Risk Assessment & Screening

Risk Assessment & Screening

Ms. Tina Jones is an American woman of African descent. She is 28 years old. She presents for her pre-employment physical examination. Ms. Jones aligns with the place, time, and person. Tina is in a pleasant mood and makes proper eye contact while interviewing. She is neatly dressed, has adequate sanitation, and appears physically in good health. She speaks clearly and audibly. She is sitting upright and seems comfortable and ready for her exam.

Ms. Jones intends to start working at Smith, Stevens, Stewart, Silver, and Company in a few weeks to come. She does not smoke tobacco. Her last marijuana use was at the age of 21. She has never used any recreational drugs. She wears a seat belt. She drinks up to three alcoholic beverages about 2-3 times per month with friends. She has never been married and, therefore, has no children. Tina currently stays with her mother and sister.

Risk Assessment & Screening

Ms. Jones risks being diagnosed with polycystic ovaries, inactivity, diabetes II includes race, hypertension, and family history. Family members share genes, behaviours, and lifestyles that influence one’s health. Tina’s family background reveals a distinct account of hyperlipidemia, diabetes type II, and hypertension. She is, therefore, at a high risk of developing diabetes, based on the above risk factors. Family history is not a modifiable risk factor.

Tina was found out that she had asthma when she was two and a half years old and was diagnosed with type 2 diabetes when she was 24. Ms. Jones has also never had to be intubated for her asthma. She checks her blood sugar every morning. She stated when she first took Metformin, it was upsetting her stomach, which she implemented yogurt into her diet, which has helped.

Tina and her family report a background of diabetes, hyperlipidemia, and hypertension. Her mother has a history of hypertension and hyperlipidemia. Tina’s father passed away in the last year at the age of 58, and had a history of hyperlipidemia, hypertension, and type 2 diabetes. Her sister has asthma, and her brother has obesity. Ms. Jones report that her maternal grandparents died both of stroke and had a history of hypertension and hyperlipidemia. Her paternal grandfather died of colon cancer; he had a history of type 2 diabetes. Her paternal grandmother has hypertension and is still alive. She states her paternal uncle suffers from alcoholism. Ms. Jones claims there is no mental illness, thyroid disease, kidney disease, or other cancers in her family.

Ms. Jones’s excessive weight increases her chances of diabetes and hypertension diagnosis. Since her previous visit, she claims to lose almost a dozen pounds. Research indicates that a weight reduction of nearly 10 percent of weight reduces the chance of developing diabetes. The best way to minimize these risks is through physical activity. Tina claims that she exercises five out of seven times in a week. Diabetes is linked to high blood pressure since the same risk factors, more or less likely, cause the two diseases.

Activities and Nutrition

Since her last visit to the clinic due to her foot injury months ago, Ms. Jones has made some alterations, including modifying what and how she eats, checking her blood sugars regularly, and exercising more often. With these changes, Tina’s health has improved. However, her medical problems list remains the same. Ms. Jones’ problem list includes hypertension, diabetes, and peripheral artery disease.

Ms. Jones’ lifestyle changes have helped her to maintain better control of her blood pressure without medication since her last visit. Ms. Jones has demonstrated healthy lifestyle choices and moves along with self-monitoring of her blood glucose. I would encourage her to continue with her regimen and continue with on-going education and nutritional advice as necessary. She will require reviews and modifications to her treatment plan based on her progress, needs, and any changes that may occur.

Recommendations include indulging in any physical activity consisting of any bodily movement. This is also essential to help prevent the development of other health conditions (Doenges, 2016). The patient should incorporate more leafy vegetables into her diet as well.

Social Support

The patient currently stays with her mother and sister. She also reveals that she just got into a new relationship. Her father is deceased, but her maternal grandmother is alive. Tina also has a brother. These family members will be essential to the nursing care plan as they will be required to encourage and support the patient through the program.

Health Maintenance

Tina claims that she has a medicine allergy to penicillin, causing her rashes and latex allergy as well. Ms. Jones also has allergies to cats, which will cause her to go into have asthma attacks, swollen eyes, and a runny nose. She also stated that dust could cause her to have asthma attacks. Ms. Jones received her gynecological exam four months ago, which was also the last exam. The GYN diagnosed Tina with the polycystic ovarian syndrome, prescribing her contraceptive, YAZ. She has reported that her cramping is less, and her cycle is regular lasting five days since beginning her contraceptive. She tested negative for STIs and HIV. Tina has never been married.

She eats healthy and tries to stay active by walking for about an hour, twice a week, and also swimming once weekly. The patient reports declined stress and better-coping abilities, which have helped with her prior insomnia. She reports no current emotional depression, anxiety, or suicidal thoughts. She is attentive and aligned to person, place, and time. Ms. Jones reports no facial fasciculation and is eloquent, fluent, and elaborate.

Ms. Tina Jones requires Proventil 90mcg/spray two puffs for her wheezing. She also needs Fluticasone propionate, 110 mcg two puffs BID, which she last used this morning. She requires Metformin, 850 mg PO BID, which she used earlier on as well. Drospirenone and Ethinyl estradiol PO QD is also prescribed as part of her medication and has to use it daily. She will need to restart her use of Albuterol 90 mcg/spray MDI 2 puffs Q4H prn which she has not used in the last three months. For her headaches, she will need Acetaminophen 500-1000 mg PO prn and Ibuprofen 600 mg PO TID for her menstrual pains, which she last used six weeks ago.

Patient Education

Apart from exercising and eating a balanced diet, Tina will be afforded programs aimed at teaching her other ways to cope with diabetes, high blood pressure, and other conditions that she has been diagnosed (Gulanick, 2016). More keenly on her diet, the program will provide her with the best diet plan that will help her manage her condition. In the plan, she will be educated on the benefits of eating leafy, green vegetables. She will be given the best work out plan that would help her reduce weight more effectively, and that best suits her.