Assignment: Health Promotion Involving Tina Jones
Assignment: Health Promotion Involving Tina Jones
NURS 360: Health Assessment
Demographics: Tina Jones is a 28-year-old African American female patient with a Bachelors degree in Accounting. She appears to have adequate health literacy as it pertains to her health, medical conditions, and maintaining her health. Health literacy, according to the article Health Literacy (2017) by Schub and Uribe, is “…the level to which patients are able to gather, process, and comprehend basic health information necessary for making appropriate choices about their health and treatment.” Ms. Jones has proven to have the ability to comprehend basic health information and make appropriate choices for her health. While at Shadow General for a pre-employment physical, she conveyed understanding of her health conditions by making lifestyle changes (proper diet and exercise) to remain in good health. In addition, there is nothing currently preventing Ms. Jones from accessing healthcare. She is independent and able to schedule her own appointments and transport herself to appointments (Schub & Uribe, 2017).Health Promotion Involving Tina Jones
Insurance/Financial status: Ms. Jones reports no issues or concerns with affording medications, a healthy diet, and other out of pocket expenses. During Ms. Jones health history and physical exam, she reported that her new job at Smith, Stevens, Stewart, Silver & Company will soon provide her with health insurance. Therefore, she will have health insurance to cover medical costs and with any costs her insurance does not cover, she will be able to afford with the money she makes at her new job as an accounting clerk.
Screening/Risk Assessment: Screening assessments are used in healthcare for the purpose of early detection of diseases/health issues and treatment according to the article Health Screening (2018) by the U.S. National Library of Medicine. The type of screening test used for patients depends on their age, sex, family history, and risk factors for certain diseases (U.S. National Library of Medicine, 2018). During Ms. Jones pre-employment physical for her new job, many health concerns were identified. She has been diagnosed with hypertension, diabetes, asthma, and polycystic ovary syndrome (PCOS). In addition, she has a family history of high blood pressure, high cholesterol, diabetes, stroke, heart attack, colon cancer, and alcoholism. She also socially drinks and plans to become sexually active in the future. She lives in a safe home, is not exposed to any violence, and not at risk for self-harm. Based on the information Ms. Jones provided and her demographic information, the health concerns for her would be risk for uncontrolled blood pressure with possible cause for adverse cardiovascular events, risk for uncontrolled blood sugar level, risk for colon cancer, risk for having a stroke/ heart attack, risk for high cholesterol, risk for misuse of alcohol, and risk for contracting STI or HIV/AIDS.
Nutrition/Activity: Ms. Jones has a mild to moderate activity level. She exercises 4-5 times a week for 30- 40 minutes at a time consisting of walking, yoga, or swimming. She lives in a safe environment for activity. In her house there is her father’s firearm, but it is currently locked up. According to the article Physical Activity and Adults (2015) by the World Health Organization, adults between the ages of 18 and 64 should at least perform moderate intensity of aerobic exercise between 150-300 minutes a week or vigorous- intensity aerobic exercise for 75-150 minutes per week for the benefit of weight management and decrease the incidence of health conditions such as coronary artery disease, high blood pressure, stroke, diabetes colon/ breast cancer, depression, and etc (World Health Organization, 2015).
Ms. Jones’s diet consists of a frozen fruit smoothie with unsweetened yogurt, eggs, and toast for breakfast. For lunch it consists of black beans, roasted butternut squash, quinoa, brown rice or tuna with olive oil, onion, cucumber, and wheat bread, or wheat wraps with chicken, spinach, tomato, and feta cheese. Her dinner consist of roasted chicken, chicken breast in olive oil, fish/salmon, quinoa, brown rice, and/or roasted vegetables. For snacks, she eats apples or carrot sticks. She will drink 4-5 glasses of water a day and 1-2 diet sodas per day. According to the article Eating Patterns and Meal Planning (n.d.) by the American Diabetes Association, the best diet for Ms, Jones would be the Dietary Approaches to Stop Hypertension diet. This diet “…promotes eating vegetables, fruits, whole grains, nuts, seeds, and lower fat or fat-free dairy products, poultry and fish.” Foods high in salt, saturated fat, red meat, sweets, added sugars and sugar sweetened drinks are limited which helps with better control of blood glucose. Also, this diet is high in fiber and rich in nutrients (potassium, calcium, and magnesium) that can aid in lowering blood pressure (American Diabetes Association, n.d.).
Social Support; Ms. Jones describes having a strong family and social support system. She states that her family and church help her to cope with stress when it comes. Ms. Jones reports that her family is there for her when she needs them especially to help with any activities.
Health Maintenance: According to the article Health screenings for women ages 18-39 (n.d.) by the U.S. National Library of Medicine, the recommended Health screenings for women from the ages of 18 – 39 are screening for blood pressure, cholesterol, diabetes, dental problems, eye problems, immunizations, cervical cancer, breast cancer, colon cancer, skin cancer, STIs/ HIV, depression, obesity/ overweight, alcohol/ tobacco use, and safety issues (U.S. National Library of Medicine, n.d.). Furthermore, there are certain conditions African Americans are at high risk for developing and be seriously screened for, and they are heart disease, stroke, cancer, and diabetes according to the article African Americans Preventative Screening Can Save Your Life (2006) by Askew and Ledford. Based on Ms. Jones medical conditions and family history, at healthcare visits she should be screened for up-to- date immunization such as the yearly flu shot, heart disease, high blood pressure cervical and colon cancer, alcohol use, breast abnormalities. Also at visits, monitoring of HGA1C, STI and HIV status, pap smear status, BMI and cholesterol is needed (Askew & Ledford, 2006).
Patient Education: During subjective data collection of Ms. Jones, there were some knowledge deficit/ educations needs and self-care needs identified. She needs to be educated on importance of monitoring her blood sugar level appropriately. She has mentioned, that she only checks her blood glucose in the morning before breakfast daily. According to Chapter 40: Nursing Care of Patients with Disorders of the Endocrine Pancreas (2015) by Hopper, since Ms. Jones uses oral medication, healthy diet, and exercise to control her diabetes she may not need to check her glucose daily. She should consult her doctor on how often to monitor her blood glucose. Also, to ensure the medication metformin is working adequately along with diet and exercise, she should be educated on monitoring her blood sugar 2-3 times a day before/ after meals. Proper education should be given on the importance of checking her glucose when symptomatic as well, in order to use interventions given to either raise or lower her blood sugar. Adequate control of blood sugar may help to prevent adverse effects of hypoglycemia and hyperglycemia, such as, diabetic ketoacidosis, macro and micro vascular complications, nerve and foot complications, and infection. Furthermore, being a diabetic and having a history of a slow healing wound and decrease in foot sensation, Ms. Jones self-care needs should focus on proper care and monitoring of her skin especially on her feet. While performing her activities of daily living, specifically skin care/ bathing; Ms. Jones should to be educated on proper washing, drying, and inspection of feet daily. As a diabetic this puts her at high risk for having poor vascularization to lower extremities, slow wound healing, increase risk for infection, and loss of sensation result in impaired skin. Education needs to be given on the wearing of well-fitted shoes and not delaying treatment when sores are noted on feet. On routine visits to the doctor, she should remove her shoes and socks to ensure a thorough examination of feet to identify any skin issues (Hopper, 2016).
Health Promotion Involving Tina Jones References
American Diabetes Association. (n.d.). Eating patterns and meal planning. Retrieved from
http://www.diabetes.org/food-and fitness/food/planning-meals/diabetes-meal-plans-and-a-healthy-diet.html
Askew, G., & Ledford, M. (2006). African-americans: preventive screening can save your
life. Retrieved from https://www.americanprogress.org
/issues/healthcare/news/2006/02/27/1849/african-americans-preventive-screening-can-save-your-life/
Hopper, P. (2015). Chapter 40: nursing care of patients with disorders of the endocrine pancreas.
In Understanding Medical Surgical Nursing. (5th ed, pp. 914–939). Philadelphia, Pennsylvania: F.A. Davis Company. Retrieved
from http://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=2013167103&site=nup-live&scope=site
Schub, T., & Uribe, L. (2017). Health literacy. CINAHL Nursing Guide. Retrieved
from http://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=T904056&site=nup-live&scope=site
U.S. National Library of Medicine. (2018, September 26). Health screening. Retrieved from
https :// medlineplus.gov/healthscreening .html
U.S. National Library of Medicine. (n.d.). Health screenings for women ages 18 to 39:
MedlinePlus Medical Encyclopedia. Retrieved from https://medlineplus.gov/ency/article
/007462.htm
World Health Organization. (2015, June 19). Physical activity and adults. Retrieved from
https://www.who.int/dietphysicalactivity/factsheet_adults/en/
The Assignment:
Identifying Data & Reliability
Tina Jones is a 28 year old African american female AOX4. Pt is reliable historian
Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
Permalink: https://nursingbay.com/health-promotion…lving-tina-jones/
Assignment: Health Promotion Involving Tina Jones
General Survey
Alert and oriented X4. Feels tired because she was just coming from her other job.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Health Promotion Involving Tina Jones Reason for Visit
Presenting to shadow health hospital clinic for a complete health assessment for a pre-employment physical.
“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”
History of Present Illness
Tina Jones is a 28year old African America female with a history of diabetes and Asthma presenting to get a complete health assessment for a pre-employment physical.
Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.
ORDER NOW
Health Promotion Involving Tina Jones Medications
Metformin 850mg twice daily Yaz birth control daily in the morning Flovent MDI twice daily proventil 90mcg/spray 2 puffs as needed for wheezing
• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)
Allergies
Penicillin- Rash, hives cats- sneezing, itchy watery eyes, asthma exacebation No Known food allergies No latex allergies
• Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.
Medical History
Asthma- diagnosed at age 2 1/2 Diabetes Type 2 – diagnosed at 24 was on metformin but stopped due to side effects
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.
Health Maintenance
Has been eating healthy and trying to stay active by walking 30-40 mins two times per week and also swimming once a week
Last Pap smear 4 months ago. Last eye exam three months ago. Last dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.
Family History
-Father died 2 1/2 ears ago in a car accident. History of high blood pressure,type 2 diabetes and high cholesterol -Mother is still alive. has history of hypertension and high cholesterol. -Brother is overweight -Sister has asthma
• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 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 problems
Social History
she does not have any children, has never been pregnant and has never been married. she lives with her mother and sister. currently works but is hoping to start a new jop as an accounting clerk at smith, stevens, steward silver company. drinksa alcohol ocassionally when she goes out with friends
Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. 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. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.
Assignment: Health Promotion Involving Tina Jones
Mental Health History
Denies any history of depression or suicidal thoughts. denies any problems with mood. no overall safety concerns.
Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear.
ASSIGNMENT INSTRUCTIONS: Health Promotion Involving Tina Jones
Please use the patient information provided below for this paper.
This assignment assesses intended course outcome(s)
#4 Use information found in patients’ health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient’s individual health promotion and disease prevention needs
Students will use the information found in Tina’s history, physical exam, and problem list to forulate an individualized health promotion and disease prevention plan of care. Recommendations should be evidence-based and from credible sources. The readings in module eight contains some suggested sources for obtaining health and screening recommendations for your patient.
The plan for addressing the health promotion and disease prevention needs for your patient should include:
Demographics:
– Age, gender and race of patient
– Education level (health literacy)
– Access to health care
Insurance/Financial status
– Is the patient able to afford medications and health diet, and other out-of-pocket expenses?
Screening/Risk Assessment
– Identified health concerns based on screening assessments and demographic information
Nutrition/Activity
– What is the patients activity level, is the environment where the patient lives safe for activity
– Nutrition recommendations based on age, race gender and pre-existing medical conditions
– Activity recommendations
Social Support
– Support systems, family members, community resources
Health Maintenance
– Recommended health screening based on age, race, gender and pre-existing medical conditions
Patient Education:
– Identified knowledge deficit areas/patient education needs (medication teaching etc).
– Self-care needs/ Activities of daily living
* The paper should be written and referenced in APA format and be no longer than 4 pages (excluding cover page and references).
Your paper will be evaluated based on the following criteria:
| Criteria | Level 3 | Level 2 | Level 1 |
| Demographics
(5%) |
Includes age, race and gender of patient | Missing one data item | Missing 2 or more data items |
| Insurance/Financial status
(10%) |
Includes information regarding patient’s insurance status and ability to afford medications and other out-of-pocket expenses | Missing some information regarding insurance status and ability to pay for medications and other out-of-pocket expenses. | Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses |
| Screening /risk assessment
(10%) |
Identifies health concerns based on screening assessments and demographic information. | Missing some information regarding health concerns, by excluding information from screening assessments and demographics | Health concerns are not identified due to information missing from screening assessments and demographics |
| Nutrition/activity
(20%) |
Completely asses patient’s nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions | Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions | Most of the information regarding the patient’s nutrition and activity levels are missing, recommendations are missing or not based on the patient’s age, race, gender and pre-existing medical conditions |
| Social support
(10%) |
Identifies support systems such as family members and community resources | Missing some information regarding support systems such as family members and/or community resources | Little to no information regarding social support |
| Health Maintenance
(20%) |
Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions | Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions | Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions |
| Patient Education
(20%) |
Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living | Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living | Lacks identification of knowledge deficit areas/patient education needs. Does not consider self-care needs or activities of daily living. |
| Organization, spelling and grammar, APA
(5%) |
Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA | Organized and easy to read, few spelling or grammar mistakes, few errors in APA | Disorganized, difficult to read, many spelling and grammar errors mistakes. Does not use APA |
| Overall score | Points
(60-100) |
Points
(24-59) |
Points
( 0-23) |
Assignment: Health Promotion Involving Tina Jones
Assignment: Health Promotion Involving Tina Jones
Leave a Reply