It is also good practice to identify the purpose of drug use, such as recreation or pain management. Example Question: Do you use any recreational drugs or substances? -Asked about exercise Finding: Reports exercising 6 to 8 hours per week at the gym Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking the client about their exercise habits can help you to assess their current levels of health and nutrition. Example Question: Do you exercise regularly? Finding: Reports being "on his feet a lot" when theater is open 7. Mental Health -Asked about mental health Finding: Denies depression Pro Tip: Asking about the client's mental health is important for understanding their overall well-being. It may also reveal problems not covered elsewhere in the assessment. Example Question: Have you been experiencing any depression? Finding: Reports situational anxiety -Asked about income Finding: Reports temporary income insecurity -Asked about family medical history Finding: Reports mother has a history of alcohol use disorder Pro Tip: A client's family medical history can indicate if the client is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a client's current condition. Example Question: Tell me about your family's medical history. Finding: Reports mother has depression Pro Tip: A client's family medical history can indicate if the client is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a client's current condition. Example Question: Tell me about your family's medical history. Finding: Reports father in good health 11. Binder Use -Asked about binder use Finding: Reports wearing binder every day Pro Tip: If a client wears a chest binder, it is important to determine the details of binder use. Long-term binder wear can sometimes affect the health of a number of bodily systems. Example Question: How often do you wear your binder? Finding: Reports wearing binder for 4 to 6 hours per day Pro Tip: If a client wears a chest binder, it is important to determine the details of binder use. Long-term binder wear can sometimes affect the health of a number of bodily systems. Example Question: How many hours do you wear your binder per day? -Followed up on binder use Finding: Reports some discomfort from binder use