Tina Jones Health Promotion Instructions
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:
– Age, gender and race of patient
– Education level (health literacy)
– Access to health care
– Is the patient able to afford medications and health diet, and other out-of-pocket expenses?
– Identified health concerns based on screening assessments and demographic information
– 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
– Support systems, family members, community resources
– Recommended health screening based on age, race, gender and pre-existing medical conditions
– 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:
Includes age, race and gender of patient
Missing one data item
Missing 2 or more data items
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
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
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 in Tina Jones Health Promotion
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
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 in Tina Jones Health Promotion
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
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
Student Documentation for Tina Jones Health Promotion
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.
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.
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)
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 (Tina Jones Health Promotion)
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.
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 (Tina Jones Health Promotion)
-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
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 (Tina Jones Health Promotion)
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
Tina Jones health promotion Nursing solution Paper .
Tina’s Individualized Health Promotion and Disease Prevention Plan of Care
Tina Jones Individualized Health Promotion and Disease Prevention Plan of Care
Care plans communicate and organize individualized actions for a patient enabling continuity of care. It is imperative to formulate an individualized plan of nursing care that concentrates on Tina’s personalized health promotion and disease prevention needs. To achieve the goal, the plan factors in details from Tina’s health history, genogram, and assessment to formulate a nursing care plan.
Tina’s Individualized Health Promotion and Disease Prevention Plan of Care
The patient is a 28-year-old of African – American woman who is not married and presents for a pre-employment physical examination. Her new employer is desirous of having a recent physical exam for the health insurance
Education level (health literacy)
Tina Jones’s health maintenance practices are up to date with recent tests for HIV/AIDS test; plan to use a condom in sexual encounters, regular Pap smear, eye, and dental exam being up-to-date. Other measures include having smoke detectors at home, strap the seatbelt while driving, and use sunscreens. However, her health maintenance approaches should consist of more self-care activities meat to manage her existing chronic diseases; namely, asthma, which was diagnosed in childhood, Type 2 diabetes (T2DM) diagnosed at 24 years as well as hypertension. While at the moment the patient has no issues with using medication therapy and non-pharmacological interventions like exercises and diet, there is a need for her to keep herself updated on the emerging treatment and management options (ADA, 2019).
Access to health care
With advancing age, she should also consider other types of cancer tests like a mammogram for breast cancer. The patient needs to maintain her regular medical checkup visits and always keep her physician updated on any emerging health issues, especially concerning drug interactions, considering the cocktail of medications she has to take daily.
Using the individualized nursing care planning entails outlining strategies to engage the patient, conduct current health assessment and health risk assessment. Both patient and provider goals are SMART – based so that there are effective care coordination and tracking. The patient’s health insurance status is up to date since she is informal employment. Medicare Part B, which deals with Medical insurance and Medicare Part D (covering prescription drug coverage), means the patient can afford the anti-diabetic drugs. Tina Jones is also in steady employment and, therefore, can provide any medication while meeting all the other out of pocket expenses like coinsurance and copayment expenses required to make the personalized nursing care plan a success (Dall et al., 2016).
Tina’s diagnosis of having polycystic ovarian syndrome (PCOS) means she is likely to have difficulties should she decide to have a child of her own. As such, the care plan involves strategies that will optimize her preconception period health. At the same time, a multi-faceted approach including but not limited to lifestyle modification and pharmacological treatment (Holton, Hammarberg & Johnson, 2018). Furthermore, the patient is advised to keep away from allergens like dust and pets to avoid asthma exacerbations.
Dietary planning and regular exercises are also to continue to manage her T2DM and hypertension as well.The T2DM friendly meals entail packing in more vegetables and fruits while also eating something every morning.The meal plan also includes fiber, and considering Patient Tina Jones is a small woman; the target is to have 1200 to 1600 calories daily. Asif (2014) also recommends that T2DM patients with comorbidities should also stay active. The care plan recommends having 30 minutes of physical activities a minimum of five days every week.
According to Rakinson, Pillay & Sibanda (2017), individuals like Tina jones living with dT2DM, hypertension, and asthma since all three impose a lifelong psychological burden on both the patient and their significant others who in this case happens to be her male partner. Current studies indicate that social support plays a vital role in the effective management of these conditions. Therefore, the ongoing care plan advises Tina to join a social support group and also include the male partner in the current care plan. Tina should also use diabetes supplies availed through Part D of her medical cover.
Considering that the patient is a young adult woman diagnosed with PCOS, regular screenings for some types of cancer like breast, liver, pancreas, and endometrium, among others, is recommended for this patient. ADA (2019) notes that diabetes is closely linked to increased risk of some types of .cancers.
The last component is the development of a diabetes self- management patient education. Chrivala, Sherr & Lipman (2016) note that more than half of diabetic patients do not meet and sustain the recommended target of less than 7% for glycated hemoglobin. At the same, only about 14% achieve the goal of non-smoking, low-density lipoprotein, and blood pressure. Therefore this care plan has a DSME intervention component meant to address this anomaly. Other studies have also determined that hypertension and T2DM can themselves be a risk factor for developing asthma (Lee & Lee, 2019). However, this is not the case with Patient Tina since has asthma was diagnosed at the age of two and a half years. Patient education addresses critical elements of diabetes like types, medication, risk factors, complications if poorly managed, and both pharmacological and non-pharmacological therapies. Emphasis is placed on the role of diet and physical exercises as well as adhering to the prescribed medications.
In conclusion, this essay has established the need to shift from the traditional medical evaluation of T2DM and comorbidities, which involved a chief complaint, history of illness, past medical history, and both family and social history. Also included in the traditional evaluation are diagnostic tests followed by assessment before a care plan can be developed. The current evidence-based care plan entails patient engagement, ongoing health assessment, a health risk assessment, then patient goals, and provider goals. The individualized plan then outlines a therapeutic strategy, coordination of care, and finally, tracking.
American Diabetes Association. (2019). 4. Comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes—2019. Diabetes care, 42(Supplement 1), S34-S45.
American Diabetes Association. (2019). Standards of medical care in diabetes—2019 abridged for primary care providers. Clinical Diabetes, 37(1), 11-34.
Asif, M. (2014). The prevention and control of type-2 diabetes by changing lifestyle and dietary patterns. Journal of education and health promotion, 3.
Chrvala, C. A., Sherr, D., & Lipman, R. D. (2016). Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient education and counseling, 99(6), 926-943.
Dall, T. M., Yang, W., Halder, P., Franz, J., Byrne, E., Semilla, A. P., & Stuart, B. (2016). Type 2 diabetes detection and management among insured adults. Population health metrics, 14(1), 43.
Holton, S., Hammarberg, K., & Johnson, L. (2018). Fertility concerns and related information needs and preferences of women with PCOS. Human reproduction open, 2018(4), hoy019.
Lee, K. H., & Lee, H. S. (2019). Hypertension and diabetes mellitus as risk factors for asthma in Korean adults: the Sixth Korea National Health and Nutrition Examination Survey. International health.
Rakinson, S., Pillay, B. J., & Sibanda, W. (2017). Social support and coping in adults with type 2 diabetes. African journal of primary health care & family medicine, 9(1), 1-8.
Serrano, V., Rodriguez‐Gutierrez, R., Hargraves, I., Gionfriddo, M. R., Tamhane, S., & Montori, V. M. (2016). Shared decision‐making in the care of individuals with diabetes. Diabetic Medicine, 33(6), 742-751. Tina Jones Health Promotion