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Comprehensive Health Assessment - Tina Jones Essay

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Comprehensive Health Assessment - Tina Jones Essay

Comprehensive Health Assessment - Tina Jones Essay
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.Comprehensive Health Assessment - Tina Jones Essay
You will use one comprehensive digital clinical experience health history and physical assessment for this assignment: Comprehensive Assessment. 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).

Introduction (including purpose statement)
Subjective Findings Synthesis
Objective Findings Synthesis
Plan of Care

Apply one nursing theory in planning care for this patient
Incorporate Healthy People 2020 Objectives into the plan of care prioritized to meet the health needs of the patient
Document evidence to support clinical reasoning for selected evidence-based plan of care
Plan of care is individualized to findings, life-span stage of development with culturally specific considerations, and patient-centered.

Conclusion
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). Comprehensive Health Assessment - Tina Jones Essay

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

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.
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.Comprehensive Health Assessment - Tina Jones Essay
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.
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.Comprehensive Health Assessment - Tina Jones Essay
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.
/10

COMMENTS:
 
TOTAL:
/100

 
Comprehensive Health Assessment - Tina Jones
A comprehensive health assessment provides physicians or nurses with understanding into the patient's physical health status through observation, self-reported symptoms, and measurement of the patient's vitals. The assessment encompasses the patient's medical history, complete physical evaluation, and general survey (Ingram, 2017). Generally, comprehensive health assessments are conducted at the time of patient admission into acute care or during their initial visit to the outpatient clinic. During a comprehensive health assessment, nurses use inspection, palpation, percussion, and auscultation techniques. An accurate health assessment is incredibly crucial as it distinguishes normal from abnormal findings. Through this, the physician can determine whether the patient requires additional medical care or diagnostic testing. With this in mind, this essay focuses on a comprehensive health assessment of Tina Jones, a 28-year-old African American presenting to the Shadow Health in need of a pre-employment physical. Here, the author discusses the comprehensive patient interview, physical assessment, and individualized care plan for Tina Jones that integrates healthy people 2020 objectives, evidence-based interventions, and patient-centered goals.Comprehensive Health Assessment - Tina Jones Essay
Subjective Findings Synthesis
Identifying Data and Reliability
Tina Jones is a lovely 28-year-old African American who visits the shadow health clinic for a pre-employment physical. As the only source of information, Ms. Jones offers data easily throughout the interview without any contradictions. The client has a vibrant and articulatedialog, and she sustains eye contact with the healthcare provider during the session.
General Survey
Ms. Jones is oriented and alert. She sits straight at the assessment table and appears to be in no outward pain. The patient is well-nourished, established, and decently dressed. She also maintains good hygiene.
Reason for Visit
"I came in because I am required to have a recent physical exam for the health insurance at my new job."
History of Present Illness
Ms. Jones reveals that she lately secured employment at Smith, Stevens, Stewart, Silver & Company. She is therefore required to obtain a pre-employment physical before startingwork. Today, the client does not have any acute health concerns. She last visited the healthcare clinic four months ago for her yearly gynecological assessment at the shadow health clinic, where the gynecologist diagnosed her with polycystic ovarian syndrome (PCOS). During that visit, the gynecologist prescribed oral contraceptives, which Ms. Jones has been tolerating well. Ms. Jones also reports that she has type two diabetes, which she regulates through diet, exercise, and Metformin, which she began five months ago. The client reports no medication adverse effects and notes that she feels healthy and anticipating tostart her new job.
Medications
Ms. Jones has been taking the following medications;

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). Comprehensive Health Assessment - Tina Jones Essay

Allergies
Ms. Jones reveals that she is allergic to penicillin, cats, and dust. She states that once in contact with allergens, her nose becomes runny, her eyes itchy and swollen, and her asthma symptoms increase. However, the client denies any latex and food allergies.
Medical History
At two and a half years, Ms. Jones was identified to have asthma. She reports the use of an albuterol inhaler when around cats. The client experienced her last asthma exacerbation three months ago, which she resolved using an inhaler. While in high school, she was hospitalized as a result of asthma complications. The client was diagnosed with type 2 diabetes at 24 and initiated Metformin five months ago. She states that she experienced gastrointestinal side effects, which quickly dissipated. The client checks her blood sugar every morning, with regular readings around 90. Ms. Jones has a history of hypertension, which resolved after she started lifestyle modifications. The client has no surgical history. She was diagnosed with PCOS four months ago and takes Yaz. Ms. Jones also tested negative for HIV and other sexually transmitted infections.
Health Maintenance
Ms. Jones had her last pap smear four months before, together with a dental examination. Her last eye test was three months ago, and she is negative for PPD. She had her tetanus booster in the past year, but her flu immunization is not current. The client has not received vaccination for the human papillomavirus. Ms. Jones believes she is current on child immunizations. She has installed smoke detectors in her room, wears seat beats while driving, and does not ride bikes. Comprehensive Health Assessment - Tina Jones Essay
Family History
The client reports that her mother, aged 50, has been diagnosed with high cholesterol levels and hypertension. Her father died after car accident a year ago at the age of 58. He was diagnosed with high cholesterol, hypertension, and type 2 diabetes. Her brother is 25 years and overweight, while her sister, 16, has asthma. Her deceased maternal grandmother had a stroke, hypertension, and stroke, similar to her maternal grandmother. Ms. Jones's paternal grandmother is 82 years with a history of hypertension, while the grandfather died at 65. He was diagnosed with type 2 diabetes and colon cancer. The client's paternal uncle has been diagnosed with alcoholism. Her family history is negative for mental health issues, sickle cell anemia, thyroid problems, and other cancers.
Social History
Ms. Jones reveals that she has never been married, has no children, and lives self-sufficiently since she was 19 years. She drinks occasionally but denies drug use. She relies on family and church to cope with stress. The client reports no recent foreign travel. She takes three meals a day and engages in moderate exercises.
Mental Health History
The client reports reduced stress and better coping abilities. She does not have any mental health concerns.
General Review of Systems
Ms. Jones reports no recent or frequent illness, chills, fatigue, fever, or night sweats. She reports ten-pound weight loss resulting from diet change and engagement in physical exercises. Comprehensive Health Assessment - Tina Jones Essay
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Objective Findings Synthesis
HEENT
Ms. Jones's head is normocephalic and atraumatic. Her eyes are bilateral, with an equal distribution of hair on the eyebrows and lashes. The client's eyelids are without lesions or edema. Conjunctiva is pink with no lesions, and her sclera is white. No hemorrhages, 20/20 vision with corrective lenses. Whispered words can be heard bilaterally, and the maxillary and frontal sinuses are non-tender to palpation. Ms. Jones's oral mucosa is moist and pink with septum midline. No dental infections, goiter, and lymphadenopathy.
Respiratory
The client's chest is asymmetric with respiration and clear to auscultation with no coughing or wheezing. In-office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.
Cardiovascular
Ms. Jones has a regular heart rate, and S1 AND S2 are audible without murmurs, rubs, or gallops. Bilateral carotids are equal with no bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. The client's bilateral peripheral pulses equal bilaterally, and her capillary refill is less than three seconds.  She has no peripheral edema.
Abdominal
Ms. Jones's abdomen is protuberant and symmetric with no notable scars, lesions, or masses. Her bowel sounds are normoactive in all quadrants and tympanic throughout to percussion. Upon palpation, no tenderness or guarding was observed. The client had no organomegaly or CVA tenderness.Comprehensive Health Assessment - Tina Jones Essay
Musculoskeletal
Ms. Jones experiences no pain with movement. Strength is 5/5 bilateral upper and lower extremities, with no swelling, masses, or deformity and with a full range of motion.
Neurological
Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs and equal bilaterally in upper and lower extremities. Reduced sensation to monofilament in bilateral plantar surfaces.
Skin, Hair, and Nails
Scattered pustules on the face and facial hair on the upper lip, acanthus nigricans on the posterior neck. Nails free of ridges or abnormalities.
Plan of Care
From the above comprehensive health assessment of Ms. Jones, the subsequent abnormal findings were observed; a BMI of 29, which implies that the client is overweight, reduced feet sensation, mild retinopathic changes in the right eye,acanthosis nigricans (neck discoloration), and abnormal growth of hair in the face. It is therefore vital that Ms. Jones's plan of care be designed in a manner that incorporates issues she experiences, such as weight management, PCOS, diabetes, and asthma.
Application of the Nursing Theory
Dorothea Orem's self-care theory is highly applicable in Ms. Jones's scenario. The theory is founded on the premise that all persons are capable of self-care (Borji et al., 2017). According to Orem, self-care encompasses activities that individuals deliberately and freely engage in to maintain health and wellbeing. Healthcare professionals follow the two-way nursing process identified in the theory to identify the client's unmet care needs and (care deficits) and help the client overcome these deficits (Mohammadi et al., 2016). Using this theory, the physician, together with Ms. Jones, can identify requisites and daily living activities and devise strategies for their improvement. Such an approach will ensure that the client's self-care needs are met. After identifying areas of self-care deficits, the health professional should guide Ms. Jones on their improvement through education and leadership.Comprehensive Health Assessment - Tina Jones Essay
Incorporation of Healthy People 2020 Objectives
Ms. Jones's care plan should consider objectives related to diabetes, weight, and nutrition. Healthy people's 2020 main goal is to eliminate the disease burden, improve functionality, and enhance population health for the general population and at-risk groups (Berge et al., 2019). Specifically, Objectives D-5 and D-16 are highly applicable to Ms. Jones's care plan as they improve diabetes management.  The former focuses on enhancing glycemic control, while the latter is concerned with increasing patients' improving preventive behaviors at a high risk of developing type 2 diabetes (Healthy People 2020). Objectives on nutrition and weight management can also be applied in Ms. Jones's care plan. Objective NWS-8 focuses on increasing the number of persons with healthy weight by encouraging lifestyle modification in the form of a healthy diet and physical exercise. While Ms. Jones has significantly improved her diet, the physician should encourage her to consume healthy diets and engage in moderate physical exercises while adhering to prescribed medications to improve her health.Comprehensive Health Assessment - Tina Jones Essay
Plan of Care Individualized To Findings, Life-Span Stage of Development with Culturally Specific Considerations, and Patient-Centered
According to Mercer et al. (2015), patients' care plans should focus on correcting the abnormal findings identified and improving their overall health. The plan of care should also incorporate relevant cultural considerations that impact Ms. JoneJones'se. For instance, the client's care plan should identify her as a high-risk individual. She is African American, a population that is disproportionately affected by type 2 diabetes. According to research, the rate at which African Americans are affected by type 2 diabetes is 60 percent higher than whites (Spears et al., 2017). The physician should, therefore, factors that are likely to increase Ms. Jones's likelihood of contracting type 2 diabetes mellitus.These include beingoverweight, PCOS, and acanthosis nigricans. The client should thus be encouraged to engage in self-management behaviors for effective management of diabetes. To improve her nutrition, the physician and the client should work collaboratively with a licensed nutritional counselor. While Ms. Jones appears to have controlled her asthma, research suggests thatthe patient's five self-care skills regarding asthma should be monitored to identify improvement areas (Majellano et al., 2019).  These are compliance with prescribed medications, peak expiratory flow meter usage, asthma action plan, daily follow-up schedule, and evasion of triggers.
Conclusion
Conclusively, a comprehensive health assessment of Tina Jones provided the physician with her present health status, health behaviors, and current health conditions. Abnormal findings such as decreased feet sensation, acanthosis nigricans, and retinopathic changes in her right eye were identified. These findings are closely linked to her current health conditions; diabetes, PCOS, and being overweight. The developed plan of care should focus on effectively managing her condition and eliminating all relevant risk factors.Comprehensive Health Assessment - Tina Jones Essay 
References
Berge, J. M., Fertig, A., Tate, A., Trofholz, A., & Neumark-Sztainer, D. (2018). Who is meeting the healthy people 2020 objectives?: Comparisons between racially/ethnically diverse and immigrant children and adults. Families, Systems, & Health, 36(4), 451-470. https://doi.org/10.1037/fsh0000376
Borji, M., Sharifi, A., Otaghi, M., & Kazembeigi, S. (2017). The impact of Orem's self-care model on the quality of life in patients with type II diabetes in Ilam. Biomedical and Pharmacology Journal, 10(1), 213-220. https://doi.org/10.13005/bpj/1100
Diabetes | Healthy people 2020. (n.d.). Healthy People 2020 |. https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes
Ingram, S. (2017). Taking a comprehensive health history: Learning through practice and reflection. British Journal of Nursing, 26(18), 1033-1037. https://doi.org/10.12968/bjon.2017.26.18.1033
Majellano, E. C., Clark, V. L., Winter, N. A., Gibson, P. G., & McDonald, V. (2019). Approaches to the assessment of severe asthma: Barriers and strategies. Journal of Asthma and Allergy, 12, 235-251. https://doi.org/10.2147/jaa.s178927
Mercer, T., Bae, J., Kipnes, J., Velazquez, M., Thomas, S., & Setji, N. (2015). The highest utilizers of care: Individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center. Journal Of Hospital Medicine, 10(7), 419-424. https://doi.org/10.1002/jhm.2351
Mohammadi, N., Hasanpour-Dehkordi, A., & Nikbakht-Nasrabadi, A. (2016). Re-designing Orem′s self-care theory for patients with chronic hepatitis. Indian Journal of Palliative Care, 22(4), 395. https://doi.org/10.4103/0973-1075.191754
Spears, E. C., Guidry, J. J., & Harvey, I. S. (2017). Measuring type 2 diabetes mellitus knowledge and perceptions of risk in middle-class African Americans. Health Education Research, 33(1), 55-63. https://doi.org/10.1093/her/cyx073
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