Table of Contents
Identifying Data & Reliability
Tina Jones is a 28-year-old African American female AOX4. Pt is a reliable historian
Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
General Survey
Alert and oriented X4. Feels tired because she was just coming from her other job.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Health Promotion Involving Tina Jones Reason for Visit Presenting to shadow health hospital clinic for a complete health assessment for a pre-employment physical.
“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”
History of Present Illness
Tina Jones is a 28year old African American female with a history of diabetes and Asthma presenting to get a complete health assessment for a pre-employment physical.
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Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with the polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job.
Health Promotion Involving Tina Jones Medications
Metformin 850mg twice daily Yaz birth control daily in the morning Flovent MDI twice daily Proventil 90mcg/spray 2 puffs as needed for wheezing
• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
• Metformin, 850 mg PO BID (last use: this morning)
• Drospirenone and Ethinyl estradiol PO QD (last use: this morning)
• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago)
• Acetaminophen 500-1000 mg PO prn (headaches)
• Ibuprofen 600 mg PO TID PRN (menstrual cramps: last taken 6 weeks ago)
Allergies
Penicillin- Rash, hives cats- sneezing, itchy watery eyes, asthma exacerbations No Known food allergies No latex allergies
• Penicillin: rash
• Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to allergens she states that she has a runny nose, itchy and swollen eyes, and increased asthma symptoms.
Medical History
Asthma- diagnosed at age 2 1/2 Diabetes Type 2 – diagnosed at 24 was on metformin but stopped due to side effects
Asthma was diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identify as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles were regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms for sexual activity. Tested negative for HIV/AIDS and STIs four months ago.
Health Maintenance
Has been eating healthy and trying to stay active by walking 30-40 mins two times per week and also swimming once a week
Last Pap smear 4 months ago. Last eye exam three months ago. The last dental exam was five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine for college. Safety: Has smoke detectors in the home, wears a seatbelt in the car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in her parent’s room.
Family History
-Father died 2 1/2 years ago in a car accident. History of high blood pressure, type 2 diabetes, and high cholesterol -Mother is still alive. and has a history of hypertension and high cholesterol. -Brother is overweight -Sister has asthma
• Mother: age 50, hypertension, elevated cholesterol
• Father: deceased in a car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes
• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma
• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
• Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems
Social History
she does not have any children, has never been pregnant, and has never been married. she lives with her mother and sister. currently works but is hoping to start a new job as an accounting clerk at smith, stevens, and steward silver company. drinks alcohol occasionally when she goes out with friends
Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single-family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, or heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is a frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or a sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.
Mental Health History
Denies any history of depression or suicidal thoughts. denies any problems with mood. no overall safety concerns.
Reports of decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation, and is cooperative. The mood is pleasant. No tics or facial fasciculation. Speech is fluent, and words are clear.
ASSIGNMENT INSTRUCTIONS: Health Promotion Involving Tina Jones
Please use the patient information provided below for this paper.
This assignment assesses the intended course outcome(s)
#4 Use information found in patients’ health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient’s individual health promotion and disease prevention needs
Students will use the information found in Tina’s history, physical exam, and problem list to formulate an individualized health promotion and disease prevention plan of care. Recommendations should be evidence-based and from credible sources. The readings in module eight contain some suggested sources for obtaining health and screening recommendations for your patient.
The plan for addressing the health promotion and disease prevention needs for your patient should include:
Demographics:
– Age, gender, and race of the patient
– Education level (health literacy)
– Access to health care
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Insurance/Financial status
– Is the patient able to afford medications and healthy diet, and other out-of-pocket expenses?
Screening/Risk Assessment
– Identified health concerns based on screening assessments and demographic information
Nutrition/Activity
– What is the patient’s activity level, is the environment where the patient lives safe for activity
– Nutrition recommendations based on age, race gender, and pre-existing medical conditions
– Activity recommendations
Social Support
– Support systems, family members, community resources
Health Maintenance
– Recommended health screening based on age, race, gender, and pre-existing medical conditions
Patient Education:
– Identified knowledge deficit areas/patient education needs (medication teaching etc).
– Self-care needs/ Activities of daily living
* The paper should be written and referenced in APA format and be no longer than 4 pages (excluding the cover page and references).
RECOMMEDED: Shadow Healthy: Clinical Decision Making- Tina Jones
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