Description
As an advanced practice nurse, your ability to gather a health history from your patient interviews is crucial to determining how you will care for the patient. Using what you’ve experienced from the patient interview simulations, you will discuss how you chose to gather the desired information from your patient and note any adjustments that were needed based on individual patient needs.
Assessment Deliverable
Based on your experience conducting the health history on Tina Jones, write a 700- to 1,050-word reflection in which you address the following:
Explain the process you used to gather a health history on Tina Jones.
What information from the health history helped you in the assessment of Tina’s symptoms?
How were you able to empathize and engage with the patient in therapeutic communication? Provide an example of how you were able to do this.
Describe the patient health conditions you were able to conclude by using the evidence you collected.
How did you prioritize the needs of the patient?
Which needs will require immediate care and why?
Discuss the ways in which you could adjust your interview to ensure you are taking the patient’s unique culture into consideration.
How can you make the patient more comfortable and inclined to provide more information regarding their immediate symptoms?
Discuss the ways you could adjust your interview based on the developmental state of your patient.
Describe how technology could be used to obtain population health data that could be relevant to your patient.
Cite a minimum of 4 scholarly resources.
Format your references and citations according to APA guidelines. Include an APA formatted Cover Sheet and write your paper in APA format.
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Identifying Data & Reliability
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish
care and with a recent right foot injury. 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
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.
Chief Complain
“I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking
pretty nasty. And the pain is killing me!”
History Of Present Illness
Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right
ankle and scraping the ball of her foot. She sought care in a local emergency department where she had
x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site twice
a day. She has been applying antibiotic ointment and a bandage. She reports that ankle swelling and pain
have resolved but that the bottom of the foot is increasingly painful. The pain is described as
“throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated
7 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports that over the
past two days the ball of the foot has become swollen and increasingly red; yesterday she noted
discharge oozing from the wound. She denies any odor from the wound. Her shoes feel tight. She has
been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a 10-pound,
unintentional weight loss over the month and increased appetite. Denies change in diet or level of
activity.
Medications
Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps) •
Tramadol 50 mg PO TID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when
around cats,” last use three days ago)
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. She uses her albuterol inhaler when she is around cats and dust. She
uses her inhaler 2 to 3 times per week. She was exposed to cats three days ago and had to use her
inhaler once with positive relief of symptoms. She was last hospitalized for asthma “in high school”.
Never intubated. Type 2 diabetes, diagnosed at age 24. She previously took metformin, but she stopped
three years ago, stating that the pills made her gassy and “it was overwhelming, taking pills and checking
my sugar.” She doesn’t monitor her blood sugar. Last blood glucose was elevated last week in the
emergency room. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with
men, identifies as heterosexual. Never pregnant. Last menstrual period 3 weeks ago. For the past year
cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral
contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for
HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs four years ago. Hematologic: Denies
bleeding, bruising, blood transfusions and history of blood clots. Skin: Reports acne since puberty and
bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and
increase facial and body hair. She reports a few moles but no other hair or nail changes.
Health Maintenance
Last Pap smear 4 years ago. Last eye exam in childhood. Last dental exam “a few years ago.” PPD
(negative) ~2 years ago. No exercise. 24-hour Diet Recall: States that she skipped breakfast yesterday,
and would typically have a baked good for breakfast, a sandwich for lunch, and a meatloaf or chicken for
dinner. Her snacks consist of pretzels or French fries. 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 in college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a
bike. Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s
room
Family History
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
Never married, no children. Lived independently since age 20, currently lives with mother and sister in a
single family home to support family after death of father one year ago. Employed 32 hours per week as
a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift
supervisor. She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She
hopes to advance to an accounting position within her company. She has a car, cell phone, and
computer. She receives basic health insurance from work, but is deterred from healthcare due to out-ofpocket costs. She enjoys spending time with friends, 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
reports stressors relating to the death of her father and balancing work and school demands, and
finances. She states that family and church help her cope with stress. No tobacco. Occasional 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. She
drinks 4 caffeinated drinks per 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.
Objective
Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound edges, right ball of foot, serosanguinous
drainage. Mild erythema surrounding wound, no edema, no tracking.
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