NU 333/ NURS 340L Tina Jones Respiratory Completed Shadow Health
NU 333/ NURS 340L Tina Jones Respiratory Completed
SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS: ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT ON NU 333/ NURS 340L Tina Jones Respiratory Completed Shadow Health
This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
Proficiency Level:
Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.
Transcript
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
It’s noon on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full respiratory exam on Ms. Jones given her history of asthma.
You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 40 and 50 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
In this assessment, you will become familiarized with the structure and content of respiratory exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
In your interview with Ms. Jones, you will ask about her respiratory system and identify any risk factors so that you can determine any current and potential issues. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to the respiratory system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her respiratory system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ respiratory system to gather objective data about the system’s health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
It’s noon on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full respiratory exam on Ms. Jones given her history of asthma.
It’s noon on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full respiratory exam on Ms. Jones given her history of asthma.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Based on your current knowledge, explain the pathophysiology of asthma.
SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS: ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT ON NU 333/ NURS 340L Tina Jones Respiratory Completed Shadow Health
Transcript
Started: May 14, 2020 | Total Time: 138 min
| Hello! | Question 0x/x4/2x 8:xx PM MDT |
|
| Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. | ||
| What is the situation? | Question 0x/x4/2x 8:xx PM MDT |
|
| It’s noon on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full respiratory exam on Ms. Jones given her history of asthma. | ||
| What else will this exam involve? | Question 0x/14/2x 8:xx PM MDT |
|
| You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation. | ||
| How will I be evaluated? | Question xxx |
|
| In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 40 and 50 minutes. You can pause and resume the assignment at any time; your work is always saved automatically. | ||
| How does this assignment prepare me for the real world? | Question xxx |
|
| In this assessment, you will become familiarized with the structure and content of respiratory exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data. | ||
| What are my objectives in this assessment? | Question 0xx |
|
| In your interview with Ms. Jones, you will ask about her respiratory system and identify any risk factors so that you can determine any current and potential issues. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to the respiratory system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her respiratory system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ respiratory system to gather objective data about the system’s health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. | ||
| What is the situation? | Question 0x/14/2x xxx PM MDT |
|
| It’s noon on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full respiratory exam on Ms. Jones given her history of asthma. | ||
| What is the situation? | Question xxx PM MDT |
|
| It’s noon on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full respiratory exam on Ms. Jones given her history of asthma. | ||
| In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Based on your current knowledge, explain the pathophysiology of asthma. | ||
| Hello. Asthma is a pulmonary condition defined by chronic inflammation of respiratory tubes, tightening of smooth muscle and bronchoconstriction | Statement 05/14/20 8:35 PM MDT |
|
| Time to begin. | ||
| Hello. My name is xxxx and I will be interviewing you today and later do a physical exam. | Greet | |
| Hey. | ||
| Please tell me what is your name | Q | |
| Tina Jones. | ||
| Your date of birth? | Question 0x/14/ |
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| February 17th. | ||
| How old are you? | Question 0xx/14/2xxx |
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| I’m 28. | ||
| What brought you to the clinic today? | Question xx/14/xxPM MDT |
| Hi. My name is xxx . I will be interviewing you today and later examine you. | Greet 10/03/20 4:23 AM EDT |
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Hey. | |
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What is your name? | Question 10/03/20 4:34 AM EDT |
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Tina Jones. | |
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What is your date of birth? | Question 10/03/20 4:45 AM EDT |
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February 17th. | |
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How a old are you? | Question 10/03/20 4:55 AM EDT |
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I’m 28. | |
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What brings you to the clinic today? | Question 10/03/20 5:56 AM EDT |
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I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does. | |
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Am sorry to hear that. | Empathize 10/03/201 5:57 AM EDT |
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I appreciate you saying that. | |
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What medical problems do you have? | Question 11/05/21 9:13 PM EDT |
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Well. . . I’ve had asthma since I was really little, though for a while there it wasn’t really much of a problem. And I have sugar diabetes, too. | |
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What do you use for your asthma? | Question 11/05/21 9:14 PM EDT |
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It’s just a regular Proventil inhaler. | |
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How often do you use your inhaler? | Question 11/05/21 9:15 PM EDT |
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I’ve been using it probably every. . . four hours or so, I’d say. | |
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When did your symptoms start? | Question 11/05/21 9:15 PM EDT |
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I don’t know if I’d call it an asthma attack, but my asthma started acting up two days ago at my cousin’s house. She has cats, and I’m allergic, so I’m used to it being a problem there, but usually the inhaler fixes it. . . it doesn’t feel totally under control, though. | |
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Am sorry to hear that | Empathize 11/05/21 9:16 PM EDT |
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Thanks for understanding. | |
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How long have you had breathing problems? | Question 11/05/21 9:17 PM EDT |
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My breathing’s been acting up off and on for the past two days. | |
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How frequent are your shortness of breath episodes? | Question 11/05/21 9:18 PM EDT |
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Sometimes it can take a few minutes for me to realize I need my inhaler, then once I use it the wheezing usually gets better. . . I’d say it takes about a minute to work at most after that. So five minutes total, at the longest? | |
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How long does one episode last? | Question 11/05/21 9:19 PM EDT |
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I haven’t had a full attack in years, but usually once I use my inhaler it only takes a minute or two for my breathing to go back to normal. . . that’s not what’s been happening recently, though. | |
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How many times have you had breathing problems in the past 2 days? | Question 11/05/21 9:20 PM EDT |
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Well. . . it’s kind of hard to count because my breathing’s been at least a little bad most of the past two days, but it’s really acted up, like with wheezing and everything, probably every four hours or so–like five times each day. | |
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Is your asthma keeping you up at night? | Question 11/05/21 9:21 PM EDT |
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My asthma doesn’t usually wake me up, but it has the past couple nights. | |
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How bad was your asthma attack? | Question 11/05/21 9:22 PM EDT |
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My asthma used to be really scary. I haven’t had a full attack in years, and if you had asked me before this I would have said my asthma wasn’t that bad anymore, but the last couple days I’ve had a lot of trouble breathing. | |
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Is there anything you can’t do because of your asthma? | Question 11/05/21 9:22 PM EDT |
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There usually isn’t anything I can’t do because of my asthma. . . I guess I try to avoid things that make my breathing worse, but that’s about it. The past couple days, though, it’s been hard to do anything. | |
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Do you wheeze during an asthma exacerbation? | Question 11/05/21 9:23 PM EDT |
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During a full attack, I would wheeze a lot, like I couldn’t breathe at all, but until the past couple days, I would usually just wheeze a little when I had breathing problems. | |
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Any chest tightness? (Clarified to Have you had chest tightness?.) | Question 11/05/21 9:23 PM EDT |
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Yeah, when my asthma gets bad my chest feels pretty tight, like I can’t take in air. It’s felt that way a lot the past two days. (Clarified to if I have had chest tightness.) | |
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Are you having any chest tightness? | Question 11/05/21 9:24 PM EDT |
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It just feels like I can’t really take in air when I breathe, sort of like breathing makes my chest tighter. . . it doesn’t hurt or anything, though. | |
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Any cough? | Question 11/05/21 9:24 PM EDT |
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I’ve been coughing a lot, yeah. | |
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How long have you had the cough? | Question 11/05/21 9:25 PM EDT |
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Since my asthma acted up two days ago. | |
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How would you describe the cough? | Question 11/05/21 9:26 PM EDT |
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Um. . . I guess I’d describe it as a small, dry cough. | |
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How would you describe the cough? | Question 11/05/21 9:27 PM EDT |
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Um. . . I guess I’d describe it as a small, dry cough. | |
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What makes your cough better? | Question 11/05/21 9:28 PM EDT |
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Drinking some water helps a little, as long as the water isn’t too cold. | |
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Have you tried to treat your cough? | Question 11/05/21 9:28 PM EDT |
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I haven’t taken medicine for it or anything. | |
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Is your asthma worse at night? | Question 11/05/21 9:29 PM EDT |
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It has been the past couple nights, yeah. | |
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Does lying on your back make your asthma worse? | Question 11/05/21 9:30 PM EDT |
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Just recently lying on my back has definitely made my breathing worse. | |
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To help your breathing, you may want to elevate your head with two pillows | Educate 11/05/21 9:31 PM EDT |
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Alright, thanks for letting me know. | |
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Any allergies? | Question 11/05/21 9:32 PM EDT |
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Yeah, I’m allergic to cats. | |
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Any medication allergies? | Question 11/05/21 9:32 PM EDT |
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Yeah, I’m allergic to penicillin. | |
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Any family history breathing problems? | Question 11/05/21 9:32 PM EDT |
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My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think. | |
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Inspected anterior chest wall | Exam Action 11/05/21 9:35 PM EDT |
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Inspected right side chest wall | Exam Action 11/05/21 9:36 PM EDT |
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Inspected posterior chest wall | Exam Action 11/05/21 9:36 PM EDT |
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Inspected left side chest wall | Exam Action 11/05/21 9:36 PM EDT |
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Inspected anterior chest wall | Exam Action 11/05/21 9:36 PM EDT |
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Palpated chest expansion: Both sides rise symmetrically | Exam Action 11/05/21 9:37 PM EDT |
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Percussed anterior right upper lobe | Exam Action 11/05/21 9:43 PM EDT |
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Percussed anterior left upper lobe | Exam Action 11/05/21 9:43 PM EDT |
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Percussed anterior right middle lobe | Exam Action 11/05/21 9:43 PM EDT |
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Percussed anterior left mid-chest (upper lobe) | Exam Action 11/05/21 9:43 PM EDT |
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Percussed anterior right lower lobe | Exam Action 11/05/21 9:43 PM EDT |
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Percussed anterior left lower lobe | Exam Action 11/05/21 9:44 PM EDT |
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Percussed posterior left upper lobe | Exam Action 11/05/21 9:45 PM EDT |
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Percussed posterior right upper lobe | Exam Action 11/05/21 9:46 PM EDT |
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Percussed posterior left mid-back (lower lobe) | Exam Action 11/05/21 9:46 PM EDT |
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Percussed posterior right mid-back (lower lobe) | Exam Action 11/05/21 9:46 PM EDT |
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Percussed posterior left lower lobe | Exam Action 11/05/21 9:46 PM EDT |
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Percussed posterior right lower lobe | Exam Action 11/05/21 9:46 PM EDT |
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Percussed posterior right lower lobe | Exam Action 11/05/21 9:46 PM EDT |
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Percussed posterior left lower lobe on side | Exam Action 11/05/21 9:46 PM EDT |
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Percussed posterior left lower lobe near spine | Exam Action 11/05/21 9:46 PM EDT |
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Percussed posterior right lower lobe near spine | Exam Action 11/05/21 9:46 PM EDT |
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Percussed posterior right lower lobe on side | Exam Action 11/05/21 9:47 PM EDT |
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Auscultated breath sounds in anterior right upper lobe | Exam Action 11/05/21 9:48 PM EDT |
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Auscultated breath sounds in anterior left upper lobe | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in anterior right middle lobe | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in anterior left mid-chest (upper lobe) | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in anterior right lower lobe | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in anterior left lower lobe | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in posterior left upper lobe | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in posterior right upper lobe | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in posterior left mid-back (lower lobe) | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in posterior right mid-back (lower lobe) | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in posterior left lower lobe | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in posterior right lower lobe | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in posterior left lower lobe on side | Exam Action 11/05/21 9:49 PM EDT |
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Auscultated breath sounds in posterior left lower lobe near spine | Exam Action 11/05/21 9:50 PM EDT |
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Auscultated breath sounds in posterior right lower lobe near spine | Exam Action 11/05/21 9:50 PM EDT |
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Auscultated breath sounds in posterior right lower lobe on side | Exam Action 11/05/21 9:50 PM EDT |
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Auscultated voice sounds in anterior right upper lobe | Exam Action 11/05/21 9:53 PM EDT |
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Ninety-nine. | |
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Auscultated voice sounds in anterior left upper lobe | Exam Action 11/05/21 9:53 PM EDT |
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Auscultated voice sounds in anterior right middle lobe | Exam Action 11/05/21 9:53 PM EDT |
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Ninety-nine. | |
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Auscultated voice sounds in anterior left mid-chest (upper lobe) | Exam Action 11/05/21 9:53 PM EDT |
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Ninety-nine. | |
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Ninety-nine. | |
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Auscultated voice sounds in anterior right lower lobe | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Ninety-nine. | |
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Auscultated voice sounds in anterior left lower lobe | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Ninety-nine. | |
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Auscultated voice sounds in posterior left upper lobe | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Auscultated voice sounds in posterior right upper lobe | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Auscultated voice sounds in posterior left mid-back (lower lobe) | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Ninety-nine. | |
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Auscultated voice sounds in posterior right mid-back (lower lobe) | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Auscultated voice sounds in posterior left lower lobe | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Ninety-nine. | |
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Auscultated voice sounds in posterior right lower lobe | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Auscultated voice sounds in posterior left lower lobe on side | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Ninety-nine. | |
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Auscultated voice sounds in posterior left lower lobe near spine | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Auscultated voice sounds in posterior right lower lobe near spine | Exam Action 11/05/21 9:54 PM EDT |
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Ninety-nine. | |
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Auscultated voice sounds in posterior right lower lobe on side | Exam Action 11/05/21 9:55 PM EDT |
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Ninety-nine. | |
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Ninety-nine. | |
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Check pulse oximetry using right hand | Exam Action 11/05/21 9:57 PM EDT |
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Checked pulse oximetry using left hand | Exam Action 11/05/21 9:57 PM EDT |
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Checked spirometer | Exam Action 11/05/21 9:58 PM EDT |
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Checked patient’s inhaler | Exam Action 11/05/21 9:58 PM EDT |
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Always make sure your inhaler is up to date. | Educate 11/05/21 11:38 PM EDT |
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Sure, I think I understand what you mean. | |
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What medications do you take? | Question 11/05/21 11:39 PM EDT |
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My inhaler is the only prescription I always have, but I usually don’t need it everyday, except for recently. . . | |
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When did you last use your inhaler? | Question 11/05/21 11:40 PM EDT |
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I had to use it early this morning. | |
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How many puffs of your inhaler are you prescribed? | Question 11/05/21 11:43 PM EDT |
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I’m supposed to just do two puffs of the albuterol inhaler. It’s 90 micrograms a spray. [AUDIO COMING SOON] | |
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Make sure to follow the Proventil instructions as prescribed. | Educate 11/05/21 11:45 PM EDT |
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Thanks for telling me. | |
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Are you taking any other medications? | Question 11/05/21 11:46 PM EDT |
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No, all I really use is my inhaler. | |
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Do you take any over-the-counter medications? | Question 11/05/21 11:52 PM EDT |
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I take Tylenol for a headache sometimes, or Advil for cramps, but not often. | |
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How much Tylenol do you take? (Clarified to How much Tylenol do you take?.) | Question 11/05/21 11:55 PM EDT |
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I just take one or two of the 500 mg acetaminophen. I usually get the headaches at night from reading — squinting I guess — and so I take one or two and go to bed. [AUDIO COMING SOON] (Clarified to how much Tylenol I take.) | |
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How much advil do you take for cramps? | Question 11/05/21 11:57 PM EDT |
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I take three 200 mg pills at a time. And I’d bet I take it up to three times a day. [AUDIO COMING SOON] | |
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Any new allergies? | Question 11/05/21 11:57 PM EDT |
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No, not that I know of. | |
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What started your recent asthma problems? | Question 11/05/21 11:58 PM EDT |
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This all started at my cousin’s house. She has cats, and I’m allergic, so my asthma always goes crazy when I’m there. | |
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Does being around dust trigger your asthma? | Question 11/06/21 12:00 AM EDT |
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Yeah, being around a lot of dust, especially hanging out in a really dusty house, can make my asthma act up. | |
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Am sorry to hear that | Empathize 11/06/21 12:03 AM EDT |
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I appreciate you saying that. | |
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Does climbing stairs trigger asthma? | Question 11/06/21 12:05 AM EDT |
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Only when I’m in a rush and have to hurry up them. | |
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Any seasonal allergies? | Question 11/06/21 12:10 AM EDT |
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A little while ago, I had some seasonal allergies, but it didn’t really bother my asthma, and it’s better now. | |
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Does anything at work make your asthma worse? | Question 11/06/21 12:11 AM EDT |
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Well. . . sometimes when there’s dust at work it can make my asthma act up, but that doesn’t happen very often. | |
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Do you see an asthma specialist? | Question 11/06/21 12:16 AM EDT |
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I used to go to Dr. Dewitt, but she moved her practice recently. Luckily she’s still been able to call in refills of my inhaler, but I haven’t actually been in to see her in about two years. | |
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It is important to follow up regularly with your asthma specialist. | Educate 11/06/21 12:18 AM EDT |
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OK, I understand. | |
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How long have you had asthma? | Question 11/06/21 12:18 AM EDT |
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I’ve had asthma a long time. . . since I was really little. | |
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How old were you when you were diagnosed with asthma? | Question 11/06/21 12:19 AM EDT |
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My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. |
SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS: ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT ON NU 333/ NURS 340L Tina Jones Respiratory Completed Shadow Health
Comprehensive Assessment of Tina Jones
Comprehensive Assessment of Tina Jones American Sentinel University Comprehensive Assessment of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed.
Health History Current Health Status
Tina Jones comes into the clinic for a general physical exam. She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. She denies any acute concerns at this visit. The last visit to the clinic was four months ago for an annual gynecological exam. At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive Yaz. She states she takes the pill daily, at the same time each day. Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. She regularly monitors her blood glucose levels, checking once a day in the morning. She also has been keeping records of her asthma by monitoring her peak flow. The rescue inhaler was last used three months ago with a total of two uses in the past year.
Psychosocial History
Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets, and increasing vegetable consumption. She also has increased her physical activity. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Tina does not smoke or use recreational drugs. Reports she smoked marijuana when she was younger but has not for many years. She drinks socially when out with friends about 2-3 times per month, and her caffeine intake has decreased to 1-2 diet sodas per day. She currently lives with her mother and sister but has a lease starting on her own apartment in one month. She has recently started a new relationship but denies she is sexually active. Her new job is as an accounting clerk, which starts in two weeks. Tina states she is very excited about the new opportunity. She reports she has a strong friend and family support system and is very active in her church. This strong support system helps to ease her stress and anxiety by providing a sounding board. She reports no depression or anxiety. She states she can cope well with upcoming life changes.
Family History
Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. Her father is deceased, age 58 in a car accident one year ago. He had hypertension, high cholesterol, and type 2 diabetes. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. Her paternal grandmother is alive and well, 82, with hypertension. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. There is no family history of other cancers, mental illness,
Physical Examination Identifying Data and Reliability
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 information and is reliable. Her speech is clear, and her eye contact is appropriate.
Chief Complaint
“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”
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Medications and Allergies
Metformin: Started five months ago. 850 mg twice daily. Reports eating probiotic yogurt helps with side effects.
Fluticasone propionate: 88 mcg/spray, two puffs twice daily.
Albuterol: 90mcg/spray MDI, two puffs every four hours as needed.
Drospirenone and Ethinyl estradiol: one pill every day. Ibuprofen: 600 mg as needed for menstrual cramps. Ms. Jones has a penicillin allergy with a reaction of rash. She is allergic to cats and dust. These allergens aggravate her asthma symptoms, so she tries to avoid them. She denies any food allergies.
Review of Systems
General.
Ms. Jones is sitting comfortably on the examination table, in no acute distress. No current complaints or recent illness. She appears well-nourished and dresses appropriately. Reports recent weight loss. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C.
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HEENT.
Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. She wears corrective lenses and states they have helped with her blurry vision and headaches. Denies changes in hearing or ear pain. Denies a runny nose or sneezing. Last dental visit was five months ago with no concerns. Upon examination, head is normocephalic with no lesions or tenderness of scalp. Hair is normal texture and distributed evenly. Sclera white, conjunctiva pink, PERRLA, EOMs intact. Left disc round with sharp margins. Mild retinopathic changes on the right. Vision 20/20 bilateral with corrective lenses. Nasal cavities pink, no discharge. Ear canal pink, tympanic membrane pearly gray, no drainage. Whispers heard bilaterally. Mucous membranes pink and moist, tonsils 2+ bilaterally. Gag reflex present, swallows without difficulty. Sinus’ palpated with no tenderness noted. No clicks on jaw palpation, full ROM. Thyroid palpable, no nodules, no goiter. Axillary and cervical lymph nodes palpated, no lymphadenopathy.
Respiratory.
Ms. Jones reports no shortness of breath or trouble breathing. No wheezing, runny nose or a cough. Last use of her rescue inhaler was three months ago and two times total over the past year. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Breath sounds present and equal bilaterally, no adventitious sounds noted. Chest resonant on percussion. Palpated fremitus equal bilaterally. Normal bronchophony results. Spirometry: FVC 3.9L, FEV1 3.15L, FEV1/FVC ratio 80.56%.
Cardiovascular.
Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Heart rate is regular, S1, S2, no murmurs, gallops or rubs. Bilateral carotids 2+, no thrill, no bruits. PMI nondisplaced, no heaves or lifts. Peripheral pulses 2+, equal bilaterally. No peripheral edema. Capillary refill <3 seconds.
Abdominal.
Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. Upon inspection, abdomen protuberant and symmetric. Coarse hair growth noted from pubis to umbilicus. Bowel sounds normoactive and present in all four quadrants. Abdomen tympanic on percussion. Liver span 7 cm MCL, palpable 1 cm below right costal margin. Abdomen soft with no tenderness, guarding or masses with palpation.
Musculoskeletal.
Ms. Jones reports no muscle pain or weakness. Her gait is smooth with equal stride. Full ROM of TMJ with no crepitus. Upper and lower extremities symmetric without lesions or swelling. Full ROM and 5/5 strength in extremities, spine, and hips. Deep tendon reflexes 2+, upper and lower.
Neurological.
Reports no dizziness, tingling, or loss of sensation. Awake and alert. Oriented to person, place, and time. Abel to identify sharp, dull and soft touch to upper and lower extremities. Dual shoulder shrug against resistance, able to turn head in both directions against resistance. Position sense in fingers and toes are normal. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Stereognosis and graphesthesia normal bilaterally. Monofilament test shows decreased sensation in both right and left great toes and forefoot.
Skin, hair, and nails.
Ms. Jones states her acne has improved due to oral contraceptive use. States skin on neck has stopped darkening. Her skin is pink, warm, with no tenting. Pustules noted on bilateral cheeks. Dark discoloration of skin on neck. Normal hair distribution. Fingernails pink without clubbing, ridges or abnormalities.
Abnormal Findings
Based on Tina’s physical examination, there were some key findings which were abnormal. First, her BMI indicates she is overweight, and only .9 points away from obese. Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). There were retinopathic changes in her right eye that are mild. Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. Another abnormal finding was the discoloration on her neck. “Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin” (Sander, 2018, para. 1). It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). Based on these assessment findings and Ms. Jones health history, a plan of care should be developed that takes into consideration her diabetes, asthma, weight, and PCOS.
Plan of Care
Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. Dorothea Orem’s self-care nursing model assumes people should be self-reliant and responsible for their care (Petiprin, 2016). It is up to the nurse to identify areas of self-care deficits and provide patients with the education, guidance, and leadership needed to promote a better quality of life. Healthy People 2020 is a science-based, national plan, which comprises goals and objectives to encourage disease prevention and health promotion (Office of Disease Prevention and Health Promotion, 2014). Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. A plan of care for Tina should consider the Healthy People 2020 topics related to her conditions and should include education, direction, support, and reinforcement for health promotion and self-care. Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. Ms. Jones should be encouraged by the additions and progress she has made. Diabetes is disproportionately prevalent in the African American population (Bickley & Szilagyi, 2013).
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Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). Risk factors for diabetes which Ms. Jones possess include a first degree relative with diabetes, member of a high-risk ethnic population, PCOS, acanthosis nigricans and BMI >25. Diabetes requires self-management behaviors for life. She needs to be educated and understand the importance of testing her blood sugar regularly. She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). She also needs to be educated on regularly seeing an ophthalmologist to perform eye exams to monitor her retinopathy. Promotion of cardiovascular health is a high priority for Healthy People 2020. Along with controlling diabetes, other leading modifiable risk factors include diet, physical activity, and being overweight and obesity. Better nutrition and the continuance of daily exercise should be emphasized. Not only are these objectives in line with Healthy People 2020 (#4 of the 24 objectives) but they will aid in the control her diabetes and PCOS. Regular physical activity should include moderate and vigorous-intensity activities and muscle-strengthening activities (Office of Disease Prevention and Health Promotion, 2014).
A dietician referral may be beneficial to educate on specifics and offer support. Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. Ms. Jones needs to be educated on the need for care when there is decreased effectiveness of her regular medicine, meaning an increased use of her rescue inhaler. Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Although Ms. Jones is not sexually active, she states she probably will be soon. Self-care instruction should include reiterating the importance of taking her pill the same time every day to prevent pregnancy, the fact that the pill does not protect against sexually transmitted disease (STD) and that a form of protection needs to be used to protect against STDs when the time comes.
Conclusion
A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. Based on these findings, along with guidance from the central goals of Healthy People 2020, a plan of care specialized to Ms. Jones was created, considering her age and culture. With the assistance of Orem’s self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health.
References
Altay, N., & Cavusoglu, H. (2013, April 23). Using Orem’s self-care model for asthmatic adolescents. Journal for Specialists in Pediatric Nursing. https://doi.org/10.1111/jspn.12032 Bickley, L. S., & Szilagyi, P. G. (2013). Bates’ guide to physical examination and history taking (11th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Elsevier Mosby.
Office of Disease Prevention and Health Promotion. (2014). About healthy people. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People
Office of Disease Prevention and Health Promotion. (2014). Physical activity. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity
Petiprin, A. (2016). Self-care deficit theory. Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php
Sander, I. (2018). Acanthosis nigricans. In A. O. Ofori (Ed.), UpToDate. Retrieved from http://www.uptodate.com
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