Comprehensive Assessment of Tina Jones
Comprehensive Assessment of Tina Jones
American Sentinel University
Comprehensive Assessment of Tina Jones
A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. Comprehensive Assessment of Tina Jones.
Current Health Status (Comprehensive Assessment of Tina Jones)
Tina Jones comes into the clinic for a general physical exam. She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. She denies any acute concerns at this visit. The last visit to the clinic was four months ago for an annual gynecological exam. At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive Yaz. She states she takes the pill daily, at the same time each day. Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. She regularly monitors her blood glucose levels, checking once a day in the morning. She also has been keeping records of her asthma by monitoring her peak flow. The rescue inhaler was last used three months ago with a total of two uses in the past year.
Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets and increasing vegetable consumption. She also has increased her physical activity. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Tina does not smoke or use recreational drugs. Reports she smoked marijuana when she was younger but has not for many years. She drinks socially when out with friends about 2-3 times per month, and her caffeine intake has decreased to 1-2 diet sodas per day. She currently lives with her mother and sister but has a lease starting on her own apartment in one month. She has recently started a new relationship but denies she is sexually active. Her new job is as an accounting clerk, which starts in two weeks. Tina states she is very excited about the new opportunity. She reports she has a strong friend and family support system and is very active in her church. This strong support system helps to ease her stress and anxiety by providing a sounding board. She reports no depression or anxiety. She states she can cope well with upcoming life changes.
Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. Her father is deceased, age 58 in a car accident one year ago. He had hypertension, high cholesterol, and type 2 diabetes. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. Her paternal grandmother is alive and well, 82, with hypertension. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. There is no family history of other cancers, mental illness,
Physical Examination – Comprehensive Assessment of Tina Jones
Identifying Data and Reliability
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 information and is reliable. Her speech is clear and eye contact is appropriate.
“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”
Medications and Allergies
Metformin: Started five months ago. 850 mg twice daily. Reports eating probiotic yogurt helps with side effects. Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. Drospirenone and ethinyl estradiol: one pill every day. Ibuprofen: 600 mg as needed for menstrual cramps.
Ms. Jones has a penicillin allergy with a reaction of rash. She is allergic to cats and dust. These allergens aggravate her asthma symptoms, so she tries to avoid them. She denies any food allergies.
Review of Systems
General. Ms. Jones is sitting comfortably on the examination table, in no acute distress. No current complaints or recent illness. She appears well-nourished and dresses appropriately. Reports recent weight loss. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C.
HEENT. Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. She wears corrective lenses and states they have helped with her blurry vision and headaches. Denies changes in hearing or ear pain. Denies a runny nose or sneezing. Last dental visit was five months ago with no concerns.
Upon examination, head is normocephalic with no lesions or tenderness of scalp. Hair is normal texture and distributed evenly. Sclera white, conjunctiva pink, PERRLA, EOMs intact. Left disc round with sharp margins. Mild retinopathic changes on the right. Vision 20/20 bilateral with corrective lenses. Nasal cavities pink, no discharge. Ear canal pink, tympanic membrane pearly gray, no drainage. Whispers heard bilaterally. Mucous membranes pink and moist, tonsils 2+ bilaterally. Gag reflex present, swallows without difficulty. Sinus’ palpated with no tenderness noted. No clicks on jaw palpation, full ROM. Thyroid palpable, no nodules, no goiter. Axillary and cervical lymph nodes palpated, no lymphadenopathy.
Respiratory. Ms. Jones reports no shortness of breath or trouble breathing. No wheezing, runny nose or a cough. Last use of her rescue inhaler was three months ago and two times total over the past year.
Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Breath sounds present and equal bilaterally, no adventitious sounds noted. Chest resonant on percussion. Palpated fremitus equal bilaterally. Normal bronchophony results. Spirometry: FVC 3.9L, FEV1 3.15L, FEV1/FVC ratio 80.56%.
Cardiovascular. Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Heart rate is regular, S1, S2, no murmurs, gallops or rubs. Bilateral carotids 2+, no thrill, no bruits. PMI nondisplaced, no heaves or lifts. Peripheral pulses 2+, equal bilaterally. No peripheral edema. Capillary refill <3 seconds.Comprehensive Assessment of Tina Jones
Abdominal. Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. Upon inspection, abdomen protuberant and symmetric. Coarse hair growth noted from pubis to umbilicus. Bowel sounds normoactive and present in all four quadrants. Abdomen tympanic on percussion. Liver span 7 cm MCL, palpable 1 cm below right costal margin. Abdomen soft with no tenderness, guarding or masses with palpation.
Musculoskeletal. Ms. Jones reports no muscle pain or weakness. Her gait is smooth with equal stride. Full ROM of TMJ with no crepitus. Upper and lower extremities symmetric without lesions or swelling. Full ROM and 5/5 strength in extremities, spine, and hips. Deep tendon reflexes 2+, upper and lower.
Neurological. Reports no dizziness, tingling, or loss of sensation. Awake and alert. Oriented to person, place, and time. Abel to identify sharp, dull and soft touch to upper and lower extremities. Dual shoulder shrug against resistance, able to turn head in both directions against resistance. Position sense in fingers and toes are normal. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Stereognosis and graphesthesia normal bilaterally. Monofilament test shows decreased sensation in both right and left great toes and forefoot.
Skin, hair, and nails. Ms. Jones states her acne has improved due to oral contraceptive use. States skin on neck has stopped darkening. Her skin is pink, warm, with no tenting. Pustules noted on bilateral cheeks. Dark discoloration of skin on neck. Normal hair distribution. Fingernails pink without clubbing, ridges or abnormalities.
Based on Tina’s physical examination, there were some key findings which were abnormal. First, her BMI indicates she is overweight, and only .9 points away from obese. Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). There were retinopathic changes in her right eye that are mild. Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. Another abnormal finding was the discoloration on her neck. “Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin” (Sander, 2018, para. 1). It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). Based on these assessment findings and Ms. Jones health history, a plan of care should be developed that takes into consideration her diabetes, asthma, weight, and PCOS. Comprehensive Assessment of Tina Jones
Plan of Care
Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. Dorothea Orem’s self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). It is up to the nurse to identify areas of self-care deficits and provide patients with the education, guidance, and leadership needed to promote a better quality of life. Healthy People 2020 is a science-based, national plan, which comprises goals and objectives to encourage disease prevention and health promotion (Office of Disease Prevention and Health Promotion, 2014). Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. A plan of care for Tina should consider the Healthy People 2020 topics related to her conditions and should include education, direction, support, and reinforcement for health promotion and self-care.
Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. Ms. Jones should be encouraged by the additions and progress she has made.
Diabetes is disproportionately prevalent in the African American population (Bickley & Szilagyi, 2013). Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). Risk factors for diabetes which Ms. Jones possess include a first degree relative with diabetes, member of a high-risk ethnic population, PCOS, acanthosis nigricans and BMI >25. Diabetes requires self-management behaviors for life. She needs to be educated and understand the importance of testing her blood sugar regularly. She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. Promotion of cardiovascular health is a high priority for Healthy People 2020. Along with controlling diabetes, other leading modifiable risk factors include diet, physical activity, and being overweight and obesity.
Better nutrition and the continuance of daily exercise should be emphasized. Not only are these objectives in line with Healthy People 2020 (#4 of the 24 objectives) but they will aid in the control her diabetes and PCOS. Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014). A dietician referral may be beneficial to educate on specifics and offer support.
Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. Ms. Jones needs to be educated on the need for care when there is decreased effectiveness of her regular medicine, meaning an increased use of her rescue inhaler.
Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Although Ms. Jones is not sexually active, she states she probably will be soon. Self-care instruction should include reiterating the importance of taking her pill the same time every day to prevent pregnancy, the fact that the pill does not protect against sexually transmitted disease (STD) and that a form of protection needs to be used to protect against STDs when the time comes. Comprehensive Assessment of Tina Jones
A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. Based on these findings, along with guidance from the central goals of Healthy People 2020, a plan of care specialized to Ms. Jones was created, considering her age and culture. With the assistance of Orem’s self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health.
Altay, N., & Cavusoglu, H. (2013, April 23). Using Orem’s self-care model for asthmatic adolescents. Journal for Specialists in Pediatric Nursing. https://doi.org/10.1111/jspn.12032
Bickley, L. S., & Szilagyi, P. G. (2013). Bates’ guide to physical examination and history taking (11th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Elsevier Mosby.
Office of Disease Prevention and Health Promotion. (2014). About healthy people. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People
Office of Disease Prevention and Health Promotion. (2014). Physical activity. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity
Petiprin, A. (2016). Self-care deficit theory. Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php
Sander, I. (2018). Acanthosis nigricans. In A. O. Ofori (Ed.), UpToDate. Retrieved from http://www.uptodate.comComprehensive Assessment of Tina Jones