TINA JONES HEALTH HISTORY NARRATIVE

Tina Jones Health History Narrative Anna M. Medina Professor Deborah Mathias NUR 3700: Nursing Health Assessment Metropolitan State University of Denver TINA JONES HEALTH HISTORY NARRATIVE Introduction A complete health history based upon work in Shadow Health was completed on Tina Jones, a twenty-eight year old woman. Ms. Jones came in through the emergency department for an injury to her right foot. Utilizing interviewing and clinical skills, and clinical reasoning skills, the ability to perform a health history was successful. Health History Finding Data and Reliability Ms. Tina Jones is a pleasant twenty-eight year old African American woman. She is seated upright in her hospital bed. She was admitted for further evaluations of her right foot injury. She is the primary source of the history. She offers information freely. Her speech is clear and coherent. She maintains good contact throughout the interview. General Evaluation Ms. Jones is alert and oriented. She appears to be in pain. She is well nourished. She is well groomed, dressed appropriately, has good hygiene, and interacts appropriately. Chief Complaint Ms. Jones’s chief complaint is that “I hurt my right foot one week ago” They said I needed to get admitted to the hospital. History of Present Illness Ms. Jones has an open wound to her right foot located on the plantar surface. She has asthma and type II diabetes. She injured her foot by scraping the bottom of a stepping stool. She states that she was barefoot at the time of the injury. She states that her current pain is 7/10, and last received medication in the emergency department that seems to be helping. She states that her pain is made worse when she stands, and is unable to bear weight on her right foot. She does 2 TINA JONES HEALTH HISTORY NARRATIVE not monitor her blood sugar and does not take any medications to control her diabetes. She reports that her asthma is triggered when exposed to cats, dust, or running upstairs. Her blood pressure is also high as well as being febrile with a temperature of 39.1 C. Medications She uses a Proventil (Albuterol 90mcg/spray MDI) inhaler for asthma. She last used her inhaler three days ago. Ms. Jones takes two pills of Advil three times per day: Morning, Noon, & Night, she does not know the exact dose other than stating “they are not extra strength. She also reports taking Tylenol for occasional headaches. Denies taking any vitamins or supplements. Allergies Ms. Jones is allergic to cats and penicillin. Cats trigger her asthma and causes wheezing, sneezing, and itching. Her Penicillin allergy causes rash and hives. Medical History Ms. Jones has uncontrolled and unmonitored type II diabetes. She has a open right foot wound that she sustained one week ago will stepping on a stool barefoot. She has asthma and was last hospitalized for asthma when she was in high school. She has experienced an unexpected weight loss of ten pounds. She states that she has been excessively thirsty. She is experiencing nocturia. Her menstrual periods are irregular and heavy, with her last menstrual period being three weeks ago. Health Maintenance Ms. Jones’ last Pap smear was more than four years ago. Her last eye exam was during her childhood. Her last dental exam was a few years ago. Her last PPD was negative approximately years ago. She does not exercise. Her typical diet consists of breakfast: a muffin or pumpkin 3 TINA JONES HEALTH HISTORY NARRATIVE bread; lunch: a sub sandwich; dinner: meatloaf or chicken with soup; snacks: pretzels or when she wants to treat herself French fries. Immunizations She reports a tetanus booster a couple of years ago. She did not receive an influenza vaccine this year and it has been several years since her last influenza vaccine.. She is up to date with childhood vaccines. Family History Ms. Jones’ mom is fifty years old. She has a medical problems both hyperlipidemia and high blood pressure. Her dad is deceased at fifty-eight years in age from a motor vehicle accident that occurred last year. Her father also had a history of high blood pressure, hyperlipidemia, and type II diabetes. Her paternal grandmother has high blood pressure. Her paternal grandfather (Grandpa Jones) died in his early sixties from colon cancer. He had a history of type II diabetes. Ms. Jones’ maternal grandmother (Nana) died at age seventy-three from a stroke. Her Nana also had a history of high blood pressure and hyperlipidemia. Her maternal grandfather (Poppa) died at age seventy-eight from a heart attack. He also had a history of high blood pressure and hyperlipidemia. Ms. Jones has a younger sister and also has asthma. Her brother has no known medical problems, but Ms. Jones reports that he is overweight as well as most of her family. Her paternal uncle is an alcoholic. Social History Ms. Jones is very active in church and with family. She goes out occasionally with friends dancing. She also enjoys bible study and volunteering with her church. She previously lived alone, but moved back in with her mom and younger sister to help with finances and to help care for her sister after the death of her father. She is working on her bachelor’s degree in accounting.