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Nicole SmithPatient Analysis Final ProjectSouthern New Hampshire University
IntroductionTina 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 whichhas 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. InterviewingWhen 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 themto 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 & AppropriatenessData 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