NUR-325-Patient Analysis and Health Promotion

NUR-325-Patient Analysis and Health Promotion

NUR-325-Patient Analysis and Health Promotion

Ms. Tina Jones is a 28 years old African-American female, who came in to Shadow General Clinic for a well visit and a pre-employment physical to support her application for a job insurance. The primary source of information is the patient herself and is a good historian. Ms. Jones was last hospitalized in Shadow General Hospital six months ago for a pain and wound in the right foot including fever and nausea. Her past medical history includes asthma that started when she was 2½ years old, diabetes type II at age 24, hypertension which she was diagnose six months ago during her last hospitalization and polycystic ovarian syndrome four months ago during her OB visit. She was last hospitalized for asthma in high school. Her hypertension was controlled by diet and exercise. She checks her blood sugar daily at home with an average reading of 90. She has no past surgical history. Her last dental visit was five months ago and eye doctor visit 2 months ago.

Ms. Jones is allergic to Penicillin, cats and dusts. Her reaction to penicillin includes rash and hives. When exposed to cats and dusts, she states that she gets a runny nose, itching and asthma exacerbation.

Medications includes Metformin 850 mg PO BID for diabetes, Flovent 88 mcg 2 puffs BID, Proventil 90 mcg 2 puffs PRN, Yaz (Drospirenone and ethinyl estradiol) PO daily for birth control, and Advil PO PRN for menstrual cramps.

Ms. Jones states that she is current in all her vaccination. She received a tetanus booster a year ago, had a hepatitis vaccine when she was a kid but could not remember if A or B. She has no record of HPV vaccine, pneumococcal or flu shots.

With health maintenance, she reports losing 10 lbs. for the last four months. She eats less carbs, avoids sweets and eat more vegetables. Her usual sleep is 9 hours a day. Last pap smear was 4 months ago and she was never tested for STD or HIV. She reports of having sex with 3 of her former boyfriends. Last menstrual period was 2 weeks ago and usually last for 5 days. She has no record of mammogram. She reports of urinating five times during the day and gets up once at night. Bowel movement is daily. Ms. Jones also wears eyeglasses.

Family history reveals father died in a car accident at age 58. He has hypertension, high cholesterol and diabetes. Mother is 50, alive and has history of hypertension and high cholesterol. Her brother Michael age 27 is healthy and younger sister Britney 15 has asthma. Paternal Grandfather died at age 65 of colon cancer, history of hypertension, high cholesterol and diabetes. Paternal grandmother age 82, still living, has history of hypertension and high cholesterol. Maternal grandfather died at the age of 80 due to heart attack, has history of hypertension and high cholesterol. Maternal grandmother died at age 73 due to stroke and has hypertension and high cholesterol. Paternal uncle has history of alcoholism.

Ms. Jones is single and lives with her mother and sister but is planning to move out in a month with her boyfriend. She is Baptist and considers other church members as a family. She is not sexually active and is using birth control pills. She does not smoke but reports that she used smoke marijuana when she was 20 or 21 and used it for about 5 to 6 years. She drinks alcohol, rum and diet coke, socially with friends every two months. Never used street drugs. She reports of having no depression, stress or any suicide ideation or mental illness.

NUR-325-Patient Analysis and Health Promotion

Patient Analysis

Interviewing

Doing a physical assessment to a patient is easier if the patient feels comfortable and respected. Before we proceed to the physical assessment however, we need to collect some other data from our patient such as the demographic data and the patient health history. Collecting subjective data on Ms. Jones should be easier since it is not her first time visit to Shadow General. Though it is not her first time, we still need to explain to her the things that we are doing. We begin our interview by introducing ourselves to her and tell her the purpose of what we are doing, most healthcare institution uses the acronym AIDET during their patient encounter. This can also apply to us. AIDET means, Acknowledge, Introduce, Duration, Explanation and Thank You. Using this technique helps reduce the patient anxiety.

To start the conversation and make the patient open up, we use the open-ended question by asking “What brought you in today?” or asking a follow up question from the patient previous visit such as “How have you been since the last time you were here?” Asking those kind of question makes our patient to answer more than yes or no. Based on the patient answer, we can make a follow up question to validate the answers but making sure that we stay focused on the things that we are doing which is to get the patient health history and not deviate from the topic. Comparing results from the patient previous visit will also make the flow of conversation going. Telling her things like, “your blood pressure looks better than you were here six months ago, can you tell me more what did you do?” Using this technique also makes the patient feels that we are concerned not only for her current visit but telling her that she is important to us.

NUR-325-Patient Analysis and Health Promotion

Data collection and Appropriateness of Techniques/Established Norm and Intervention

For simplicity and continuity of discussion, data collection technique, appropriateness of data collection technique and established norms is combined into one section.

Skin/Hair/Nail Assessment. Technique used in collecting the data for skin assessment is first doing a general inspection, then asking Ms. Jones for any concerns regarding any skin disorder or problems that she has. General inspection is done first before we ask specific question. this is done first so that we can focus on the specific question that we going to ask depending on the type of skin problem we identified. After identifying the problem, the ABCDE of melanoma detection is used to gather more data. Palpation is done last to assess for skin temperature.

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