Identifying data and reliability health assessment example

Please use the patient information provided below for this paper.

This assignment assesses intended course outcome(s)

#4 Use information found in patients’ health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient’s individual health promotion and disease prevention needs

Students will use the information found in Tina's history, physical exam, and problem list to formulate an individualized health promotion and disease prevention plan of care. Recommendations should be evidence-based and from credible sources. The readings in module eight contains some suggested sources for obtaining health and screening recommendations for your patient.

The plan for addressing the health promotion and disease prevention needs for your patient should include:

Demographics:

- Age, gender and race of patient

- Education level (health literacy)

- Access to health care

Insurance/Financial status

- Is the patient able to afford medications and health diet, and other out-of-pocket expenses?

Screening/Risk Assessment

- Identified health concerns based on screening assessments and demographic information

Nutrition/Activity

- What is the patients activity level, is the environment where the patient lives safe for activity

- Nutrition recommendations based on age, race gender and pre-existing medical conditions

- Activity recommendations

Social Support

- Support systems, family members, community resources

Health Maintenance

- Recommended health screening based on age, race, gender and pre-existing medical conditions

Patient Education:

- Identified knowledge deficit areas/patient education needs (medication teaching etc).

- Self-care needs/ Activities of daily living

* The paper should be written and referenced in APA format and be no longer than 4 pages (excluding cover page and references).

Your paper will be evaluated based on the following criteria:

Criteria

Level 3

Level 2

Level 1

Demographics

(5%)

Includes age, race and gender of patient

Missing one data item

Missing 2 or more data items

Insurance/Financial status

(10%)

Includes information regarding patient’s insurance status and ability to afford medications and other out-of-pocket expenses

Missing some information regarding insurance status and ability to pay for medications and other out-of-pocket expenses.

Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses

Screening /risk assessment

(10%)

Identifies health concerns based on screening assessments and demographic information.

Missing some information regarding health concerns, by excluding information from screening assessments and demographics

Health concerns are not identified due to information missing from screening assessments and demographics

Nutrition/activity

(20%)

Completely asses patient’s nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions

Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions

Most of the information regarding the patient’s nutrition and activity levels are missing, recommendations are missing or not based on the patient’s age, race, gender and pre-existing medical conditions

Social support

(10%)

Identifies support systems such as family members and community resources

Missing some information regarding support systems such as family members and/or community resources

Little to no information regarding social support

Health Maintenance

(20%)

Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions

Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions

Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions

Patient Education

(20%)

Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living

Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living

Lacks identification of knowledge deficit areas/patient education needs. Does not consider self-care needs or activities of daily living.

Organization, spelling and grammar, APA

(5%)

Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA

Organized and easy to read, few spelling or grammar mistakes, few errors in APA

Disorganized, difficult to read, many spelling and grammar errors mistakes. Does not use APA

Overall score

Points

(60-100)

Points

(24-59)

Points

( 0-23)

Health History

Student Documentation

Model Documentation

Identifying Data & Reliability

Tina Jones is a 28 year old African american female AOX4. Pt is reliable historian

Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Alert and oriented X4. Feels tired because she was just coming from her other job.

Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.

Reason for Visit

Presenting to shadow health hospital clinic for a complete health assessment for a pre-employment physical.

"I came in because I'm required to have a recent physical exam for the health insurance at my new job."

History of Present Illness

Tina Jones is a 28year old African America female with a history of diabetes and Asthma presenting to get a complete health assessment for a pre-employment physical.

Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.

Medications

Metformin 850mg twice daily Yaz birth control daily in the morning Flovent MDI twice daily proventil 90mcg/spray 2 puffs as needed for wheezing

• 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)

Allergies

Penicillin- Rash, hives cats- sneezing, itchy watery eyes, asthma exacebation No Known food allergies No latex allergies

• Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.

Medical History

Asthma- diagnosed at age 2 1/2 Diabetes Type 2 - diagnosed at 24 was on metformin but stopped due to side effects

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.

Health Maintenance

Has been eating healthy and trying to stay active by walking 30-40 mins two times per week and also swimming once a week

Last Pap smear 4 months ago. Last eye exam three months ago. Last dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.

Family History

-Father died 2 1/2 ears ago in a car accident. History of high blood pressure,type 2 diabetes and high cholesterol -Mother is still alive. has history of hypertension and high cholesterol. -Brother is overweight -Sister has asthma

• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Social History

she does not have any children, has never been pregnant and has never been married. she lives with her mother and sister. currently works but is hoping to start a new jop as an accounting clerk at smith, stevens, steward silver company. drinksa alcohol ocassionally when she goes out with friends

Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.

Mental Health History

Denies any history of depression or suicidal thoughts. denies any problems with mood. no overall safety concerns.

Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear