Nursing Health Assessment of Tina Jones, Exams of Nursing

Download Nursing Health Assessment of Tina Jones and more Exams Nursing in PDF only on Docsity! 1 NUR 3700: Nursing Health Assessment LATEST UPDATED 2023// 2TINA JONES HEALTH HISTORY NARRATIVE 1 INTRODUCTION A complete health history based upon work in Shadow Health was completed on Tina Jones, a twenty-eight year old woman. Ms. Jones came in through the emergency department for an injury to her right foot. Utilizing interviewing and clinical skills, and clinical reasoning skills, the ability to perform a health history was successful. 5TINA JONES HEALTH HISTORY NARRATIVE Ms. Jones’s chief complaint is that “I hurt my right foot one week ago” They said I needed to get admitted to the hospital. 5 HISTORY OF PRESENT ILLNESS Ms. Jones has an open wound to her right foot located on the plantar surface. She has asthma and type II diabetes. She injured her foot by scraping the bottom of a stepping stool. She states that she 6TINA JONES HEALTH HISTORY NARRATIVE was barefoot at the time of the injury. She states that her current pain is 7/10, and last received medication in the emergency department that seems to be helping. She states that her pain is made worse when she stands, and is unable to bear weight on her right foot. She does 7TINA JONES HEALTH HISTORY NARRATIVE not monitor her blood sugar and does not take any medications to control her diabetes. She reports that her asthma is triggered when exposed to cats, dust, or running upstairs. Her blood pressure is also high as well as being febrile with a temperature of 39.1 C. 6 MEDICATIONS She uses a Proventil (Albuterol 90mcg/spray MDI) inhaler for asthma. 10TINA JONES HEALTH HISTORY NARRATIVE hospitalized for asthma when she was in high school. She has experienced an unexpected weight loss of ten pounds. She states that she has been excessively thirsty. She is experiencing nocturia. Her menstrual periods are irregular and heavy, with her last menstrual period being three weeks ago. 9 HEALTH MAINTENANCE 11TINA JONES HEALTH HISTORY NARRATIVE Ms. Jones’ last Pap smear was more than four years ago. Her last eye exam was during her childhood. Her last dental exam was a few years ago. Her last PPD was negative approximately years ago. She does not exercise. Her typical diet consists of breakfast: a muffin or pumpkin 12TINA JONES HEALTH HISTORY NARRATIVE bread; lunch: a sub sandwich; dinner: meatloaf or chicken with soup; snacks: pretzels or when she wants to treat herself French fries. 10IMMUNIZATIONS She reports a tetanus booster a couple of years ago. She did not receive an influenza vaccine this year and it has been several years since her last 15TINA JONES HEALTH HISTORY NARRATIVE heart attack. He also had a history of high blood pressure and hyperlipidemia. Ms. Jones has a younger sister and also has asthma. Her brother has no known medical problems, but Ms. Jones reports that he is overweight as well as most of her family. Her paternal uncle is an alcoholic. 12SOCIAL HISTORY Ms. Jones is very active in church and with family. She goes out occasionally 16TINA JONES HEALTH HISTORY NARRATIVE with friends dancing. She also enjoys bible study and volunteering with her church. She previously lived alone, but moved back in with her mom and younger sister to help with finances and to help care for her sister after the death of her father. She is working on her bachelor’s degree in accounting. 17TINA JONES HEALTH HISTORY NARRATIVE She does not use tobacco products and is exposed to secondhand cigarette smoke when she is out with friends. She does not use drugs, but tried pot when younger. Ms. Jones drinks diet coke soda. She drinks socially only two to three times per month when out with friends. She is currently single. She is currently not on contraceptives, but used birth control while sexually active with previous partner. She is not currently 20TINA JONES HEALTH HISTORY NARRATIVE the headaches. There is no family history of headaches. She denies any head trauma. Patient states that her vision gets blurry when reading or studying. She states that her eyes do not hurt when her vision gets blurry. Her eyes get red and itchy when she is around cats. She also sneezes and experiences rhinitis and congestion around cats. She has not had an eye exam since childhood. She does not wear glasses or contacts. She states 21TINA JONES HEALTH HISTORY NARRATIVE that she has no problems with her mouth. She states that her nose is fine, denies nasal discharge. She states that her hearing is fine. There is no family history of hearing problems. She denies head and neck trauma, ringing in the ears, ear pain, discharge, and loss of balance. She does not have a history of sinus problems, frequent colds or infections. She denies difficulty swallowing and changes to her voice. She denies any dental issues and 22TINA JONES HEALTH HISTORY NARRATIVE has not gone to the dentist since she was a kid. She has not had any changes in her taste. 25TINA JONES HEALTH HISTORY NARRATIVE breath, chest pain, and congestion. She admits that she gets congested around cats. Her sister rarely has issues with her asthmas. She denies smoking, drug use, and she denies the use of tobacco. She is only around second hand smoke when she goes out with friends. She has been hospitalized as a child and in high school for problems with her asthma. She denies a history of TB, chest pain, difficulty breathing, and cough. 26TINA JONES HEALTH HISTORY NARRATIVE 16ABDOMINAL Ms. Jones denies digestive problems. She states that she has recently lost ten pounds without trying over the past month. She denies flank pain, dysuria, and urgency. She denies UTI’s. She also states that she is really thirsty and has been drinking a lot of water. She denies, reflux, problems swallowing, nausea, vomiting, constipation, changes in bowel habits, abdominal pain, and blood in her 27TINA JONES HEALTH HISTORY NARRATIVE urine. Polyphagia, polydipsia, polyuria, and nocturia have been occurring during the past month. She denies vaginal discharge and itching. She does not have a history of sexually transmitted diseases. She has never been pregnant. Her period are irregular. 30TINA JONES HEALTH HISTORY NARRATIVE her memory is good. She denies: any issues with her memory, consciousness, confusion, disorientation, decrease in sensation, dizziness, tremors, altered gait or balance, and tingling. She denies having difficulty swallowing. She states that her hearing is fine. She denies weakness and denies a decrease in strength. She denies a decrease in sensation. She denies any changes in her ability to taste and smell. Her mood and 31TINA JONES HEALTH HISTORY NARRATIVE affect are appropriate. She is able to provide a clear account of historical and recent events. She denies any history of neurological injuries and complications. She reports headaches that occur once a week behind the eyes with prolonged reading. These headaches are resolved with acetaminophen and sleep. She denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. She reports 32TINA JONES HEALTH HISTORY NARRATIVE occasional clumsiness. Denies history of traumatic brain injury. Denies recent changes in memory and mood changes. 35TINA JONES HEALTH HISTORY NARRATIVE diagnoses include: asthma, fever, weight loss, diabetes, allergies, and right foot open wound. She will need to be assessed for infection; her asthma may need to be furthered assessed with possible medication changes. Her diabetes will be also need to be further assessed. Clinical reasoning was used to decide upon and list these diagnoses through notation and by localizing abnormal findings. Her family history 36TINA JONES HEALTH HISTORY NARRATIVE also impacts the clinical reasoning of nurses. 21CARE PLAN The care plan is wide-ranging. Her care plan will include her life-span stage of development. It will include education, medications, tests, referrals, return visits, and support. It will further include responses to the plan and results from tests and referrals. Including the patient’s support system and goals is also 37TINA JONES HEALTH HISTORY NARRATIVE important for a successful plan. Tina’s individualized Plan of Care based upon her clinical findings will include medications, blood work, imaging and further tests. She is in need of a consult for diabetic education. She will need routine glucometer checks. Due to her fever she will need antibiotics as well as Tylenol to stop the infection as well as stop the 40TINA JONES HEALTH HISTORY NARRATIVE increased hunger, fatigue, vision problems, and the slow healing of her right foot open wound are most likely caused by her uncontrolled type II diabetes. By monitoring and controlling her diabetes these symptoms will decrease. She will need to be re- prescribed medications for her diabetes along with education about the medications to treat her medical problems. Referring her to a diabetes 41TINA JONES HEALTH HISTORY NARRATIVE educator will be beneficial in providing Ms. Jones with comprehensive diabetes education, control, medication, and maintenance. Her fever, high blood sugar, as well as her high blood pressure should also be further examined. She should also be referred to a gynecologist to have her irregular and heavy bleeding assessed and treated. 22CULTURAL CONSIDERATIONS 42TINA JONES HEALTH HISTORY NARRATIVE According to the CDC the ten leading causes of death for African Americans are heart disease, cancer, stroke, diabetes, unintentional injuries, kidney disease, chronic lower respiratory disease, homicide, septicemia, and Alzheimer’s disease. Ms. Jones not only is African American, but she also has a strong family history of heart disease, cancer, stroke, and diabetes, which 45TINA JONES HEALTH HISTORY NARRATIVE The first category of individual characteristic applies to Ms. Jones’s diabetes, asthma, and family history of stroke, heart attack, hypertension, and high cholesterol. Her previous behaviors such as not exercising, not monitoring and treating her diabetes; and not seeking regular health, dental, and eye exams are also fall in the first category. In addition, to the category are the cultural and ethnic 46TINA JONES HEALTH HISTORY NARRATIVE factors that cause her to be at an increased risk for specific diseases. With the proper guidance as well as education Ms. Jones will being able to understand the impact that her current medical problems and that by following the action plan will result in a change to her health promotion behavior.