Comprehensive Assessment on Tina Jones in Shadow Health Essay
Comprehensive Assessment on Tina Jones in Shadow Health Essay
Please follow the grading Rubic very carefully. I have not be passing with work done by you all. Pleae come through with this paper please!! Final Project Final Project The Final Project (6-8 page paper) synthesizes the previous weeks' study of advanced physical assessment by conducting a comprehensive assessment in ShadowHealth. The final project synthesis is focused upon designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan. Assessment of competency is based on the Comprehensive Patient Interview, Physical Examination and Individualized Plan of Care incorporating Healthy People 2020 and evidence-based interventions and patient-centered goals. You will use one comprehensive digital clinical experience health history and physical assessment for this assignment: Comprehensive Assessment. Comprehensive Assessment on Tina Jones in Shadow Health Essay. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. The use of Headers in your paper is strongly encouraged. Submission Parameters: For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 6-8 pages, which does not include the cover page and reference page(s). 1.Introduction (including purpose statement) 2.Subjective Findings Synthesis 3.Objective Findings Synthesis 4.Plan of Care1.Apply one nursing theory in planning care for this patient 2.Incorporate Healthy People 2020 Objectives into the plan of care prioritized to meet the health needs of the patient 3.Document evidence to support clinical reasoning for selected evidence-based plan of care 4.Plan of care is individualized to findings, life-span stage of development with culturally specific considerations, and patient-centered. 5.Conclusion 6.References (use primary and/or reliable electronic sources) In regards to APA format, please use the following as a guide: •Include a cover page and running head (this is not part of the 6-8 pages limit) •Include transitions in your paper (i.e. headings or subheadings) •Use in-text references throughout the paper •Use double space, 12 point Times New Roman font •Apply appropriate spelling, grammar, and organization •Include a reference list (this is not part of the 6-8 pages limit) •Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP) The Final Project documentation is due in Week Seven. Please see the Final Project below to help you complete the assignment. Final Project Rubric Competency 20 18 16 0 Earned/ Possible Points The history, assessment and key findings are synthesized Documentation clearly shows student has completed a comprehensive assessment with a written synthesis of key findings. Comprehensive Assessment on Tina Jones in Shadow Health Essay. Documentation supports the student has completed the comprehensive assessment with key findings. Documentation supports the student has completed the assessment without documentation of key findings. Documentation supports the student attempted to complete the comprehensive assessment without identification of key findings. The comprehensive health history is briefly documented and lacks depth and specificity. /20 20 18 16 0 Documented Prioritized Physical Examination Findings Documentation clearly shows student has completed the physical examination with findings prioritized. Documentation supports the student has completed the physical examination with findings. Documentation supports student completed some of the physical examination. Documentation is accurate but lacks depth. No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability. /20 20 18 16 0 Documented Evidence to Support Clinical Reasoning with External Course Resources Discourse clearly shows the student has studied the topic and has given thought in developing the final plan of care with one nursing theory applied and integration of Healthy People 2020. Discourse supports the student has studied the topic and has given thought in developing the final plan of care. Lacks integration of either one applied nursing theory or integration of Healthy People 2020. Discourse supports student studied some of the topic, however, lacks detail and depth in developing the final plan of care. Lacks integration of either one applied nursing theory or integration of Healthy People 2020. No evidence that that student has read or studied the topic. Discourse lacks depth. May be presented in a rambling manner. Comprehensive Assessment on Tina Jones in Shadow Health Essay. Content is inaccurate &/or is unclear. No use of one applied nursing theory or integration of Healthy People 2020. /20 20 18 16 0 Individualized and Prioritized Plan of Care is Based Upon Clinical Findings Accurately presents an individualized plan of care based upon clinical findings. Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted. Presents a plan of care that is not individualized based upon the clinical findings. A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings. /20 5 4 3 0 Developmentally and Culturally Specific Accurately documents a development-ally and culturally specific assessment and plan of care for the selected patient. Documents a development-ally and culturally specific assessment and plan of care. Presents a development-ally and culturally specific assessment or plan of care and one or both are not based upon the selected patient. A development-ally and culturally specific assessment and plan of care are not presented or based upon the selected patient's findings. /5 5 4 3 0 Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the comprehensive physical assessment. Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation. Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the comprehensive physical assessment or inaccuracies are evidenced in the written assessment. Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the physical assessment. /5 10 9 8 0 Grammar, Spelling, and Punctuation APA Format APA Format, grammar, punctuation and spelling is accurate with errors. APA Format, grammar, punctuation and spelling is accurate with less than two types of errors. APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors. APA Format, grammar, punctuation and spelling is accurate with more than five types of errors. Comprehensive Assessment on Tina Jones in Shadow Health Essay
Comprehensive Assessment on Tina Jones in Shadow Health
The aim of Shadow Health physical comprehensive assessment is to examine and demonstrate the assessment skills, competency in taking the health history, and clinical reasoning. The learning experience in this assignment involved Tina Jones, a 28-year-old woman. She came to the clinic for a pre-employment physical examination that was required in her new job. This assignment will analyze the learning experience throughout the course through documentation of the comprehensive assessment for this patient, using specific nursing theory, and incorporating the relevant Health People 2020 (HP2020) goals.In addition, the paper will discuss a patient-tailored and evidence-based care plan that integrates the cultural considerations for this patient.
Synthesis of the Subjective Findings
Ms. Jones presented for a physical assessment required at her new workplace. The patient reported that her current medications include metformin, Acetaminophen, ibuprofen, ethinylestradiol, albuterol, Yaz birth control, and fluticasone. She denied side effects from other medications but reported bloated with metformin, which she was relieving using yogurt. Comprehensive Assessment on Tina Jones in Shadow Health Essay
She manages the diabetes condition by taking metformin, lifestyle modifications such as healthy eating and exercises, and by closely monitoring her blood glucose levels. The range of the patient's blood sugar levels are 90 which indicates that her blood glucose levels are within the normal limits, and thus her diabetes is well controlled (Tayek et al., 2018).
Tina Jones reports that asthma is also well controlled since asthma exacerbations have significantly reduced with the use of inhaler treatment. She reports that she went for the annual vision assessment and was given glasses, and since then her vision is excellent. The patient also reported that she has reduced caffein intake and this has stopped palpitations. She reports the diet change and exercises have helped her lose weight and denied any recent back pain. According to the patient, oral contraceptives have stabilized her menstrual cycle.
For her social life, she reports that she is in a relationship, an active member in her church, lives with the mother even though she has plans to move out soon, and interacts well with her friends. She states that her family members are close to each other. She denies any form of stress, depression, anxiety, and reports she generally feels satisfied and happy with life, especially with the new job. She also denied any nervousness or sleep problems. The patient denies any muscle pain or joint pain indicating that her musculoskeletal system is okay and further denies any form of numbness, lightheadedness, and dizziness. The patient denied any abnormal heartbeat, palpitations, or tachycardia. She also denied any nausea, vomiting, diarrhea, abdominal pain, or constipation. Comprehensive Assessment on Tina Jones in Shadow Health Essay
Synthesis of Objective Findings
All the vital signs for this patient are within the normal range. The respiratory system for this patient is okay as indicated by clear breathing sounds, symmetrical chest, and chest resonant to percussion. According to the spirometry readings, the functioning of her lungs is normal. The assessment of the cardiovascular system indicated that there were no life, heaves, or bruits within the carotid arteries. Her blood flow is also normal since her capillary refill was less than two seconds (Sansone et al., 2017).
The GIT system for the patient is normal since the assessment indicated that there were no masses, no flank pain, and all quadrants had normal bowel sounds. The liver was palpable but the kidneys and the spleen were not palpable. After assessing the musculoskeletal system, it was identified that the range of motion in all limbs was present, and also the muscle strength and motor skills were normal for this patient.
The neurological assessment showed that graphesthesia, stereognosis, and rapid alternation movements are normal. However, it was noted that the sensation to monofilament in planter surfaces had reduced (Yang et al., 2018). This indicates a likely peripheral neuropathy which is a common complication in patients with diabetes. Therefore, it will be important to refer her for a foot examination for further assessment. The nails and the hair for the patient appear normal. Upon inspecting the skin, the face has acne, abnormal facial hair on the face, and a darkening skin on the part of the skin. Comprehensive Assessment on Tina Jones in Shadow Health Essay
Plan of Care for the Patient
The patient has a diagnosis withpolycystic ovary syndrome (PCOS) four months ago. PCOS is a hormonal disorder in females and it is characterized by symptoms such as irregular periods, polycystic ovaries, and excess androgen that shows as severe acne and facial hair. Complications associated with PCOS consist of type 2 diabetes, infertility, sleep apnea, depression, endometrial cancer, abnormal uterine bleeding, and eating disorders. Obesity is among the major risk factors for PCOS and thus lifestyle modification that facilitates weight loss is useful in treating PCOS. Other treatment approaches in PCOS include the use of contraceptives, medications that trigger ovulation, and progestin (Williams et al., 2016).
The patient also has type 2 diabetes which is a disease that affects the way the body metabolizes glucose. The prevalence of diabetes is very high within America and it is characterized by symptoms like excessive thirst and hunger, weight loss, fatigue, blurred vision, frequent urination, and slow healing of wounds (Davies et al., 2018). Diabetes for this patient is well controlled as she did not report these symptoms. The risk factors in type 2 diabetes are overweight/obesity, poor nutrition, sedentary lifestyle, old age, and PCOS. The common complications in people with diabetes include neuropathy, vision problems, nephropathy, foot problems, and skin problem. The management approaches when treating type 2 diabetes include healthy eating, physical activities, adhering to the treatment regimen, and close monitoring and checking of the blood glucose levels (Davies et al., 2018).
According to Healthy People 2020, lifestyle modifications through healthy eating and exercising is an effective approach towards the management and prevention of type 2 diabetes. Effective monitoring of blood glucose levels for people with diabetes is among the goals of Healthy People 2020. The patient regularly monitors her blood glucose levels, has adopted healthy eating and exercises, and adheres to the prescribed treatments; therefore, Ms. Jones has met this goal of Healthy People 2020. Comprehensive Assessment on Tina Jones in Shadow Health Essay
Another goal of Healthy People 2020 is to increase the number of individuals with diabetes attending the annual eye examination. Ms. Jones reported that she went for eye examination and was given glasses to correct her eyesight. This shows that she has met this goal. Additionally, it is the goal of Healthy People 2020 to increase the number of individuals with diabetes who undergo foot examination. It is therefore important for Ms. Jones to undergo a foot examination and also ensure her A1c levels are tested.
The BMI of the patient is about 29 and this means that she is overweight. The main causes of overweight include lack of physical activities, eating an unhealthy diet, low socioeconomic status, and low level of education (Hruby & Hu, 2015).Being overweight is associated with diseases such as diabetes, cardiovascular conditions, cancer, hypertension, gynecological problems, and high cholesterol levels (Surani, 2016). Moreover, the prevalence of diabetes is higher among Africa Americans (King et al., 2018). Therefore, since Tina Jones is an African American, she is predisposed to diabetes.
The appropriate nursing theory for this patient is Orem's Self-Care Deficit Theory. According to Orem's self-care theory, people should take care of their health and focus on self-care. Self-care includes activities performed and behaviors adopted by an individual to maintain and ensure good health. The self-care theory stipulates that people should take care of their health by maintaining adequate and healthy food intake, clean air, and water; have adequate rest; have good social interactions and find time to be alone; prevent dangers and risks to well-being and life; and promote good human functioning (Malekzadeh et al., 2018).
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Self-care also involves seeking healthcare when necessary, adhering to the prescribed treatment, and accepting one's health status, and coping with the diagnosis. The patient is living as per the Orem's self-care theory as indicated by her practices to seek healthcare services whenever necessary, for example when she seeks treatment for the irregular periods and annual vision assessment. Ms. Jones is also adhering to the treatment regimen, including medications and the appropriate lifestyle modifications. Additionally, as per the self-care theory, she has accepted the health conditions and she is putting efforts to manage and improve the conditions by making positive lifestyle modifications and adhering to the treatment regimen(Malekzadeh et al., 2018). She is also taking care of her health as demonstrated by the efforts to maintain the vaccinations updated, practicing safe sex, and attending annual vision and gynecological examinations. The patient demonstrates a positive self-care in accordance with Orem's self-care theory. Comprehensive Assessment on Tina Jones in Shadow Health Essay
The patient did not have any clinical problems but needed to undergo a pre-employment physical assessment that was required at her new workplace. She reported that her pre-existing conditions include asthma and type 2 diabetes. She was also diagnosed with PCOS which was treated using oral contraceptives. She also wears glasses for her vision problems. The assessment revealed that she is generally healthy and her diabetes and asthma are well controlled. However, loss of sensation was discovered in her feet and thus she must undergo further foot examination. Ms. Jones needs to continue with weight loss because she is overweight; adhere to the treatment; closely monitor her glucose blood level; exercise regularly; and consume a healthy diet. The recommended health strategies for this patient include undergoing further foot examination and ensuring her A1c are tested. Comprehensive Assessment on Tina Jones in Shadow Health Essay
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Healthy People 2020. Comprehensive Assessment on Tina Jones in Shadow Health Essay