Tina Jones Assessment and Plan of Care Sample

The care of a patient depends primarily on physical examination and health history findings. Other additional tests such as laboratory workups and radiological studies are majorly confirmatory tests. The nurse should hence perform an inclusive physical assessment and take a comprehensive health history. Health history is essential in determining the risk and actual diagnosis of a patient. For example, a family history of sickle cell would indicate that the patient might be at risk of having sickle celled children. With a comprehensive health history and physical examination, cues are easily picked, synthesized, and a logical clinical judgment is made. Thus, a comprehensive assessment is key to finding a definitive diagnosis. The diagnosis informs the interventions ad rationale and thus determines the patient outcome. The care given to a patient should be guided by existing nursing theories and conform to the government and responsible bodies’ guidelines.

Tina Jones Assessment and Plan of Care Sample

Health History

Ms. Tina Jones visited the clinic requesting a physical examination. The physical examination was necessary to help her obtain her health insurance which was a prerequisite for her newly found job at Smith, Stevens, Stewards and Silver Company. She appears excited, has a euphoric mood, and is eager to sign in to her new job finally. Ms. Jones reports that she has been in good health without health concerns since her last medical visit was four months ago. Throughout the interview, she maintains direct eye contact. She is alert and well oriented. Her speech is clear and coherent.

Ms. Jones is a known asthmatic patient since the age of 21/2 years. The asthma is well controlled. She is on a daily Flovent inhaler. When she was in form two, she had a severe asthmatic attack, got admitted but was never intubated during her hospitalization. She has a known allergy to penicillin, cats, and dog fur. At times, asthmatic attacks are triggered by cats and dust, which she relieves using an albuterol inhaler.

Ms. Jones was diagnosed with type 2 diabetes at 24. Her condition had not been well managed, with reports of non-compliance to diabetes medications, stoppage of using metformin, and inadequate self-glucose monitoring. However, she reports having changed; she monitors her glucose levels regularly (average daily reading of around 90). She takes metformin twice daily and has also resulted in dieting and exercise as management of diabetes. She feeds on lean proteins, fruits and vegetables. She does her exercises four to five times a week.

Ms. Jones is also a known hypertensive. However, her blood pressure today was normotensive (128/82). This is primarily due to her diet and exercise interventions. Her menarche was at eleven, and she has never been pregnant. Four months ago, her doctor diagnosed her with Polycystic Ovary Syndrome. She was put on oral contraceptive management (Yaz birth control pills). She reports that her menstrual bleeding has been moderate and regular after taking oral contraceptives, with each cycle taking five days. Her last cycle was five days long and was two weeks ago. She also reports that her acne has resolved after taking the oral contraceptives. She has been sexually active since eighteen and verbalizes using condoms. She does a regular pap smear, her most recent being four months ago. The results were negative. Her HIV and VDRL tests were also negative. Ms. Jones developed gastrointestinal side effects of metformin which decreased after a while. She reports no observed side effects currently.

For her safety, she does not ride bikes. She wears her seatbelt when using vehicles, keeps guns that belonged to her father in a safe house, and uses sunscreen lotion to protect her skin from radiation. All her childhood immunizations are up to date, including tetanus boosters and college meningococcal vaccine. However, she did not receive her influenza and human papillomavirus vaccines.

Current medications

Ms. Jones is on Fluticasone propionate, 110mg 2 puffs twice a day, per oral metformin, 850mg twice daily, per oral Drosiperidone, and Ethinyl estradiol four times daisy, which she last used this morning. She takes albuterol 90mcg/spray-on exacerbation of symptoms, and which she took three months ago. She takes acetaminophen 500-1000mg to manage headaches and ibuprofen 600mg three times a day to manage menstrual bleeding pain.

Family History

As she presents, Ms. Jones’ family history is of great significance to her past and current health. Her mother is 50, lives with hypertension and hypercholesterolemia. Her father died in a road accident at 58. He lived with hypertension, type 2 diabetes, and hypercholesterolemia. Her brother Michael, 25, is overweight. Her 14-year-old sister, Britney, is asthmatic. Her maternal grandmother died at 73, and her maternal grandfather died at 78 due to stroke complications, type 2 diabetes, and hypercholesterolemia. Paternal grandmother is 82 and lives with hypertension. Paternal grandfather dies of colon cancer at 65. He also lived with diabetes type 2. Her paternal uncle has been diagnosed with alcoholism. There is no history of other acute and chronic illnesses such as sudden death, kidney diseases, thyroid problems, or other cancers in the family.

Social history

Ms. Jones is single with no children. She has been living independently since 19 but currently lives with her mother and sister. She plans to move to her apartment in a month. She is eager to join her new job at Smith, Stevens, Stewart, Silver, and Company. Tina is a practicing Christian. She is actively involved in church roles, and she reports attending church, volunteering in church activities, and bible study faithfully. Her social support system is tied around her family and the church. They are her primary source of comfort during stressful times. Ms. Jones has no history of tobacco, cocaine, methamphetamines, or cocaine use. She reports having used cannabis from age fifteen to twenty-one. She occasionally takes alcohol when out with her friends, but not more than three drinks per episode. Her diet is relatively healthy and controlled. No reports of recent travels, and she keeps no pets. Her exercise regime consists of walking, yoga, or swimming at least four times a week.

Mental health history

Ms. Jones reports that her mental state has stabilized and has developed stress coping mechanisms, which have helped deal with sleep problems. The general appearance is good. She is appropriately dressed to the weather and occasion. She is alert and well oriented to person, time, and place. She is well-groomed, neat and her hair is well-kempt. She is cooperative and participates in the conversation, denies being depressed, anxious or having suicidal ideations. Her speech is clear, coherent, and fluent. No facial tics or facial fasciculation.

Review of systems

General- Reports no recent or frequent illnesses, fatigue, fever, chills, or sweating at night. After a routine exercise and dieting plan, she has lost 10 pounds in the last few months.

HEENT- Reports no problems with vision, visual changes, or current headaches. Has no eye redness, itching, ocular pain, or discharge. She wears corrective lenses and had her eye check-up three months ago. Smell senses are intact, no drainage, pain swelling, epistasis, or sinus pressure. No general hearing problems or hearing changes, no pain, drainage, swelling, or redness of the ears. No current mouth concerns. No jaw, gum, or tongue problems. No rashes, no oral thrush, sores, dry mouth, or pain. She has no swollen nodes, dysphagia, sore throat, or dental problems. She visited a dentist five months ago.

Her head is normocephalic, no trauma, no edema, hair is evenly distributed. No rashes or lesions, no periorbital edema or ptosis. No pallor, no lesions, and the sclera are white. PERLA bilaterally, no nystagmus, and EOMS is intact. Mild visual changes of the left eye. Snellen 20/20 for right eyes and 20/20 left eyes with corrective lenses intact. The left fundus shows no hemorrhages and has sharp disc margins. N goiter or lymphadenopathy. The thyroid glands are bilateral and not enlarged. The gag reflex is intact.

Respiratory- Reports no wheezing, dyspnea, pain, or coughing. Chest symmetrically rising during respiration. On auscultation, her breath sounds are clear bilaterally. On percussion, the chest elicits a resonant sound throughout. The spirometry readings: FVC 3.91L, FEV 3.15L.

Cardiovascular- She reports no chest pain, no palpitations, tachycardia, easy bruising, or edema. S1 and S2 preset with no murmurs, rubs, or gallops. No bruits over central and peripheral blood vessels. No edema present, and the capillary refill is less than one second.

Gastrointestinal: Reports no appetite changes over the past few days. Denies nausea, vomiting, or any abdominal pain. Regular bowel movements, her last being yesterday. She has lost 10 pounds recently due to dieting and exercises. No scars, lesions, or rashes were observed. Bowel sounds are present in all quadrants. They are normoactive in quality. On percussion, tympany is elicited in all quadrants. The abdomen is non-tender to either light or deep palpation. No organomegaly is noted on palpation.

Genitourinary- Urine regular frequency and amount, no urine cloudiness or foul smell. No pain on micturition, no blood in urine, and no flank pain.

Gynecologic- She is a para­ 0+0 gravida 0. Her menarche was at eleven, and her last menstrual period was two weeks ago. Four months ago, her doctor diagnosed her with Polycystic Ovarian Syndrome and put her on oral contraceptives. Sexually active from 18. She tested negative for HIV AND STIs in her routine visit.

Musculoskeletal- Reports no muscle pain, swelling, weakness, or edema. Limbs are bilaterally symmetrical with a full range of motion. No swelling, masses, edema, or pain in the limbs. She verbalizes no pain with movement and exhibits appreciable muscle tone (5/5) in the upper and lower extremities.

Neurologic- she denies feeling dizzy, light-headed, tingling sensations, loss of coordination, or loss of balance. Normal stereognosis, graphesthesia, and exhibits rapid alternating movements. Cerebellar functions are intact. She has decreased monofilament sensations in plantar surfaces bilaterally.

Mental health- She verbalizes regression of stress and has developed stress coping abilities. She previously had sleep difficulties which have recently subsided. She denies being depressed, anxious, or having suicidal or homicidal ideations. She is eager to start her new job and move into her apartment. She reports no history of mental illnesses.

Tina Jones nursing plan of care

Ms. Tina Jones has been proactive in managing her health. Despite living with type 2 diabetes, Polycystic Ovary Syndrome, asthma, and hypertension, her general health condition is fair, and she has no significant health concerns. She has been taking her medication faithfully and has developed a healthy diet and exercise plan. The two seem to be working well for her as she has lost 10 pounds in the last few months and has managed to control her hypertension without medications. Managing this patient and her planning her care primarily rotates around health promotion and illness prevention practices. She is living with chronic illnesses hence the need for palliative care. The nursing plan of care shall be guided by existing nursing theories and the Healthy People 2020 initiative.

As seen from her history, she is aware of the importance of treatment compliance. She reports that after taking her diabetes medication, regular exercises, healthy dieting, and monitoring, blood sugar levels have stabilized. She also reports that she has not had an asthmatic attack for the last three months after taking her asthma medications. She verbalizes awareness and enthusiasm to control her diet. She should be encouraged to continue with the treatment regimen, exercises, and a healthy diet.

Ms. Jones is overweight, has a family history of hypertension, hypercholesterolemia, and stroke. She is also an African American woman, and all these factors expose her to developing cardiovascular health conditions. Thus, it is vital to educate her on the risk, as patient education is part of nursing care. The nurse should encourage her to continue exercises and healthy dieting and lose more weight to reduce her risks of developing cardiovascular conditions. Referral to established social groups regarding weight loss could also prove beneficial.

From the physical examination findings, she was found to have developed signs of diabetic peripheral neuropathy. These include decreased sensation to monofilament in the planta surfaces bilaterally, which she was unaware of (Selvarajah et al., 2019 Tina Jones Assessment and Plan of Care Sample). Due to her diabetic case, she must avoid any injuries due to poor healing associated with diabetes and report any injuries that involve skin breakages to the healthcare providers. She should also inspect her feet daily for any signs of complications of diabetes or hypertension such as edema, unexplained skin breakages, lesions, and ingrown toenails. According to Selvarajah et al. (2019), diabetic patients are more prone to complications of the extremities. Thus, it is essential to refer her to a podiatric for more specialized management.

Ms. Jones has developed slight retinopathic changes, which raises the alarm in this diabetic patient. She was given corrective lenses during her recent eye examination. From existing literature, retinopathic changes are a diabetes complication (Wang & Lo, 2018 Tina Jones Assessment and Plan of Care Sample). Diabetes is notorious for causing eye problems, commonly known as diabetic ophthalmopathy. High blood sugar causes leakage of blood in tiny blood vessels, and retinopathy could indicate capillary hemorrhages in vital internal organs (Wang and Lo, 2018). If not well managed, diabetes can lead to blurred vision and, at times, blindness. Retinopathy is the leading cause of blindness and visual impairments among the diabetic population (Papatheodorou et al., 2018). Early detection of retinopathic complications can inform management and prevent vision loss which can at times be irreversible. It is recommended that the diabetic population attend a yearly comprehensive dilated eye exam yearly. The anti-vascular endothelial growth factor (VEGF) therapy can prove helpful to M. Jones (Wang & Lo, 2018). Ms. Jones should ensure she sees an ophthalmologist every year to monitor for complications. She should also continue monitoring her blood glucose levels, taking metformin daily, and continuing exercise and dieting to ensure the diabetes is adequately controlled.

African Americans have a high prevalence of obesity. About four of five African American women are overweight or obese. According to statistics, Hispanic blacks were 1.3 times at more risk of being overweight or obese compared to non-Hispanic whites (CDC, 2020, Tina Jones Assessment and Plan of Care Sample). More so, African American women are 1.5 times more likely to be overweight or obese than non-Hispanic whites. Ms. Jones has a body mass index of 29.0 which means she is overweight. According to her height, she should be less than 160 pounds. Existing evidence associates overweight with complicating conditions such as hypercholesterolemia, worsening existing hypertension and diabetes type 2, heart diseases, stroke, and certain cancers such as breast, colon, and endometrial cancers (CDC, 2020). Ms. Jones is committed to ensuring her weight is well managed. She should be encouraged to continue with exercises and dieting to ensure she loses more weight to avoid weight complications.

Healthy people 2020

The healthy people 2020 initiative was developed to pilot the improvement of the health status of all Americas by the year 2020. The core objectives of healthy people 2020 are to attain high-quality and longer lives free of preventable disease, disability, injury, and premature deaths (Healthy People 2020.gov n.d.). Other objectives include achieving health equity, eliminating health disparities, and improving the health of all groups. The initiative also aims at creating social and physical environments that promote good health for all Americans. The fourth objective is to promote quality of life, healthy development, and healthy behaviors across all stages of life. The initiative does so by encouraging care collaboration, empowering individuals to make informed health decisions, and evaluating the effectiveness of illness prevention interventions (Healthy People 2020.gov n.d. Tina Jones Assessment and Plan of Care Sample). As at that, the initiative is integral in “identifying national priorities for health improvement, educating the public on determinants of health and opportunities for improvements, and providing achievable health goals at the national and local levels to improve the health of the citizens” (Healthy People 2020.gov, n.d.).

According to the history and physical findings of Ms. Jones, she can satisfactorily achieve the four overarching goals. Ms. Jones understands that to live a longer and disease-free life, individuals’ efforts are necessary. Given her current medication adherence, healthy diet, and exercises regimen, she can achieve a healthy, long life that is disease-free and of high quality.

Ms. Jones is a mother from the minority groups prone to health inequity and health disparities (Tyler, 2019). However, she is lucky to have access to all the health resources she requires. She visits her dentist, gynecologist, ophthalmologist often and has regular health check-ups. She has attained a college education ad is securing a job soon. She has a sound transport system because, as seen, she can access the hospital on various occasions to do her follow-up check-ups and routine health check-ups. She also has access to health insurance.

Social support is very integral in maintaining the mental health status of an individual. It aids in the prevention and resolution of mental health and psychological issues such as depression and anxiety. Ms. Jones exhibits a solid social support. She verbalizes that the family and church are always there for her. She has an established social support system and consults the church and family whenever she is faced with a stressful situation. She is active in her church, and her friends also provide sufficient social support.

Ms. Jones appears to be living a quality life. The quality of life can be attributed to her health awareness, desire, and willingness to live a high-quality life. As seen from her health history, she participates in healthy living by doing exercises and healthy dieting. She also does regular health check-ups and complies with her treatment regimen. Ms. Jones has modified her physical and social environments in a way that promotes her wellbeing. All she needs is encouragement and more education on her condition. The nurse should encourage her to keep losing weight because, as we saw earlier, she must resolve her overweight for better health outcomes due to diabetes and hypertension. Ms. Jones seems to be living a quality life, and more so, she is doing her best to ensure that she is living a high-quality life. If she continues with her excellent practices, she will most likely keep all the health conditions controlled, prevent complications, live a quality, disease-free life, and achieve all the goals of healthy people 2020.

A nursing theory applicable to the Care of Ms. Jones- Sister Callister Roy Adaptation Model

The theory most applicable to this patient is Sister Callister Roy Adaptation Theory/Model. The theory has been widely in nursing practice. For this patient, she might seem stable, but she must adapt to her conditions because, as mentioned earlier, they are chronic and require palliative care.

The theory by Sister Callister Roy has several assumptions helpful in managing Ms. Jones. One such assumption is that humans are accountable for integrating creative processes (Majeed et al., 2020). For example, Ms. Jones is expected to utilize creative ways to ensure she does not miss her regimens and sticks to her training regimen. The nurse can support her in coming up with a plan that shall enable her to remember her medication without fail, such as setting alarms and reminders. Another assumption is that thinking and feeling mediate human action. Awareness forms the basis for action. When an individual feels susceptible to a condition, they tend to act. The nurse should emphasize the criticality of her situation. He/she should emphasize the effects of hypertension and type 2 diabetes when not appropriately managed. Essay

The assumption that system relationships should include acceptance, protection, and fostering of interdependence is essential for Ms. Jones in that she requires a robust social support system. Accepting her condition, as she has done, shall be the basis of working on it and thus influencing the quality of health outcomes.

Sister Callister Roy described the primary constructs of the theory as adaptation, goals of nursing, person, the environment, and health. These constructs are a function of each other, and they are inseparable. Adaptation is a process that involves conscious choices mediated by the individual’s interaction with the environment (Majeed et al., 2020 Tina Jones Assessment and Plan of Care Sample). She described health as an integrated/holistic person. Therefore, for one to be healthy, all other aspects of their life, such as social and spiritual aspects, must also be okay. The environment is anything outside the individual affecting their health and behavior. The person is described holistically as a bio-psycho-social being. Nursing goals, in this case, are the overarching objective of protection, promotion, and optimization of health and abilities. These constructs must be balanced for an individual to be termed healthy. When the five constructs of the adaptation model are well managed, an individual successfully achieves good health and lives a quality life as they aspire (Majeed et al., 2020).

The Standard Nursing Practice by ICN

The ICN controls nursing practice around the world. According to the ICN, a nurse has four primary responsibilities: promoting health, preventing illnesses, restoring health, and alleviating suffering (Stievano & Tschudin, 2019 Tina Jones Assessment and Plan of Care Sample). The nurse should always uphold these responsibilities and ensure that their patient receives quality care. The nurse’s role is to educate Ms. Jones on her health conditions and interventions necessary for health promotion. The care of Ms. Jones shall involve managing current health problems such as the developing peripheravascular and retinopathic complications of diabetes. The nurse should inform the patient of these abnormal findings and stress the need to take her medication: metformin, regular exercises, dieting, and taking her daily glucose readings (The Lancet Diabetes and Endocrinology, n.d.). The nurse should also educate Ms. Jones on intermittent fasting as an effective way of losing weight. The step is aimed at restoring her BMI to within normal levels. The ICN nursing code of ethics shall inform the care of Ms. Jones. One applicable ethical guideline is that the nurse sustains a collaborative and respectful relationship with co-workers in nursing and other fields (Stievano & Tschudin, 2019). Management of this client requires collaboration with the patient, family, society, and other healthcare providers. The nurse should ensure that Ms. Jone’s care plan incorporates the podiatric for foot care, nutritionist for diet management, and the family for social support, among other professionals.

Conclusion

The care of Ms. Jones shall involve a multidisciplinary team, as seen above. Her care is palliative, requiring lifetime management hence the need for proper education and a robust social support system. Care of patients goes beyond curative aspects to preventive and promotive aspects. Proper management of conditions leads to better patient experiences and health outcomes. Being closest to the patient, the nurse is tasked with the responsibility to ensure that the patient receives quality and holistic care. The nurse should also ensure that the patient’s care meets ethical and policy guidelines that inform nursing practice.

Tina Jones Assessment and Plan of Care Sample References

  • American Diabetes Association. (2018). Economic costs of diabetes in the US in 2017. Diabetes Care, 41(5), 917–928. DOI: 10.2337/dci18-0007
  • Centers for Disease Control and Prevention. (2020). National diabetes statistics report, 2020. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services, 12-15.
  • Diabetic peripheral neuropathy: advances in diagnosis and strategies for screening and early intervention. The Lancet Diabetes & Endocrinology, 7(12), 938-948. https://doi.org/10.1016/S2213-8587(19)30081-6
  • Healthy People.gov. (ND). About healthy people. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People
  • Majeed, I., Sehar, S., Afzal, M., Gilani, S. A., Parveen, K., & Ahmed, R. (2020). 34. Effect of Roy’s adaptation model-based interventions on quality of life in patients with type II diabetes. Pure and Applied Biology (PAB), 9(1), 332-339. http://dx.doi.org/10.19045/bspab.2020.90038
  • Papatheodorou, K., Banach, M., Bekiari, E., Rizzo, M., & Edmonds, M. (2018). Complications of diabetes 2017. https://doi.org/10.1155/2018/3086167
  • Stievano, A., & Tschudin, V. (2019). The ICN code of ethics for nurses: a time for revision. International Nursing Review, 66(2), 154-156. https://doi.org/10.1111/inr.12525
  • Taylor, J. (2019). Racism, inequality, and health care for African Americans. Retrieved from http://arks.princeton.edu/ark:/88435/dsp01ng451m58f
  • Wang, W., & Lo, A. C. (2018). Diabetic retinopathy: pathophysiology and treatments. International Journal of Molecular Sciences, 19(6), 1816. doi: 10.3390/ijms19061816