Tina Jones Health History Narrative 2020 | NUR 3700: Nursing Health Assessment

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Tina Jones Health History Narrative Anna M. Medina Professor Deborah Mathias NUR 3700: Nursing Health Assessment Metropolitan State University of Denver Introduction A complet... e 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. Health History Finding Data and Reliability Ms. Tina Jones is a pleasant twenty-eight year old African American woman. She is seated upright in her hospital bed. She was admitted for further evaluations of her right foot injury. She is the primary source of the history. She offers information freely. Her speech is clear and coherent. She maintains good contact throughout the interview. General Evaluation Ms. Jones is alert and oriented. She appears to be in pain. She is well nourished. She is well groomed, dressed appropriately, has good hygiene, and interacts appropriately. Chief Complaint 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. 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 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 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. Medications She uses a Proventil (Albuterol 90mcg/spray MDI) inhaler for asthma. She last used her inhaler three days ago. Ms. Jones takes two pills of Advil three times per day: Morning, Noon, & Night, she does not know the exact dose other than stating “they are not extra strength. She also reports taking Tylenol for occasional headaches. Denies taking any vitamins or supplements. Allergies Ms. Jones is allergic to cats and penicillin. Cats trigger her asthma and causes wheezing, sneezing, and itching. Her Penicillin allergy causes rash and hives. - - - - - - - - - - - Ms. Jones’ care plan needs to incorporate achievable health measures that will include measures of progress to assess how she is doing with meeting the goals. Measures of progress that can be incorporated into her plan are: self-assessed health status, limitation of activity, and assessment of how her chronic disease prevalence, gender, race, and her well-being and health-related quality of life all affect her health and access to health. 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 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. [Show More]

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