Journal Of Hospital Medicine Essay
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. 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) Journal Of Hospital Medicine Essay.
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Comprehensive Assessment of Tina Jones in Shadow Health
A comprehensive health assessment details the client’s physical, psychological, and psychosocial conditions affecting his or her health status. Similar to advanced focused review, the thorough evaluation allows the attending physician to analyze the client’s condition, conduct diagnosis accurately, and plan an appropriate plan of care (Zambas et al., 2016). The purpose of this final project synthesizes previous week’s studies on advanced focused assessments of Tina Jones, a pleasant 28-year-old African American visiting the shadow health clinic for a pre-employment physical. Using the information obtained from the client’s current and past medical history, the author discusses subjective and objective patient data and analyzes the information provided to establish a list of differential diagnoses. Further, the author formulates an individualized plan of care for the client, which encompasses Healthy People 2020 objectives and an apt nursing theory that is relevant to the client’s care plan. Acknowledged evidence that backs clinical reasoning for the selected evidence-based plan of care is comprehensively discussed. Lastly, the author individualizes the client’s plan of care into findings, lifespan stage development with culturally specific considerations, and patient-centred.
The focus of the Assessment
The assessment focuses on a pre-employment physical. According to Scepula (2020), a pre-employment physical assessment assures prospective companies that a prospective employee is physically and mentally fit to handle expected job responsibilities effectively. Generally, the examination includes an evaluation of a client’s vital signs, blood pressure, temperature, and weight.Journal Of Hospital Medicine Essay. The assessment may also entail specific tests such as alcohol, drug tests, physical inability, and psychological tests.
Subjective Findings Analysis
Ms Jones is a 28-year-old single African American woman presenting to the shadow health clinic for a pre-employment physical. She serves as the only cradle of history and offers information generously without any flaw. Tina Jones speech is clear and articulate, and she is alert and sustains eye contact during the entire interview. When asked for the reason to visit the clinic, she stated that she visited as she was required to have a current physical exam for the health insurance at her new job at Smith, Stevens, Stewart, Silver & Company. General survey reveals that the client is attentive and oriented, seated upright on the examination table, and without suffering. Ms Jones is well nourished, well developed, and dressed decently.
Current Health Status
When asked about a history of present illnesses, Ms Jones stated that she lacks any serious care concerns. She last had an appointment four months ago where she had her yearly gynecological assessment where she was diagnosed with the polycystic ovarian syndrome. The physician recommended oral contraceptives, which Ms Jones is tolerating well. The client also has type 2 diabetes which she controls by taking Metformin and lifestyle medications, including diet and exercise. Ms Jones reports that she does not experience any side effects and feels healthy at the moment.
Medications and Allergies
The client has been taking several medications such as metformin, Fluticasone propionate, Drospirenone and Ethinyl estradiol PO QD, Albuterol, acetaminophen for headaches, and Ibuprofen for menstrual cramps. The patient develops an allergic reaction to penicillin that occur as rashes and is also allergic to dust and cats. Ms Jones reveals that she has allergic symptoms such as the runny nose, itchy and swollen eyes, and increased asthma symptoms. Often, she treats the symptoms using an inhaler.
Ms Jones medical history shows that she was diagnosed with asthma at the age of two and a half. At 24 years, the client was diagnosed with type 2 diabetes. She started using metformin five months ago and had gastrointestinal side effects that later dissoluted. Ms Jones has a history of hypertension which regularized after initiating diet and exercise modifications. Tina Jones has never been pregnant and was diagnosed with PCOS two months ago.Journal Of Hospital Medicine Essay. To maintain her health, Tina Jones had a pap smear, eye, and dental exam in the past five months. She is current on tetanus boosters and child vaccines. However, she does not have a current influenza vaccine and has not received the human papillomavirus.
According to Ms Jones family history, it is revealed that her mother, aged 50, has hypertension and high cholesterol levels. Her deceased father suffered from hypertension, high cholesterol levels, and type 2 diabetes. While her brother aged 25 is overweight, Ms Jones sister is asthmatic. Her maternal grandmother and grandfather had a history of hypertension, cholesterol and diabetes. However, the family does not have an account of mental illnesses, cancers, or kidney disease.
Socially, Ms Jones does not have children, never been married, and is active in community activities. She is a social drinker but does not do drugs. The client denies any symptoms of depression and reports reduced stress and improved coping skills. She has no signs of current or frequent illness and reports recent weight loss as a result of diet and exercises modifications.
The physician began physical assessment for Ms Jones with a HEENT. HEENT is a physical examination technique concerned with the evaluation of the Head, eyes, ears, nose, and throat. The assessment revealed that the patient had no signs of headache, head injury, or visual damages. She does not experience any pain in the eyes, itchiness, or any redness. Notably, the client states that she wears corrective lenses. Ms Jones has no signs of mouth and ear problems. Similarly, she does not have difficulty swallowing, sore throat, or swollen nodes.
Objective Findings Synthesis
Ms Jones head is normocephalic and atraumatic. Her eyes are bilateral with identical hair dispersal on both the eyebrows and the lashes. She has no lesions in the lids or signs of edema. Her conjunctiva is pink, with no lesions, and has white sclera. PERRLA bilaterally, EOMs intact bilaterally, and no nystagmus. Mild retinopathy changes are visible on the right Left fundus with sharp disc margins, with no hemorrhages. 0/20 right eye, 20/20 left eye with corrective lenses, TMs intact and pearly grey bilaterally, and positive light reflex. Whispered words can be heard bilaterally, and the frontal and maxillary sinus is not tender to palpation. Ms Jones nasal mucosa is moist and pink, and her septum is midline. Her oral mucosa is moist, with no alterations or lesions. Further, the client’s gag reflex is intact, and dentation is without any signs of infection. Tonsils 2+ bilaterally, her thyroid smooth with no nodules, and she has no goitre or lymphadenopathy. Journal Of Hospital Medicine Essay.
After a respiratory assessment, it was reported that Ms Jones had no chest pains, cough, dyspnea, wheezing or shortness of breath. Her chest was symmetric with respiration, clear to auscultation, and bilateral without coughs or wheezes. She was resonant to percussion throughout and spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.
Ms Jones cardiovascular objective assessment revealed that the client had no palpitations, easy bruising, tachycardia, or edema. The client had a steady heart rate, and S1 and S2 sounds were audible without murmurs, rubs, or gallops. Bilateral carotids were equivalent jointly without bruit. There were PMI at the midclavicular line, 5th intercostal space, and there were no heaves, thrills, or lifts. The bilateral peripheral pulses were equal bilaterally, and capillary refill was less than 3 seconds. Notably, the patient had no peripheral edema.
Ms Jones abdominal assessment examination focused on the gastrointestinal area. The client reported no nausea, vomiting, constipation, pain, diarrhea, or any excessive pomposity. She also had no food bigotries, and the genitourinary assessment showed no nocturia, hematuria, pain, vaginal discharge, polyuria, or itching. Tina Jones bowel sounds were normal in all quadrants with no visible masses, scars, or lesions. Course hair from the pubis to the umbilicus. There were no tenderness or guarding to percussion, no organomegaly and no CVA tenderness.
Ms Jones musculoskeletal assessment reported no joint pains, weakness, or swelling. There were no pain in movement and Strength 5/5 bilateral upper and lower extremities, without masses, deformity or swelling. All joints were moving in full range.
The neurological assessment found no signs of dizziness, tingling, light-headedness, or a sense of disequilibrium. There was Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally and cerebral functioning tests were regular. Reduced sensation to monofilament in bilateral plantar surfaces was noted.
Nails, Hair, and skin
Scattered pustules on the face and facial hair on the upper lip were visible. She also had acanthosis nigricans on the posterior neck and nails free of ridges or abnormalities were noted on Ms Jones. Journal Of Hospital Medicine Essay.
Abnormal Findings from Ms Jones Assessment
Tina Jones physical assessment revealed several abnormal findings. First, the client has a body mass index of 29, meaning that she is overweight. Second, she is experiencing reduced sensation in the feet, which is detected in the monofilament test. Reduced feet sensation can be attributed to peripheral neuropathy which is caused by diabetes. By definition, peripheral neuropathy refers to the damage of nerves caused by chronic diabetes or elevated blood sugar. The condition causes numbness, loss of sensation, and pain in the feet. It is a common complication for diabetes (Schreiber, 2015). The client also had mild retinopathic changes in her right eye. Diabetic retinopathy is a condition that affects the eyes. Forth, Ms Jones had a neck discolouration, identified as acanthosis nigricans. Acanthosis nigricans is a skin condition pigeon-holed by dark velvet patches in body folds. In most cases, the disease occurs in obese individuals or those with diabetes. Fifth, the client has abnormal hair growth in the face, which is a likely result of PCOS. Based on these findings, it is incredibly crucial that Ms Jones plan of care be designed in a way that considers her diabetes, weight management, PCOS, and asthma.
Plan of Care
According to Mercer et al. (2015), all patients’ plans of care must be individualized and tailored to the specific needs of the patient. For Ms Jones, her plan of care should centre on diabetes, weight management, PCOS, and asthma. Specifically, the client should be encouraged to practice self-care to manage her conditions best. Dorothea Orem self –care theory is a nursing theory applicable to Ms Jones plan of care. The theoretical framework focuses on an individual’s capacity to perform self-care activities. Here, self-care is defined as practising exercises that a person initiates and perform to maintain life, health, and wellbeing. As per the theorist, self-care requisites are requirements needed for individuals to achieve sufficient healthcare (Younas, 2017). They are categorized into universal requisites, developmental, and healthcare deviation self-care requisites. Universal requirements comprise food, water, air, maintaining the balance between rest and activity, and social interaction. Health deviation self-care encompasses seeking appropriate medical assistance, adhering to medical prescriptions, and modifying environmental and pathological states that affect the disease. Orem’s self-care theory maintains the patient should be responsible for his or health. When implementing the plan of care, the nurse should identify Ms Jones areas of self-care deficit and provide the client with guidelines, education, and leadership required to improve the client’s quality of life.
Healthy People 2020 objectives related to weight status, diabetes, and nutrition can also be incorporated into Ms Jones plan of care. Healthy People 2020 is a science-based global framework that contains goals and objectives for disease prevention and health promotion. The primary goal for Healthy People 2020 is to alleviate the disease burden of diabetes mellitus and improve the quality of life for individuals affected and those at high risk. Objectives D-5 and D-16 are specifically applicable to Tina Jones plan of care. Objective D-5 focuses on improving glycemic control among persons with diabetes, while the latter focuses on increasing preventive behaviours among persons at high risk of diabetes mellitus. Healthy People 2020 objectives on nutrition and weight status are also applicable in Ms Jones plan of care. Its goal is to reduce the incidence of chronic health conditions by consuming healthy diets and maintaining a healthy weight. Journal Of Hospital Medicine Essay. Objective NWS-8 is to increase the number of adults with a healthy weight. From Ms Jones reports, it is evident that she has initiated preventive care by incorporating healthy practices in her daily routine. She has significantly improved her diet, and this has translated into weight loss. The physician should encourage the patient to incorporate physical exercises and adhere to the prescribed medications.
In addition to being individualized and patient-centred, Ms Jones plan of care should take into consideration cultural-specific aspects. Tina Jones is an African American, a population in which diabetes is disproportionately prevalent. Research suggests that African American adults are 60 per cent highly likely to be diagnosed with diabetes compared to whites (Ajuwon & Love, 2020). Diabetes significantly increases the risk of cardiovascular illnesses. Risk factors for diabetes that Ms Jones have a first degree relative with diabetes, being a member of a high-risk ethnic population, overweight, PCOS, and acanthosis nigricans. Control of diabetes requires the client to initiate self-management behaviours. When designing Ms Jones, the physician should educate the patient and emphasize on the importance of regularly monitoring the blood sugar. She should also be referred to a podiatrist to monitor her peripheral neuropathy. Tina Jones should also be educated on the significance of regular visits to the ophthalmologist for an eye examination. Adequate control of diabetes will require the client to modify her lifestyle and incorporate physical exercises and healthy diets (Kerrison et al., 2017). The client can be referred to a nutritional counsellor to assist her in diet and nutrition. While she appears to have controlled her asthma, her five self-care skills should be evaluated. These are medication adherence, peak expiratory flow meter usage, asthma action plan, daily follow-up schedule, and avoidance of triggers.
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In summary, a comprehensive health assessment of Ms Jones identified her current health status, health behaviours, and potential healthcare conditions. Using these findings as the central guide, a detailed plan of care, incorporating Dorothea Orem’s self-care theory and Healthy People 2020 goals were designed, taking into consideration cultural-specific elements. Using the theoretical framework, Ms Jones can reflect on her health behaviours and implement self-care strategies to monitor her diabetes. The physician can also identify areas of self-care deficits. Ms Jones can also introduce healthy diets and physical exercises in a lifestyle to maintain a healthy weight. Provision of education and guidance will significantly assist Tina Jones to achieve optimal health. Journal Of Hospital Medicine Essay.
Ajuwon, A. M., & Love, R. (2020). Type 2 diabetes and depression in the African American population. Journal of the American Association of Nurse Practitioners, 32(2), 120-127. https://doi.org/10.1097/jxx.0000000000000240
Diabetes | Healthy people 2020. (n.d.). Healthy People 2020 |. https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes
Kerrison, G., Gillis, R. B., Jiwani, S. I., Alzahrani, Q., Kok, S., Harding, S. E., Shaw, I., & Adams, G. G. (2017). The effectiveness of lifestyle adaptation for the prevention of prediabetes in adults: A systematic review. Journal of Diabetes Research, 2017, 1-20. https://doi.org/10.1155/2017/8493145
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
cepura, R. C. (2020). The challenges with pre-employment testing and potential hiring bias. Nurse Leader, 18(2), 151-156. https://doi.org/10.1016/j.mnl.2019.11.014
Schreiber, A. K. (2015). Diabetic neuropathic pain: Physiopathology and treatment. World Journal of Diabetes, 6(3), 432. https://doi.org/10.4239/wjd.v6.i3.432
Younas, A. (2017). A foundational analysis of Dorothea Orem’s self-care theory and evaluation of its significance for nursing practice and research. Creative Nursing, 23(1), 13-23. https://doi.org/10.1891/1078-45220.127.116.11
Zambas, S. I., Smythe, E. A., & Koziol-Mclain, J. (2016). The consequences of using advanced physical assessment skills in medical and surgical nursing: A hermeneutic pragmatic study. International Journal of Qualitative Studies on Health and Well-being, 11(1), 32090. https://doi.org/10.3402/qhw.v11.32090. Journal Of Hospital Medicine Essay.