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 slip- ons. 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.
- Spring '16
- Tara Delle Chiaie