Tina Jones Comprehensive Assessment
NSG323
NSG 323
Comprehensive Assessment:
Tina Jones
Tina Jones is a 28 year old African America women. She
... [Show More] came into the clinic for a physical exam.
She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. She is required to have a physical exam for her health insurance. Tina's health history was taken, a physical assessment was done and a plan of care was made.
Health History
Health history is a very important part of assessment for practitioners. When interviewing the patient the practitioner is able to get a health history and the history of the patients chief complaint. Through the interview process the practitioner is als
o able to find out what the patient believes is most important about their health (Bickley, 2013).
Tina is a 28 year old African American women. She is in the clinic today for a physical exam for her new job. She is the primary source of health history. Tina's speech
is clear and coherent. She maintains eye contact throughout the interview. Tina is alert and oriented. She is well-developed and dress appropriately with good hygiene.
She does not appear to be in any distress.
Tina is allergic to cats, she states that she tries to avoid cats but when she is around them her asthma "acts up" (T. Jones, Shadow Health Interview, February 13, 2016). She states that she has tightness in her chest and wheezing. She is allergic to PCN. She states that she "got a ra sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). She denies any food and latex allergies. She denies having any recent allergies to dust or pol
len. She states that she has had problems in the past but they have not h
appened in "a while" (T. Jones, Shadow Health Interview, February 13, 2016). She states that her daily inhaler has helped with her environmental allergies.
Tina has been diagnosed with diabetes, asthma and polycystic ovarian syndrome (PCOS). Tina was diagnosed with Diabetes at age 24. Tina checks her blood sugar once a day, in the morning. Her diabetes is being treated with metformin 850 mg PO BID. She has changed her diet recently to help with her diabetes. She limits her carbohydrates and avoids sugar. Tina was diagnosed with asthma at age 2 1/2. She is treating her asthma with a daily inhaler as well as
a rescue inhaler. Her daily inhaler is Flovent 88mcg/spray MDI 2 puff BID. Her rescue inhaler is 90 mcg/spray MDI 2 puff PRN for shortness of breath. She states that her daily inhaler has improved her asthma. She states that her last asthma attack was 3 months ago. She states that when she has an attack her chest feel tight and she has wheezing. She states that it feels like she "cant' get enough air”. Her last asthma related hospitalization was when she was 16. She states that her asthma is worst when around cats but she also has problems with dust and running up stairs. Tina was recently diagnosed with
PCOS
.
Her OB/GYN started her on Yaz birth control to treat the PCOS. The
Yaz is
being used to co ntrol
and lessen symptoms of PCOS.
She has noticed that her periods are more regular and her cramps are not "as bad
" (T.
Jones, Shadow Health Interview, February 13, 2016).
She also states that her
menstrual flow is medium. She had a pap smear done 4 months ago.
She uses Advil
to
treat her cramps
when she gets them (T. Jones, Shadow Health Interview, February 13, 2016).
TINA JONES ASSESSMENT
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She has a family history of hypertension (HTN), high cholesterol, diabetes, and colon cancer. Her mother is still aliv
e and has high cholesterol and HTN. Her father died
a year ago in a car accident. He had a history of HTN, high cholesterol and diabetes. Tina's paternal Grandfather died from Colon cancer and also had HTN and diabetes. Her paternal Grandmother is living
and has a history of HTN. Her maternal Grandfather died
from a heart attack and had a history of HTN and high cholesterol. Tina's maternal Grandmother died from a stroke and had a history of HTN and high cholesterol. Her Sister has asthma and her Brother i
s over
-
weight
(T. Jones, Shadow Health Interview, February 13, 2016)
.
A review of systems was done with Tina. The practitioner found the following:
General:
Tina has lost some weight due to diet and exercise changes. Pt denies any fever or night sweats. P
t is alert and oriented She is coherent to answer questions. HEENT:
Denies fever. Reports that she has not been sick recently. She states that she has been sleeping well and has a good amount of energy. Tina denies any ear problems. She denies any hearing
problems
or pain in her ears. She is wearing eye glasses. She denies any
recent blurry vision. She had an eye appointment 3 months ago. She states that at her eye appointment the doctor stated that she was near sighted and needed to wear glasses. She denie
s recent headaches. She states that she has not had a hea da
che in 6 months. She
thinks that her last headache was when she was studying. Denies any nasal problems or surgeries. She states that she only sneezes when she is around cats. She denies having any nosebleeds. Denies any mouth problems. Denies any changes in taste. Denies mouth pain
or dryness. Denies any problems with jaw. Denies any oral surgeries. She states that she went to the dentist 5 months ago. She states that the dentist said her teeth loo
ked good.
TINA JONES ASSESSMENT
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Denies neck pain. Denies any changes in voice. Respiratory: She denies any shortness of breath, wheezing, cough and chest pain. Cardiac: Tina denies any cardiac problems. She has had elevated BP in the pa
st but her BP today is normal.
She denies
any dizziness or lighthead
ed
ness. She had an EKG done in the clinic, but she doesn't
remember the rests.
She
states that she know that everything was "normal." She denies any edema and easy bleeding.
Abdominal: Tina
has lost some wait since her first visit to the Shadow Health
Clinic. She has started eating better and exercising. She denies any nausea, diarrhea, constipation or any other GI problems. She states that her bowel movements are regular although she cannot describe her bowel movements. She has no
history of GI problems
and she has no family history of GI problems. Musculoskeletal: Tina denies any problems with her joints or muscles. She has n
o
t had any trouble walking and her gait is normal.
She denies any pain in her joints at this time. Pt denie s any numbness. She denies any
sprains or broken bones. Neurological: Tina is alert and oriented. She is able to hold conversation. No speech issues noted. Pt denies neck pain. She denies any vision changes. She denies any loss of sensation, numbness or ti
ngling. Pt denies trouble sleeping
(T. Jones, Shadow Health Interview, February 13, 2016)
.
Tina graduated with her BA in accounting a few months ago. She is starting a new job in two weeks as an
accounting
clerk. She is currently living with her mom and s ister,
but she has plans to move into an apartment
next month.
She
also states that she is in a
new relationship. She has been seeing someone for 1 month now. They are not yet sexually active. Tina has changed her diet recently. She is eating more whole gr ains,
vegetables and low fat foods. She limits her carb
ohydrate
intake and does not eat sweets.
Her 24 hr diet yesterday was: Breakfast
-
a poached egg on wheat toast with probiotic TINA JONES ASSESSMENT
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yogurt; Lunch
-
brown rice, roasted butternut squash, and black beans; Din ner
-
Chicken
breast, brown rice and roasted broccoli with garlic. She drinks diet coke occasionally. She drinks 4
-
5 glasses of water daily. She drinks alcohol 2
-
3 times a month. She drinks 2
- 3
drinks in a sitting. Tina states that she is up to date with h er immunizations. She denies
that
she got the flu shot this year
(T. Jones, Shadow Health Interview, February 13, 2016)
.
Physical Assessment There are different scope s
of assessment that can be done on patients. Focused assessments address a specific conc
ern or problem.
The comprehensive assessment helps
to identify chronic problems. It also helps to creates a platform for health promotion using education and strengthens the patient
-
provider relationship (Bickley, 2013). Tina
needs this comprehensive phys
ical exam for her health insurance at her new job. Tina is a 2
8 year old African American
women in no acute distress. She is alert
and oriented. She answers questions appropriately and makes eye contact throughout the interview.
She denies headache. She
had 5/5 strength in her neck and spine. Cranial nerves intact.
She has Acnes noted on bilateral cheeks and acanthosis nigricans on posterior neck.
Bilateral eyes with no lesions
, no ptosis, no edema, conjunctiva clear.
Extraocular movements intact bilater
ally. Pupils equal round and reactive to light bilaterally. Vision 20/20 bilate
rally with corrective lens. Ear sharp equal bilaterally.
External
canals with inflammation bilaterally. Whisper test normal bilaterally.
No
abnormalities noted on sca lp. Hair i
s well groomed.
Septum is midline, nasal mucosa is pink. No pain with palpation of fromt al or maxillary sinuses.
Mouth mucosa pink and
moist .No wounds seen. No t onsil inflammation noted. Thyroid is
smooth with no
TINA JONES ASSESSMENT
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important to consider Tina
's financial situation because if
she cannot afford the medications or treatments that are recommended then she is not likely to follow the plan of care. Communication is key to a successful patient/practitioner relationship as well as patient-centered care. Communication is also a huge part of the assessment process. It is important that a practitioner has good communication with their patients in order to get
an accurate health history.
It is
also important that practitioner
recognize different styles of
communication
. It is important to also think about the literacy level of patients. Health literacy
of the patient
is also important to consider.
By taking all these things on to considerati
on the practitioner can develop a good rapport with the patient (Boykins,
2014).
Tina has implanted many lifestyle changes recently. These changes will continue
to help Tina be healthier and lower her risk for complications with her diabetes. The change
s will also help to prevent her from getting other diseases. Good nutrition is essential for heart health. Limiting salt intake is important for Tina to help prevent
hypertension and other possible heart problems. Tina is a risk for high cholesterol due t o
her family history. It will be good for her to eat a low fat diet and when eating fats it is important to eat healthy fats such as Avocado and nuts (American Heart Association, 2016).
Tina has added moderate exercise into her daily routine. This can h
elp with
weight loss, lower his risk for heart disease and help control her diabetes. Getting 150 minutes of moderate exercise a week is what the American Heart Association recommends for adults (American Heart Association, 2016).
Nursing Theory
TINA JONES ASSESSMENT
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Educati
on models come from psychology. They can be used in nursing education
to help nurses understand how patients learn, if they are ready to learn, and if they are understanding what we are teaching. There are 4 different learning models discussed in the text,
each give a different prospective on learning and education. The learning models give nurses tools to address the ed
ucation needs of their patients
(Butts & Rich, 2015). T
he humanistic learning theory's
goal is patient centered learning. With this
model
education comes from collaborative relationships with health care providers and discussion of feelings about the topic
(Butts & Rich, 2015)
. I feel that for Tina
it is
important that she
ha
s a relationship where she feel
s she
can ask questions and talk abo
ut her
feelings to better educate
her on her health and maintaining a healthy lifestyle. [Show Less]