NURS 6512 DCE: Tina Jones Comprehensive Assessment Final Paper

NURS 6512 DCE: Tina Jones Comprehensive Assessment Final Paper

Name: Tina Jones

Comprehensive Assessment

Vitals: BP- 128/82,  HR- 78,  RR- 15, TEMP- 37.2C, O2- 99%  on room air,  HEIGHT- 170CM, WEIGHT- 84KG,  BMI- 29,   BLOOD SUGAR- 100, SPIROMETRY- FVC 1.78L, FEV1- 1.549L.

Health History

Student Documentation

Identifying Data & Reliability

Ms. Tina Jones is a 28 years old African American female who came into the clinic for pre-employment assessment. she came in alone, alert, and oriented X4, speech is clear and appropriate for her age makes eye contact. Patient dressed appropriately for the weather. Ms. Jones tolerated the assessment with ease. Tina Jones Comprehensive Assessment Final Paper

General Survey

Patient is oriented to time, place, and situation. Patient is obese but practicing healthy eating and physical activity in her daily routine. Patient appears not to be in distress. She is excited to start her new jo in the city.

Reason for visit Tina Jones Comprehensive Assessment Final Paper

Patient verbalized “I came in here because, I’m required to have a recent physical examination for the health insurance at my new job.”

History of Present illness

The patient is here, for physical assessment for work insurance for a new job. Patient presents with other health issues that is under control. She wears a prescription glasses to help with blurry vision and headaches. Tina Jones Comprehensive Assessment Final Paper

Medications 

Metformin 850 mg- started 5 months ago. BID to manage diabetes type 2, she takes yogurt with this medication, which helps with stomach upset.

Albuterol 90 mcg/spray MDI -two puffs every 4 hours PRN- inhaler to manage asthma exacerbation.

Fluticasone Propionate 88 mcg/spray- BID to manage asthma

YAZ- 1 pill every morning- for birth control and to manage PCOS

Advil – 2 tabs. for menstrual pain and headaches.

Allergies

Penicillin – Rash, hives, last taken as a childhood.

Cat – aggravates asthma symptoms.

Patient denied food, seasonal, and latex allergy.

Medical History 

Asthma: since childhood, takes albuterol, and Proventil.

Diabetes type 2: diagnosed at age 24 years. Takes metformin and daily blood sugar checks in the mornings and results normally in 90s.

PCOS: takes Drospirenone and ethinyl estradiol

Hypertension: normal blood pressure readings.

Near sighted and blurry vision- wears glasses to help with vision.

Health Maintenance Tina Jones Comprehensive Assessment Final Paper

Patient has been eating healthy, using recipes from online for diabetes. she is limiting carbohydrates “staying away from sweets and increasing vegetables”.

Typical meals daily include:

Breakfast – Smoothie, fruit, yogurt, and eggs.

Lunch – Sometimes left-over dinner or wheat bread sandwich.

Dinner – Chicken or fish, vegetables and rice or quinoa on the side.

She verbalized recent weight loss from exercise. Recently she is active. Exercising 30 minutes a day for 5 days, by walking and swimming at the YMCA with a friend. she drinks occasionally with friends once or twice a week Tina Jones Comprehensive Assessment Final Paper.

Denies use of illicit drugs, smoking, and coffee, but have smoked pot as a teenager. Her caffeine intake is reduced to 1-2 sodas per day. Visits her dentist, gynecologist- 4 months ago, and ophthalmologist 3 months ago. Brushes teeth twice a day. she monitors her asthma by using the peak flow.

Family History Tina Jones Comprehensive Assessment Final Paper

Mother- (50 years) hypertension and high cholesterol.

Father- (58 yrs.) deceased in car crash, hypertension, high cholesterol.

Type 2 diabetes – Maternal Grandparents: both deceased in age 70s-stroke, hypertension, high cholesterol.

Paternal grandmother- alive and well. 82 years, hypertension.

Maternal grandfather- deceased at 65 years- colon cancer and diabetes type 2