Ms. Jones states she has never been married, lives with her mother and sister, although she is planning to move out into an apartment in a month, to live independently. She is a member of the Baptist Church and has attended for many years. She does not use tobacco but states she did smoke marijuana during her early twenties and used it for a few years. She goes out with her friends a couple of times a month and may drink up to four alcoholic drinks. Ms. Jones states she has no history of depression. Ms. Jones denies stress currently or mental health-related issues. Interviewing Techniques A comprehensive assessment includes a complete health history and physical exam that is often performed at an annual physical exam, during an admission to the hospital or a long-term care facility. The assessment is usually done from head to toe. During the interview, the nurse will determine if there are health concerns, obtain the patient's health history, family history and personal histories such as past medical, surgical procedures and other medical diagnosis or treatments. History will also include current medications, dosages, and reasons for their use, the “patients perception of health and discuss health promotion” (Jensen, 2015, p.10). Good interaction between the patient and the healthcare team will help with the information the nurse needs to get from the patient and the patient can easily come forth with any health concerns.
RUNNING HEAD: HEALTH PROMOTION When the nurse walks into the room, the first assessment will be patient safety and the use of two identifiers before beginning patient care. Asking the patients full name and date of birth are necessary to make sure the right patient is being assessed. Then I would proceed with infection control procedures such as hand hygiene. I would then as permission to take vital signs and document them into the chart. Obtain the current demographic information from Ms. Jones, before moving on to the thorough patient health history. The process will start with the nurse introducing themselves and explaining the process of the comprehensive assessment. It will also enable a positive relationship and likely improve the outcome of the assessment, the satisfaction of the patient, and the care needs for Tina Jones (Jensen, 2015). When starting the comprehensive assessment and obtaining the health history, it is important to ask open-ended questions. I would follow the heat to toe assessment and start my subjective collection from the HEENT, to respiratory, cardiac, gastrointestinal, musculoskeletal, neurological, and skin/hair. While also following the inspection, palpation, percussion, and auscultation according to each system. Starting with the HEENT, I would use inspection, palpation, and auscultation to assess the head, neck, eyes, and mouth of Ms. Jones. If any concerns were brought up in the initial exam by Ms. Jones then I would pay attention to that in detail as I go through the exam. First is inspection and that is the visually looking at the patient and seeing if the face is symmetric, eyes
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- Fall '17
- Ms. Jones