A comprehensive health assessment gives the nurses insight into a patient’s physical status through observation, the measurement of vital signs and also self-reported symptoms. It will include a medical history, a general survey and a complete physical examination. Nurses use health assessments to get baseline data about the patients and to build a rapport with them that can reduce anxiety. Generally, a comprehensive health assessment is conducted at the time of admission into an acute care facility or during the first visit to an outpatient clinic.
Shadow Health Comprehensive Assessment of Tina Jones
Tina Jones, a 28-year-old woman, presents to the clinic for a pre-employment physical. A comprehensive assessment of Tina Jones will be performed. Also, key findings will be determined. A comprehensive physical assessment will provide fundamental, personalized knowledge regarding a patient and creates the basis for health promotion via education and counseling. An individualized plan of care taking into consideration Tina Jones’ age, nursing theory, physical examination results, and Healthy People 2020 objectives will be discussed.
Current Health Status
Tina Jones goes to the clinic for a general physical exam. She reports that she recently got a new accounting clerk job at a Company and they asked her to get a pre-employment physical. Tina Jones denies any acute concerns at this visit. The last visit to the clinic was 4 months ago for an annual gynecological exam.
At that time, Tina Jones was diagnosed with PCOS (polycystic ovarian syndrome) in which Tina Jones was prescribed the oral contraceptive Yaz. Tina Jones states that she takes the pill daily, at the same time each day. Her last physical exam was 5 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, she was given prescription eyeglasses.
Tina Jones states that the glasses increase her vision, reduce her blurry vision and also have helped eliminate her headaches. Tina Jones reports her type 2 diabetes is being well managed with diet, metformin, and exercise. Tina Jones regularly monitors her blood glucose levels, checking once a day in the morning. Also, she has been keeping records of her asthma by monitoring her peak flow. The rescue inhaler was last utilized three months ago with a total of two uses in the past year.
Psychosocial History
Tina Jones reports that she has improved her diet by limiting carbohydrates, staying away from sweets, and boosting vegetable consumption. Also, she has increased her physical activity. Tina Jones states that she goes for a 30-40-minute walk 4-5 times per week and also swims one time per week. She does not smoke or use recreational drugs. In addition, she reports that she smoked marijuana when she was younger, however has not for many years. She drinks when out with friends about 2-3 times per month. Her caffeine intake has decreased to 1-2 diet sodas per day.
Currently, Tina Jones lives with her mother and sister, however has a lease starting on her own apartment in one month. Recently, she has started a new relationship, but denies she is sexually active. Her job right now is as an accounting clerk, which starts in two weeks. Tina Jones states that she is very excited about the new chance. She says that she has a strong family support system. This strong support system assists to ease her stress and anxiety. Tina Jones reports no depression or anxiety. She states that she can cope well with upcoming life changes.
Family History
Jones’ mother is alive, has hypertension and high cholesterol. Her father died in a car accident one year ago. Jones’ father had hypertension, high cholesterol, and type 2 diabetes. In their 70s, her maternal grandparents both died from stroke and also had a history of hypertension and high cholesterol. Her paternal grandmother is alive, age 82, with hypertension. But, her maternal grandfather died at 65 years old of colon cancer and also had a history of type 2 diabetes. There is no family history of other cancers and mental illness.
Identifying Data and Reliability
Tina Jones is an African American single woman, age 28, who presents for a pre-employment physical. Tina Jones is the primary source of information and is reliable. Her speech is clear, also eye contact is appropriate.
Chief Complaint
“I came in because I am required to have a recent physical exam for the health insurance at my new job.”
Medications and Allergies
Metformin: Started 5 months ago. 850 mg twice daily. Reports eating yogurt helps with side effects. Albuterol: 90mcg, two puffs every four hours. Fluticasone: 88 mcg, two puffs twice daily. Drospirenone and ethinyl estradiol: everyday one pill. Ibuprofen: 600 mg as required for menstrual cramps. Tina Jones has a penicillin allergy with a reaction of rash. Also, she is allergic to cats and dust. These allergens can aggravate her asthma symptoms. Thus, she tries to avoid them. Tina Jones denies any food allergies.
Review of Systems
General: Tina Jones is sitting on the examination table comfortably, and in no acute distress. There are no current complaints or recent illness. Tina Jones appears well-nourished and dresses appropriately. Reports recent weight loss. Vitals: Weight 84 kg, Height 170 cm, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C.
HEENT: Tina Jones reports no headaches, eye pain, vision changes, or itchy eyes. Tina Jones wears corrective lenses and states that they have helped with her blurry vision and headaches. She denies changes in hearing or ear pain. Also, she denies a runny nose or sneezing. Five months ago was her last dental visit with no concerns.
Upon examination, her head is normocephalic with no lesions or tenderness of the scalp. Her hair is normal and also distributed evenly. Conjunctiva pink, Sclera white, PERRLA, EOMs intact. On the right, Mild retinopathic changes. Vision 20/20 bilateral with corrective lenses. Her nasal cavities are pink, no discharge. Ear canal pink too, tympanic membrane pearly gray, no drainage. Mucous membranes pink, tonsils 2+ bilaterally. Sinus’ palpated with no tenderness noted. On jaw palpation, no clicks. Thyroid palpable, no goiter, no nodules. On axillary and cervical lymph nodes palpated, no lymphadenopathy.
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