NUR 3700 Nursing Health Assessment Tina Jones Health History Narrative
Health History
Pertinent Clinical Information:
“Tina Jones is
... [Show More] a 28 year old African American female who has been admitted to Shadow General Hospital after a fall at home 2 weeks ago. In the fall, she scraped her right foot. She is seeking medical care because that scrape has become infected and is painful. She has a history of asthma and type 2 diabetes.
This week you will meet Tina and complete a comprehensive review of systems on her. I hope you will enjoy talking with and getting to know her. When taking a health history, whether practicing on Tina or talking with one of your patients in a clinical setting, it is important to be able to identify both pertinent positive and negative findings quickly in order to provide optimal care and create your plan of care for your patients. You will use these skills every day, and we will continue to hone and refine your skill set throughout the semester.”
Top of the Document
Notes:
HEENT
Pertinent Clinical Information:
“Tina has a couple different things to pick up on during the HEENT exam. First, she has some complaints of worsening vision over the last few years. Vision 20/20 in left eye, 20/40 in right eye. Mild retinopathic changes in the right eye. Acanthosis nigricans noted on neck.
You will be performing an assessment of the Head, Eyes, Ears, Nose and Throat (HEENT) on Tina as well as an assessment of her skin. These assessments are each in their own respect an important piece of the entire picture. By performing a thorough HEENT assessment you can detect things like strokes (uneven smile), cranial nerve damage (asymmetry, as seen in bell’s palsy), and hearing loss.”
Respiratory
Pertinent Clinical Information:
“Tina reports asthma and inhaler use, difficulty breathing around cats resolved with inhaler use. Expiratory wheezing, prolonged expiration (LLL, RLL, LML, RML). Muffled voice sounds throughout. No current respiratory distress.
The lungs work in conjunction with the heart to oxygenate the blood, and then circulate that blood through our bodies, thereby keeping us alive. There are many different types of respiratory sounds that you will need to familiarize yourself with – consolidation, wheezing, and decreased breath sounds are among some of the most frequently seen in clinical practice.”
Cardiovascular
Pertinent Clinical Information:
“In this assessment, you will find that Tina has decreased peripheral pulses and mild edema (+1) in her right foot. She has no murmurs, gallops, or bruits.
The human heart is one of the most important and complex organs in our bodies. There is a lot to learn in order to be able to assess it properly. We cannot use our eyes for the assessment, so we need to rely heavily on our ears and hands to do the work. It takes a lot of patience and practice to be proficient at differentiating between bruits, murmurs, gallops, and normal heart sounds.”
Abdominal
Pertinent Clinical Information:
“Tina has lost 10 pounds this month, is eating more, drinking more, and voiding more. She discontinued taking her metformin on her own about 3 years ago. Protruberant abdomen with striae and normal BS.
Abdominal pain can be a daunting complaint to hear from a patient in your primary care office or hospital setting. The diagnosis can range from something as benign as constipation, to something as acutely serious as pancreatitis or appendicitis. It is important to understand the anatomy and physiology of both normal function and pathologic conditions of the abdomen to enable you to logically rule in or rule out specific conditions on your list of differential diagnoses.”
Musculoskeletal
Pertinent Clinical Information:
“Tina’s right ankle: 1+ pitting edema, no masses, deformity, or discoloration. 2.5cm round wound noted on the ball of her foot. Right leg is without swelling or deformity. Right ankle is found to have limited range of motion and decreased strength.
The Musculoskeletal exam can be time consuming because it is a large system with a lot of different parts. Back pain and neck pain are some of the most common presenting complaints no matter what setting you work in – whether you are a nurse in the hospital or a primary care office. Discussing functional limitations, symptoms, past or recent injuries as well as using your eyes and hands to do you a physical assessment will give you a nice picture of your patient’s motor function.”
Neurological
Pertinent Clinical Information:
“Tina is alert and oriented x3, memory is good, denies numbness, tingling, recent mood changes, or history of depression or mental illness. On exam it is uncovered that Tina does have decreased sensation in both her left and right foot. Neuropathy like this is often seen in diabetic patients – especially in the extremities.
A thorough neurologic exam in order to use it as a screening tool or an investigative tool, and can tell you a great deal about your patient’s brain. You will look at sensory and motor responses, reflexes, and talk with them to determine their memory and orientation to time, place, and day. Putting all of the parts of your assessment together will give you a pretty clear picture of your patient’s neurologic health.”
Skin, Hair, and Nails
Pertinent Clinical Information:
“Tina has a 2.5 cm round wound on her right foot. There is edema present, along with discharge. The area is warm to the touch.
The skin is the largest organ in the body. Performing a thorough assessment can tell us a lot about the patient’s general physical condition. Cyanosis around the mouth or on the extremities can tell us about their oxygenation status, skin pallor can tell us a great deal about their hemoglobin level, and changes in nail thickness, splitting, discoloration, breaking, and separation from the nail bed may be a sign of a systemic condition.” [Show Less]