overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died atage 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problemsSocial HistoryTina is currently working on her bachelor's degree in accounting Patient states she talks with family and friends to relieve stress as well as attend Church Patient lives at home currently with her mom and sister Does not add salt to her foodConsumes diet soda Last marijuana usage was at the age of 21 Patient states she consumes alcohol occasionally in social activities Exposed to secondhand smoke in Social encountersNever married, no children. Lived independently since age 20, currently lives with mother and sister in a single family home to support family after death of father one year ago. Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift supervisor. She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company. She has a car, cell phone, and computer. She receives basic health insurance from work, but is deterredfrom healthcare due to out-of-pocket costs. She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support
Student ResponseModel Documentationsystem. She reports stressors relating to the death of her father and balancing work and school demands, and finances.She states that family and church help her cope with stress. No tobacco. Occasional cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. She drinks 4 caffeinated drinks per day (diet soda). No foreign travel. No pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday.Objectivevitals 101.1, HR 86, resp 19, BP 142/82, spo2 99% weight 90kg, BMI 31, BG 238, wound is 2cmx 1.5cm and 2.5mm depth wound swabbed and sent to lab for culture and sensitivity Wound bed has granulation tissue and is red.Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound edges, right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema, no tracking.
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- Fall '15