Running head: 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.

4

TINA JONES HEALTH HISTORY NARRATIVE

She does not use tobacco products and is exposed to secondhand cigarette smoke when she is out

with friends. She does not use drugs, but tried pot when younger. Ms. Jones drinks diet coke

soda. She drinks socially only two to three times per month when out with friends. She is

currently single. She is currently not on contraceptives, but used birth control while sexually

active with previous partner. She is not currently sexually active. She has never been married

and has never been pregnant. She has had a total of three (guy) partners, and has never been

diagnosed with any STI ‘s.

Subjective Data

HEENT

Ms. Jones states that she gets headaches when reading or studying. These headaches feel tight

and throbbing behind her eyes. The headaches last for a couple of hours. She takes Tylenol to

help with the headaches. There is no family history of headaches. She denies any head trauma.

Patient states that her vision gets blurry when reading or studying. She states that her eyes do not

hurt when her vision gets blurry. Her eyes get red and itchy when she is around cats. She also

sneezes and experiences rhinitis and congestion around cats. She has not had an eye exam since

childhood. She does not wear glasses or contacts. She states that she has no problems with her

mouth. She states that her nose is fine, denies nasal discharge. She states that her hearing is fine.

There is no family history of hearing problems. She denies head and neck trauma, ringing in the

ears, ear pain, discharge, and loss of balance. She does not have a history of sinus problems,

frequent colds or infections. She denies difficulty swallowing and changes to her voice. She

denies any dental issues and has not gone to the dentist since she was a kid. She has not had any

changes in her taste.

5

TINA JONES HEALTH HISTORY NARRATIVE

Cardiovascular

Ms. Jones denies cough, chest pain, palpations, dyspnea on exertion, dyspnea, peripheral

edema, varicosities, she states other than her right foot she does not have pain in lower

extremities. She denies a history of cardiac problems, stroke, and heart attack.

Respiratory

Patient states that she has not had a full-blown asthma attack in years, but had to use her

inhaler a few days ago when she was visiting her cousin. Cats are what usually triggers

problems with her asthma. She states that she is allergic to cats. She was able to breathe

normally after a few puffs of her inhaler. She uses a regular Proventil inhaler since she was a

kid. Her younger sister also has asthma. She denies: cough, shortness of breath, chest pain, and

congestion. She admits that she gets congested around cats. Her sister rarely has issues with her

asthmas. She denies smoking, drug use, and she denies the use of tobacco. She is only around

second hand smoke when she goes out with friends. She has been hospitalized as a child and in

high school for problems with her asthma. She denies a history of TB, chest pain, difficulty

breathing, and cough.

Abdominal

Ms. Jones denies digestive problems. She states that she has recently lost ten pounds

without trying over the past month. She denies flank pain, dysuria, and urgency. She denies

UTI’s. She also states that she is really thirsty and has been drinking a lot of water. She denies,

reflux, problems swallowing, nausea, vomiting, constipation, changes in bowel habits, abdominal

pain, and blood in her urine. Polyphagia, polydipsia, polyuria, and nocturia have been occurring

during the past month. She denies vaginal discharge and itching. She does not have a history of

sexually transmitted diseases. She has never been pregnant. Her period are irregular.

6

TINA JONES HEALTH HISTORY NARRATIVE

Musculoskeletal

States that she injured her right foot one week ago. This has caused limited ability for her

to be able to walk as well as not being able to bear any weight on her foot. This has caused her

to limp. She states that her right ankle has felt stiff and swollen. She denies joint pain. She does

not exercise.

Neurological

Tina states that she does get headaches when studying and reading for prolonged times.

She states that she takes Tylenol when this occurs. She has not had an eye exam since she was in

high school. She does not recall a recent headache. She notices that she has been having

problems with her vision lately. She states her vision becomes blurry when reading and

studying. She does not wear glasses or contacts. She states that her memory is good. She denies:

any issues with her memory, consciousness, confusion, disorientation, decrease in sensation,

dizziness, tremors, altered gait or balance, and tingling. She denies having difficulty swallowing.

She states that her hearing is fine. She denies weakness and denies a decrease in strength. She

denies a decrease in sensation. She denies any changes in her ability to taste and smell. Her

mood and affect are appropriate. She is able to provide a clear account of historical and recent

events. She denies any history of neurological injuries and complications.

She reports headaches that occur once a week behind the eyes with prolonged reading. These

headaches are resolved with acetaminophen and sleep. She denies fainting, dizziness, vertigo,

weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. She reports occasional

clumsiness. Denies history of traumatic brain injury. Denies recent changes in memory and mood

changes.

7

TINA JONES HEALTH HISTORY NARRATIVE

Psychological

Tina reports that she had a difficult time when her father died, but through the support of

her family, friends, and church she is now doing well. She experiences anxiety from finances

and from school. She denies current depression, feelings of hopelessness, suicidal thoughts,

insomnia, or changes in mood, concentration, and any problems or changes with her attention

span. She denies any changes in remote and recent memory. She is not having any problems

with confusion. She denies any history of mental problems.

Clinical Reasoning

Using clinical reasoning while identifying abnormal findings through interviewing and patients

chart and tests. These findings were localized anatomically and were interpreted. Her diagnoses

include: asthma, fever, weight loss, diabetes, allergies, and right foot open wound. She will

need to be assessed for infection; her asthma may need to be furthered assessed with possible

medication changes. Her diabetes will be also need to be further assessed. Clinical reasoning

was used to decide upon and list these diagnoses through notation and by localizing abnormal

findings. Her family history also impacts the clinical reasoning of nurses.

Care Plan

The care plan is wide-ranging. Her care plan will include her life-span stage of development. It

will include education, medications, tests, referrals, return visits, and support. It will further

include responses to the plan and results from tests and referrals. Including the patient’s support

system and goals is also important for a successful plan. Tina’s individualized Plan of Care

based upon her clinical findings will include medications, blood work, imaging and further tests.

She is in need of a consult for diabetic education. She will need routine glucometer checks. Due

to her fever she will need antibiotics as well as Tylenol to stop the infection as well as stop the

8

TINA JONES HEALTH HISTORY NARRATIVE

complications from the right foot open wound infection. She will need to be re-prescribed

medications to treat her diabetes. She will need to be placed on a diabetic diet as well as monitor

both her glucose as well as blood pressure. If her glucose or blood pressure is unable to be

controlled then she will need to be placed on medication as well as reinforced teaching to

decrease it.

She will need to be educated on the care and management of her right foot open wound and her

type II diabetes. She will need to learn about healthy eating, staying active, medication and

blood glucose monitoring compliance, doctor visits, and stress management. She will need to

gain an understanding about how her diabetes is affecting her overall health. She will need to be

educated on why she is experiencing increased thirst, increased hunger, fatigue, vision problems,

and the slow healing of her right foot open wound are most likely caused by her uncontrolled

type II diabetes. By monitoring and controlling her diabetes these symptoms will decrease. She

will need to be re-prescribed medications for her diabetes along with education about the

medications to treat her medical problems. Referring her to a diabetes educator will be

beneficial in providing Ms. Jones with comprehensive diabetes education, control, medication,

and maintenance. Her fever, high blood sugar, as well as her high blood pressure should also be

further examined. She should also be referred to a gynecologist to have her irregular and heavy

bleeding assessed and treated.

Cultural Considerations

According to the CDC the ten leading causes of death for African Americans are heart

disease, cancer, stroke, diabetes, unintentional injuries, kidney disease, chronic lower respiratory

disease, homicide, septicemia, and Alzheimer’s disease. Ms. Jones not only is African American,

but she also has a strong family history of heart disease, cancer, stroke, and diabetes, which

9

TINA JONES HEALTH HISTORY NARRATIVE

increase her chance of being diagnosed with these disease. Her current medical problems are

asthma and type II diabetes. The complications that she is experiencing are from her

unmonitored and uncontrolled diabetes and put her at an increased risk of bacteremia,

amputations as well as more severe health problems.

Ms. Jones’ care plan needs to incorporate achievable health measures that will include

measures of progress to assess how she is doing with meeting the goals. Measures of progress

that can be incorporated into her plan are: self-assessed health status, limitation of activity, and

assessment of how her chronic disease prevalence, gender, race, and her well-being and health-

related quality of life all affect her health and access to health.

The first category of individual characteristic applies to Ms. Jones’s diabetes, asthma, and family

history of stroke, heart attack, hypertension, and high cholesterol. Her previous behaviors such

as not exercising, not monitoring and treating her diabetes; and not seeking regular health,

dental, and eye exams are also fall in the first category. In addition, to the category are the

cultural and ethnic factors that cause her to be at an increased risk for specific diseases.

With the proper guidance as well as education Ms. Jones will being able to understand the impact

that her current medical problems and that by following the action plan will result in a change to

her health promotion behavior.

10