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Tina Jones Health History
Nursing Nclex review (Nur003)
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Tina Jones Health History
Shift Assessment
Student Documentation Model Documentation
Chief Complaint
The patient states that she got and scrape on her foot a while ago and it got really infected.
Right foot pain, fever, nausea
History of Present Illness
Patient states she got the wound on her foot a week ago while she was changing a light bulb. The wound is located on the ball of her right foot, and it's red and swollen. Patient refers a whitish drainage from the wound. Patient states she used Neosporin on her wound with not relieve. Patient states a pain level 7 in the scale of pain. Patient refers some relief after takin Advil at home. Patient states she is unable of performing her activities of daily living because of the wound on her foot
Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. She is a good historian. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. The injury occurred about one week ago. Her pain has worsened, and the swelling has persisted. She tried ibuprofen, but it didn't work well. The foot feels better when she rests, and it hurts more when she walks on it. Her pain is a 9 when she tries to ambulate. She took her temperature at home and reports it was 102. She has not been eating much and has been staying in bed the last few days, per patient report. The scrape is red and swollen with exudate and has no odor; she reports the swelling and exudate started two days ago. She reports diarrhea overnight. Pain improved with oxycodone. Stomach upset.
Pain Assessment
Patient refers a pain level of 7 in the pain scale. Patient states the pain is continuous and throbbing. She says the pain is sharp if she tries to put weight on it
Pain is rated as 7. Pain is localized to ball of foot related to wound. Dull and constant ache. Patient has tried ibuprofen, but reports it does not work well. Patient states there is relief when foot is elevated, not walking on it. Patient answers questions clearly and consistently. Offers information without hesitation. Vital signs are within range.
Allergies
Patient states she is allergic to cats. When she is around cats, she starts sneezing, gets itchy eyes, and her asthma triggers. Patient states she is allergic to penicillin. She does not remember the reaction to it because she was pretty little. She thinks she got a rash like hives, and the doctor told her not to take it again. Sometimes her asthma triggers with dust. No allergic to mold or pollen No food allergies No latex allergies
- Penicillin: rash • Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation • No food allergies • Not allergic to latex
Immunizations
Patient states she had all required vaccinations when she was a kid and during college. She says she has a vaccination record at home. Patient had a tetanus booster a year ago. She did not get the flu vaccine.
Up-to-date. Received tetanus and HPV vaccines within the last year. Denies recent flu shot.
Medications
Home medications Advil for her foot wound pain. And for cramps every month Albuterol inhaler for asthma Neosporin on her foot wound twice daily Tylenol for headache once a week Inpatient medications Clindamycin 600mg/ 50ml IV Q6 Insulin glargine 10units HS Insulin lispro sliding scale AC Oxycodone 5 mg PO Q4 PRN for pain Promethazine 25mg PO Q4 PRN for nausea Acetaminophen 325mg 2 tabs PO Q4 PRN for fever greater than 38 C Albuterol MDI 2 puffs Q4 PRN for wheezing 0 NaCl IV 100mL/hr. cont. Decrease to 50ml/hr. cont. after 12 hrs.
- Albuterol 90 mcg/spray MDI, 1-3 puffs, as needed for wheezing • Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache • Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps
Medical History
Patient has Diabetes Type 2. She is not taken any medications for it. She used to take Metformin for diabetes management but states she stopped using it 3 years ago because she got tired of it. She has a blood sugar monitor at
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she experiences exacerbations, such as from dust or cats; she never uses it more than twice a week. She was exposed to cats a few days ago and had to use her inhaler once. She is prescribed 1-3 puffs as needed; she reports having to use 3 puffs
pressure High cholesterol Brother Health No known medical issues Sister Health Asthma
age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism
Social History
Patient is currently studying a Bachelor's degree. She is living with her mother. Patient is Baptist. Patient denies she or anyone at home smoke. She says she drinks alcohol sometimes. Patient denies illicit drugs use. Patient admits she has smoked marijuana before. She says she has not smoked marijuana since she was 21 years old.
Never married, no children. Lived independently since age 19, currently lives with mother and sister to support family after death of father one year ago, anticipates moving out in a few months. She works 32 hours/week as a supervisor at a printing and shipping company and is in her last semester of a bachelor’s of accounting program. She hopes to advance to an accounting position within her company. Has a car, cell phone, and computer. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. She is very active in her Baptist church, faith is important to her, and church community is a large part of her social network. No exercise. She wears her seat belt, drives frequently. Guns are locked up. No tobacco. Occasional alcohol (10 - 12 drinks/month). No concerns about alcoholism. Occasional cannabis use from age 15 to age 21. She drinks four caffeinated drinks/day (diet soda). No foreign travel. No pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday. She denies suicidal and homicidal ideation.
Review of Systems
Constitutional Health Fatigue Fever Weight loss Pain Mental health Anxiety Head Headache Ears Not reported problems Eyes and Vision changes in vision Nose clear discharge with allergies Mouth and Jaw Not reported problems Neck, throat and glands Not reported problems Respiratory Wheezing with asthma Cardiovascular Not reported problems
Head: Reports headaches that occur weekly with reading in the past year. The headache lasts a few hours and is relieved with acetaminophen and sleep. Headaches are described as a “tight and throbbing feeling behind the eyes.” Denies head and neck trauma. Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. Eyes: Complains of blurred vision associated with “reading and studying,” which has worsened
Gastrointestinal Not reported problems Urinary Increased urination Reproductive Irregular menses Heavy menstrual cycle Cramps Musculoskeletal Not reported problems Neurological Headache Skin, Hair and nails wound on the ball of the right foot hair growth on her chin, mustache area and her abdomen
over the past few years. No visual acuity testing since childhood. Does not wear corrective lenses. Reports eye itching associated with exposure to cats. Denies discharge and pain. Nose: Rhinitis and congestion related to cat allergy. Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. Mouth: Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste. Throat and Neck: Denies sore throat, dysphagia, and changes to voice quality. Denies goiter, hyper/hypothyroidism. Respiratory: Denies history of pneumonia, tuberculosis, and chronic bronchitis. Denies cough, dyspnea, current wheezing, hemoptysis, or recent cough. Cardiovascular: Denies palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and pain in lower extremities. Reports no blanching in fingertips when exposed to cold. Gastrointestinal: Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. Denies gallbladder and liver disease. Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months. Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Denies history of recurrent urinary tract infections and kidney stones. Denies vaginal discharge and vaginal itching. Menses irregular. No history of sexually transmitted infections. No pregnancies. Musculoskeletal: Denies history of fractures, gout, and arthritis. Denies myalgias and arthralgias. Denies back and neck pain and trauma. Denies generalized weakness. Does not exercise regularly. Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis.
Tina Jones Health History
Course: Nursing Nclex review (Nur003)
University: Chicago School of Professional Psychology
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