NURS 6512 Health History of Tina Jones

Walden University NURS 6512 Health History of Tina Jones-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 6512 Health History of Tina Jones assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 6512 Health History of Tina Jones                     

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Health History of Tina Jones depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 6512 Health History of Tina Jones                     

The introduction for the Walden University NURS 6512 Health History of Tina Jones is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NURS 6512 Health History of Tina Jones                     

After the introduction, move into the main part of the NURS 6512 Health History of Tina Jones assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6512 Health History of Tina Jones                     

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6512 Health History of Tina Jones                     

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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A Sample Answer For the Assignment: NURS 6512 Health History of Tina Jones

Title: NURS 6512 Health History of Tina Jones

NURS 6512 Health History of Tina Jones Assessment

NURS 6512 Health History of Tina Jones Assessment

SUBJECTIVE DATA:

The patient is Tina Jones 28 years of age who came to the facility in regards to a scrape on her foot that is not healing as expected that she got due to an accident. She does not  live alone but together with her sister and her mother. She is a student who is studying   bachelor in accounting. Furthermore, she is working at company known as Mid-  American Copy & Ship as a supervisor.

In terms of a relationship she does not have a boyfriend and reports she has not been sexually active for about 2 years. Apart from those she lives with her family further consists of a brother, a maternal grandmother and  paternal grandparents. She lost her father due to a road accident and reports that her maternal grandfather also passed away.

Chief Complaint (CC): Pain on her foot due to a scrape that has persisted and won’t heal on its despite wound care.

History of Present Illness (HPI):

Patient has come into the facility due to a scrape on her foot that isn’t healing normally despite appropriate interventions and is also giving her pain. She ranks the pain at 7 out of a scale of 1-10 and reports the pain is aggravated by when she attempts to stand while her pain medication tramadol provides partial relief. The wound was a result of scrapping it on a cement step the previous week.

After that she did go to the emergency room and has been taking tramadol pills as part of pain management. Her wound care consists of using bandages together with neosprin. She is not able to engage in activities of daily living as before as her ability to walk has been impaired thus limiting her in tasks she could perform.

Medications:

90 micrograms inhaler taking 2 puffs per required need for asthma treatment

50 mgs tramadol taken orally two pills three times daily

Patient was prescribed metformin but is no longer compliant with that medication

Allergies:

Patient reports she is allergic to cats that causes wheezing, sneezing and itchy eyes

Patient reports she is allergic to dust that causes wheezing, sneezing and itchy eyes

Patient reports she is allergic to penicillin that in her childhood caused hives.

Past Medical History (PMH):

Patient reports she has been previously diagnosed with asthma

Patient reports she has been previously diagnosed with diabetes type 2

Patient reports she is not compliant with her diabetes medication that she last took 3 years ago and her management involves not taking sweets and diet soda.

Patient reports she does not regularly monitor her glucose levels.

Patient reports her last asthma attack was in high school.

Patient reports exacerbation 3 days ago

Patient reports she uses an inhaler for her asthma per required need.

Patient reports dust, cats and running up the stairs can trigger her asthma.

Past Surgical History (PSH):

Patient has not had a surgical procedure before.

Sexual/Reproductive History:

Patient reports her last sexual activity was about 2 years ago, she is not currently in a relationship and has had 3 previous sexual partners.

Patient reports not to be under any current form of contraception.

Patient reports previous condom and oral birth control use.

Personal/Social History:

Patient reports to take alcohol though when her friends are around.

Patient reports previous marijuana use that she no longer takes.

Patient reports an increase in appetite.

Patient reports not to have stress

Patient denies to take tobacco.

Patient denies caffeine consumption.

Immunization History:

Patient reports to have had all her childhood vaccines and is up to date with current vaccines she is supposed to take.

Health Maintenance:       

Patient reports that she is no longer compliant with her diabetes medication and her management from the condition involves not taking sweets and drinking diet soda instead of regular.

Patient reports to manage her pain due to the scrape in her foot she takes

tramadol pain pills and wound care that involves bandages applied with neosprin.

Patient reports asthma management that involves use of an inhaler per required need and staying away from her asthma triggers.

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Patient reports a family history of high cholesterol and high blood pressure from her parents, maternal as well as paternal grandparents.

Patient reports a family high history of diabetes that her father had.

Patient reports that her sister had been diagnosed with asthma

Review of Systems

General: Patient reports an occurrence of weight loss, fever and fatigue.

            HEENT: Patient reports occasional headaches, blurry vision but reports no ear     pain, nosebleeds or sore throat

Neck:  Patient reports no neck problems

            Breasts: Patients reports having regular breast exams with no problems noted.

            Respiratory: Patient reports at the time no wheezing, chest tightness or pain while breathing.

            Cardiovascular/Peripheral Vascular: Patient reports no palpitations or edema.

            Gastrointestinal: Patient reports no nausea or vomiting.

            Genitourinary: Patient reports increased urine frequency though no blood in the urine

Reproductive: Patient reports irregular periods.

            Musculoskeletal: Patient reports no swelling of joints, no back pain and no pain   in the joints

            Psychiatric: Patient denies having suicidal ideations.

            Neurological: Patient denies having seizures, tingling or feeling dizzy.

            Skin: Patient reports having acne, dry skin at times, excessive hair in the body      and moles.

            Hematologic: Patient reports not having excessive bleeding.

            Endocrine:  Patient reports not having issues in her thyroid.

A comprehensive health history is essential to providing quality care for patients across the lifespan, as it helps to properly identify health risks, diagnose patients, and develop individualized treatment plans. To effectively collect these heath histories, you must not only have strong communication skills, but also the ability to quickly establish trust and confidence with your patients. For this DCE Assignment, you begin building your communication and assessment skills as you collect a health history from a volunteer “patient.”

Links to an external site.

Bhalodkar, A., Sonmez, H., Lesser, M., Leung, T., Ziskovich, K., Inlall, D., Murray-Bachmann, R., Krymskaya, M., & Poretsky, L. (2020). the effects of a comprehensive multidisciplinary outpatient diabetes program on hospital readmission rates in patients with diabetes: a randomized controlled prospective study. Endocrine Practice, 26(11), 1331–1336. https://doi-org./10.4158/EP-2020-0261

McCance, K.L. & Huether, S.E. (2019). Pathophysiology: The biologic basis for disease in

adults and children (8^th ed.). St. Louis, MO: Mosby/Elseier

Mishra, Vinaytosh, Samuel, Cherian &Sharma, S.K. (2018). Supply chain partnership assessment of a diabetes clinic. International Journal of Health Care Quality Assurance, 31(6), 646–658. https://doi-org./10.1108/IJHCQA-06-2017-0113

Obuobi, S., Chua, R. F. M., Besser, S. A., & Tabit, C. E. (2021). Social determinants of health and hospital readmissions: can the HOSPITAL risk score be improved by the inclusion of social factors? BMC Health Services Research, 21(1), 5. https://doi-org./10.1186/s12913-020-05989-7

Photo Credit: Sam Edwards / Caiaimage / Getty Images

Sample Answer for NURS 6512 Health History of Tina Jones Included

To Prepare

• Review this week’s Learning Resources as well as the Taking a Health History media program, and consider how you might incorporate these strategies. Download and review the Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment.
• Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Shadow Health Student Orientation media program and the Useful Tips and Tricks document provided in the week’s Learning Resources to guide you through Shadow Health.
• Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
DCE Health History Assessment:

Complete the following in Shadow Health:

Orientation (Required, you will not be able to access the Health History without completing the requirements).
• DCE Orientation (15 minutes)
• Conversation Concept Lab (50 minutes, Required)
Health History
• Health History of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve total score of 80% or better(includes BOTH DCE and Documentation), but you must take all attempts by the Week 4 Day 7 deadline.
Submission and Grading Information
No Assignment submission due this week but will be due Day 7, Week 4.
Grading Criteria

To access your rubric:
Week 4 Assignment 2 DCE Rubric

________________________________________
What’s Coming Up in Module 3?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
In Module 3, you will examine advanced health assessments using a system focused approach.
Next week, you will specifically explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings while conducting health assessments. You will also complete your first Lab Assignment: Differential Diagnosis for Skin Conditions as well as complete your DCE: Health History Assessment in the simulation tool, Shadow Health.

Week 4 Required Media

Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Lab Assignment. There are several videos in varied lengths. Please plan ahead to ensure you have time to view these media programs to complete your Assignment on time.
Next Module

To go to the next module:
Module 3
Week 3: Assessment Tools, Diagnostics, Growth, Measurement, and Nutrition in Adults and Children
Many experts predict that genetic testing for disease susceptibility is well on its way to becoming a routine part of clinical care. Yet many of the genetic tests currently being developed are, in the words of the World Health Organization (WHO), of “questionable prognostic value.”
—Leslie Pray, PhD

Obesity remains one of the most common chronic diseases in the United States. As a leading cause of United States mortality, morbidity, disability, healthcare utilization and healthcare costs, the high prevalence of obesity continues to strain the United States healthcare system (Obesity Society, 2016).  More than one-third (39.8%) of U.S. adults have obesity (CDC, 2018). The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; the medical costs for people who are obese were $1,429 higher than those of normal weight (CDC, 2018).

According to the Centers for Disease Control and Prevention (CDC), the rate of childhood obesity has tripled in the past 30 years, with an estimated 13.7 million children and adolescents considered obese (CDC, 2018). When seeking insights about a patient’s overall health and nutritional state, body measurements can provide a valuable perspective. This is particularly important with pediatric patients.

Measurements such as height and weight can provide clues to potential health problems and help predict how children will respond to illness. Nurses need to be proficient at using assessment tools, such as the Body Mass Index (BMI) and growth charts, in order to assess nutrition-related health risks and pediatric development while being sensitive to other factors that may affect these measures. Body Mass Index is also used as a predictor for measurement of adult weight and health.

Assessments are constantly being conducted on patients, but they may not provide useful information. In order to ensure that health assessments provide relevant data, nurses should familiarize themselves with test-specific factors that may affect the validity, reliability, and value of these tools.

This week, you will explore various assessment tools and diagnostic tests that are used to gather information about patients’ conditions. You will examine the validity and reliability of these tests and tools. You will also examine assessment techniques, health risks and concerns, and recommendations for care related to patient growth, weight, and nutrition.

Learning Objectives

Students will:
• Evaluate validity and reliability of assessment tools and diagnostic tests
• Analyze diversity considerations in health assessments
• Apply concepts, theories, and principles related to examination techniques, functional assessments, and cultural and diversity awareness in health assessment
• Apply assessment skills to collect patient health histories
________________________________________

Learning Resources

Required Readings (click to expand/reduce)

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
• Chapter 3, “Examination Techniques and Equipment”
This chapter explains the physical examination techniques of inspection, palpation, percussion, and auscultation. This chapter also explores special issues and equipment relevant to the physical exam process.

• Chapter 8, “Growth and Nutrition”
In this chapter, the authors explain examinations for growth, gestational age, and pubertal development. The authors also differentiate growth among the organ systems.

• Chapter 5, “Recording Information” (Previously read in Week 1)
This chapter provides rationale and methods for maintaining clear and accurate records. The text also explores the legal aspects of patient records.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Student checklist: Health history guide. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Centers for Disease Control and Prevention. (2018). Childhood overweight and obesity. Retrieved from http://www.cdc.gov/obesity/childhood

This website provides information about overweight and obese children. Additionally, the website provides basic facts about obesity and strategies to counteracting obesity.

Chaudhry, M. A. I., & Nisar, A. (2017). Escalating health care cost due to unnecessary diagnostic testing. Mehran University Research Journal of Engineering and Technology, (3), 569.

This study explores the escalating healthcare cost due the unnecessary use of diagnostic testing. Consider the impact of health insurance coverage in each state and how nursing professionals must be cognizant when ordering diagnostics for different individuals.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

• Chapter 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom Analysis”

This chapter introduces the diagnostic process, which includes performing an analysis of the symptoms and then formulating and testing a hypothesis. The authors discuss how becoming an expert clinician takes time and practice in developing clinical judgment.

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Gibbs , H., & Chapman-Novakofski, K. (2012). Exploring nutrition literacy: Attention to assessment and the skills clients need. Health, 4(3), 120–124.

This study explores nutrition literacy. The authors examine the level of attention paid to health literacy among nutrition professionals and the skills and knowledge needed to understand nutrition education.

Martin, B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., & Johns-Wommack, R. (2014). Weight status misperception as related to selected health risk behaviors among middle school students. Journal of School Health, 84(2), 116–123. doi:10.1111/josh.12128
Credit Line: Weight status misperception as related to selected health risk behaviors among middle school students by Martin, B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., & Johns-Wommack, R., in Journal of School Health, Vol. 84/Issue 2. Copyright 2014 by Blackwell Publishing. Reprinted by permission of Blackwell Publishing via the Copyright Clearance Center.

Noble, H., & Smith, J. (2015) Issues of validity and reliability in qualitative research . Evidence Based Nursing, 18(2), pp. 34–35.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). History subjective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.

This History Subjective Data Checklist was published as a companion to Seidel’s Guide to Physical Examination (8th ed.) by Ball, J. W., Dains, J. E., & Flynn, J.A. Copyright Elsevier (2015). From https://evolve.elsevier.com

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
• Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Week 1)
• Chapter 5, “Pediatric Preventative Care Visits” (pp. 91 101)
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Document: Shadow Health Support and Orientation Resources (PDF)

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

• Chapter 3, “The Physical Screening Examination”
• Chapter 17, “Principles of Diagnostic Testing”
• Chapter 18, “Common Laboratory Tests”

Required Media (click to expand/reduce)

Taking a Health History

How do nurses gather information and assess a patient’s health? Consider the importance of conducting an in-depth health assessment interview and the strategies you might use as you watch. (16m)
Assessment Tool, Diagnostics, Growth, Measurements, and Nutrition in Adults and Children – Week 3 (11m)

Rubric Detail

Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6512_Week_4_DCE_Assignment_2_Rubric

Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments.

Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.

• Grid View
• List View
Excellent Good Fair Poor
Student DCE score

(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)

Note: DCE Score – Do not round up on the DCE score. Points Range: 56 (56%) – 60 (60%)
DCE score>93 Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92 Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85 Points Range: 0 (0%) – 45 (45%)
DCE Score <79

No DCE completed.
Subjective Documentation in Provider Notes

Subjective narrative documentation in Provider Notes is detailed and organized and includes:

Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)

ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.

You should list these in bullet format and document the systems in order from head to toe. Points Range: 36 (36%) – 40 (40%)
Documentation is detailed and organized with all pertinent information noted in professional language.

Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Points Range: 31 (31%) – 35 (35%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language.

Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Points Range: 26 (26%) – 30 (30%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.

Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Points Range: 0 (0%) – 25 (25%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.

No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

or

No documentation provided.
Total Points: 100
Name: NURS_6512_Week_4_DCE_Assignment_2_Rubric

Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.