NURS 325 Final Project Tina Jones Already Passed

FINAL PROJECT TINA JONES 1 Health History of Tina Jones Karen A. McCoy American Sentinel University FINAL PROJECT TINA JONES 2 Health History According to Bickley (2013) a clear, well organized clinical record is ...

FINAL PROJECT TINA JONES 1 Health History of Tina Jones Karen A. McCoy American Sentinel University FINAL PROJECT TINA JONES 2 Health History According to Bickley (2013) a clear, well organized clinical record is one of the most important adjuncts to patient care and gathering information using open-ended questions, then closed ended questions to prompt specific responses. This paper provides an overview of clinical reasoning and the nurse’s decision making after providing a complete advanced health history and physical assessment. It will also give insight into the nursing process and how it may enhance clinical thinking, reasoning and judgement in the nursing practice. Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents for complete physical examination and evaluation for right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Ms. Jones is alert and oriented, is seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Her chief complaint, “I hurt my foot a couple of weeks ago and went to the ER. They said I should get a check-up . . . it's been awhile since I've had one.” Ms. Jones reports that two weeks ago she tripped while walking on concrete stairs outside, twisting her right ankle and “scraping” the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site when she showers. She has been applying antibiotic ointment with a Band-Aid. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp, shooting” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 5 to 6 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She feels she “cannot walk on it.” She FINAL PROJECT TINA JONES 3 reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted some “blood and pus” oozing from the wound, requiring her to apply a bandage. She denies any odor from the wound. Her shoes feel tight. She has been wearing slipons. She reports subjective fevers over the past two days with an episode “just the other day I felt feverish, hot and cold.” She denies recent illness. Reports a 20-pound, unintentional weight loss over past month and increased appetite. Denies change in diet or level of activity. Her medications include, • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago). Her allergies include, • Penicillin: rash • Denies food and latex allergies • Cats: sneezing, itchy eyes, wheezing. Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. She rarely uses her inhaler. She was exposed to cats a few days ago and had to use her inhaler once. She was last hospitalized for asthma in high school but never intubated. Type 2 diabetes, diagnosed at age 24. She used to take metformin, but she stopped taking it three years ago, stating that the pills made her gassy and “it felt like I was taking pills and checking my sugar all the time, it was a pain to get refills so I just stopped.” She doesn't monitor her blood sugar. Last blood glucose was elevated at the hospital. Denies ever having any surgeries. Menarche started at the age of 11. First sexual encounter at age 18, sex with men, identifies as heterosexual and never pregnant. Last menstrual period 6 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs at age 22. She denies bleeding, bruising, blood transfusions and history of blood clots. FINAL PROJECT TINA JONES 4 Last Pap smear more than 4 years ago. Last eye exam in childhood. Last dental exam “a few years ago.” PPD (negative) ~2 years ago. She states that she does not exercise. Her 24-hour Diet Recall is that she skipped breakfast yesterday, and would typically have toast for breakfast, a sub sandwich for lunch, and a meatloaf or chicken with soup for dinner. Her snacks consist of pretzels and granola bars. Immunizations are, Tetanus booster was received two weeks ago in emergency department, 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 in college. Family has a smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room. Ms. Jones family history: • Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 62, 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. She never married, and no children. Lived independently since age 20, currently lives with mother and sister in a single family home to support family after death of father one year ago, and anticipates moving out in a few months. Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift FINAL PROJECT TINA JONES 5 supervisor. She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company. She has a car, cell phone, and computer. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. She enjoys spending time with friends, 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 reports stressors relating to the death of her father and balancing work and school demands, and finances. She states that “staying organized, trying to plan, and attending church” help her to cope. No tobacco. Occasional cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking “a few” drinks per episode. She drinks 4 caffeinated drinks per day (diet soda). She has not experienced foreign travel and does not have any pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday. Complete Physical Assessment Head Reports headaches that occur weekly with reading for the past few years. The headache lasts a few hours and is relieved with acetaminophen and sleep. Headaches are described as a “tight and throbbing feeling behind the eyes.” Denies head and neck trauma, brain cancer, migraines, seizures, dizziness, hair loss, and syncope. Ears: Denies difficulty hearing, tinnitus, ear pain, discharge, and loss of balance. Denies history of chronic otitis media and perforated tympanic membrane. Eyes: Complains of blurred vision associated with “reading and studying,” which has worsened over the past few years. No visual acuity testing since childhood. Does not wear corrective lenses. Reports eye redness and itching associated with exposure to cats. Denies FINAL PROJECT TINA JONES 6 discharge, pain, and diplopia. Denies glaucoma and congenital cataracts. Nose: Rhinitis and congestion related to cat allergy. Denies sinus problems, frequent colds/infections, and epistaxis. Throat, Mouth, Neck: Denies sore throat, dysphagia, and changes to voice quality. Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste. Denies goiter, hyper/hypothyroidism Normocephalic, atraumatic with no masses to palpation. Full distribution of hair on scalp, coarse hair noted on lateral face, chin, and upper lip. Eyebrows intact. Facial expression relaxed and symmetric without tics or drooping. No maxillary or frontal sinus tenderness. TMJ vertical and lateral movements smooth and symmetric. No clicking or crepitus. Ears: Normal shape without deformities, Darwin tubercle, redness or scaling. Auditory canals without edema or erythema. Tympanic membranes bilaterally pearly gray and intact with cone of light and bony landmarks visualized. No tenderness elicited when tragus palpated. No lesions noted. Hearing intact to whisper. Weber without lateralization. Rinne AC > BC bilaterally. Eyes: Skin free of redness, scaling or lesions. No entropion, ectropion, or edema noted. No pain elicited with palpation of the lacrimal gland, no discharge or pain noted with palpation of the lacrimal sac. PERRLA, anicteric sclera, conjunctiva pink and moist. EOMI, peripheral vision intact, 20/20 acuity left eye, 20/40 acuity right eye. Ophthalmologic examination reveals well-defined bilateral discs. Cotton wool spots and dot-and-blot hemorrhages scattered throughout right fundus. No lesions or exudates visualized in left fundus. No nicking, crossing changes, or papilledema seen bilaterally. Nose: Nose midline without deviation. Nasal mucosa pink, no exudates or polyps appreciated, inferior turbinates pink and moist. Frontal and maxillary sinuses not tender to palpation and percussion. Throat, Mouth, Neck: Oral mucosa pink, moist and intact. Uvula rises midline. Gag reflex intact. No dental caries. Velvety, hyperpigmentation noted FINAL PROJECT TINA JONES 7 circumferentially on distal neck near folds. Symmetric, midline without torticollis. Active range of motion - flexion, extension, rotation and lateral bending. Neck supple, without lymphadenopathy. Thyroid smooth and symmetric with no nodules or enlargement. No thyroid bruit. Respiratory History of poorly controlled asthma. Asthma diagnosed at age 2 1/2. Rarely uses inhaler. Uses albuterol inhaler when around cats. Was exposed to cats a few days ago and had to use inhaler once at that time. Last hospitalized for asthma in high school. Never intubated. Denies history of pneumonia, tuberculosis, and chronic bronchitis. Denies chest pain, dyspnea, current wheezing, hemoptysis, or recent cough. Respiratory rate: 22. Respirations easy and regular, able to speak in complete sentences. Skin without cyanosis. Normal trapezius muscle development. No scoliosis, kyphosis, pectus excavatum, or carinatum. Chest symmetric with equal expansion. AP < transverse diameter. Sternum midline without pectus excavatum or carinatum. Scapula equal and symmetric. Anterior and posterior chest wall is symmetric without lesions. Spine midline without kyphosis or scoliosis. Fremitus present and symmetric over all lobes. All lung fields resonant to percussion. Anterior lungs clear to