NURS 6512N Week 4 Assignment II

Week Four Assignment: Shadow Health Nursing Documentation Lok Yee Schoenthaler Psychiatric Mental Health Nurse Practitioner (PMHNP) programs Walden University NURS 6512N: Advanced Health Assessment & Diagnostic Reasoning December 24, 2022 Introduction This shadow health assessment was done on Tina Jones, a 28 years old single African American woman who presented to the clinic for an infected injury to her right foot. Tina Jones's health assessment involves collecting patient data by interviewing this patient to understand any risk factors that may contribute to her health. Health History Finding Data and Reliability Ms. Jones is a 28-year-old, single African American female. She presents to the office today for a physical examination with a complaint of right foot pain from scraping and injury to her right foot on the stair when she was barefoot. I obtained history and medical records from this patient, maintained good eye contact and clear speech throughout the interview, and provided all information without difficulty. General Evaluation Ms. Jones is alert and oriented X 4 throughout the interview. She was in a pleasant mood, and her memory was intact. Report her right foot pain and could not bear weight on her right foot. Chief Complaint Right foot pain after her recent injury History of Present Illness Ms. Jones had a history of asthma and type II diabetes. She does not monitor her blood sugar or take any medications to control her diabetes. Her asthma is usually triggered when exposed to cats, dust, and pollen. She presents to the clinic with an open wound on her right foot in the plantar area after she injured her foot by scraping the bottom of a stepping stool when she was barefoot. She rates her foot pain as 7/10. She last received Tramadol in the emergency department, and practical for her right foot pain. She reported pain worsens when she stands up and cannot bear weight on her right foot. Medications She uses an inhaler Proventil for her asthma; her last use was three days ago. Ms. Jones takes two pills of Advil three times per day and Tylenol for occasional headaches or menstrual cramps. Currently, she takes Tramadol 100 mg three times daily for her foot pain. Ms. Jones is allergic to cats and penicillin. Cats trigger her asthma and cause wheezing, sneezing, and itching. Her Penicillin allergy causes rash and hives. Medical History Ms. Jones has type II diabetes and does not monitor her blood sugar or take any medications to control her diabetes. Ms. Jones has asthma, and her last hospitalization for asthma was when she was in high school. She reported an unexpected weight loss of ten pounds noticed. Her menstrual periods are irregular and heavy; her last menstrual period was three weeks ago. Family History Ms. Jones' mom is 50 years old with a past medical history of hyperlipidemia and Hypertension. Her dad died at 58 years old from a car accident a year ago, and his past medical history of Hypertension, hyperlipidemia, and type II diabetes. Her grandmother has a past medical history of Hypertension, and she died from a heart attack; her grandfather died from colon cancer and a history of type II diabetes. Social History Ms. Jones goes to church with her family and volunteers with her church for humanitarian acts. Ms. Jones is working on her bachelor's degree in accounting while working as a supervisor in a store. She denies tobacco use or exposure to any secondhand cigarettes. She is single, not pregnant, and not on birth control now. She has never been diagnosed with STIs. Subjective Data Ms. Jones reports getting headaches, and blurry vision noticed when she was reading or studying and is relieved when taking Tylenol. Ms. Jones reported her eyes itching when she is around cats. She had her eye exam in her childhood and did not wear glasses or contacts. Denied any problems with her mouth and denies nasal discharge/ pain. Ms. Jones reports adequate