patient analysis final project.docx - Nicole Smith Patient...

Nicole Smith
Patient Analysis
Final Project
Southern New Hampshire University

Introduction
Tina Jones is a 28-year-old African American female who came to Shadow Health ED
for a right foot injury about 6 months ago. She is now at the clinic requesting a pre-employment
physical that is needed for her new job. Tina presents for her appointment neatly dressed. She
appears overweight. Her speech is clear and she’s coherent. She wears glasses and makes
appropriate eye contact. She has a PMH of asthma which was diagnosed at about 2 ½ years of
age. Type II diabetes which she was diagnosed in her mid-20’s. She was diagnosed with
hypertension; however she has been leading a fairly healthy lifestyle and trying to exercise which
has kept her increased blood pressure under control. Tina’s family history revealed her mother
who is still alive has hypertension and high cholesterol. Her father who died in a car accident at
age 58 had hypertension, high cholesterol and diabetes. Her sister also has asthma. Tina’s
paternal grandfather died at age 65 due to colon cancer and had hypertension, high cholesterol,
and diabetes. Paternal grandmother is 82, alive and has a history of hypertension and high
cholesterol. Her maternal grandmother died at age 73 from a stroke and also had hypertension
and high cholesterol.
Interviewing
When discussing a patients current and past health conditions, it’s important to approach
the patient in a professional manner. This includes always introducing yourself and asking the
patients’ names and date of birth before beginning. Being friendly and allowing the patient time
to answer questions is also very important. Responding to the patient with educational and
professional answers in a nonjudgmental way. Have the patient lead the discussion to allow them
to have as much input as possible so you can learn about their concerns. Make sure follow up
questions are open ended as much as possible to get clear answers rather than just yes or no
questions. Its essential to always listen to the patient and maintain good eye contact. Always stay
focused during interviews with all patients.

Data Collection & Appropriateness
Data is collected through the process of inspection, palpation, percussion and
auscultation. Subjective and Objective data is obtained through the interview and then the
physical assessment is performed. General information is gathered to help the nurse determine
the patient’s general health. To see if there are any acute findings that need to be addressed. Tina
Jones was asked about her self-care and general health. She then was asked more specific