Complete the History Assignment for Tina Jones before completing the discussion question. Your response to the discussion questions will be based on the findings in the Shadow Health assessments.
You must submit the assessment to receive credit for the activity. Assessments that have not been submitted cannot be verified as complete.
In the health history, Tina informed you about her acute foot pain resulting from her infected wound. After your assessment, identify four SMART goals for Tina based on the findings with two evidence-based practice nursing interventions for each. How will you know if your intervention worked? If you were to perform this exam within tight time constraints, what tasks, questions and assessments would be priorities for Tina? Include a minimum of two references to support your evidence-based plan. Support your discussion and opinions with facts, relevant examples from personal nursing practice, and at least two citations from the reading or peer-reviewed professional nursing literature. Remember to use APA 6th edition formatting for all discussion posts and reference citations.
Complete the History Assignment for Tina Jones before completing the discussion question
**Health History Assessment for Tina Jones:**
**Chief Complaint:** Tina reports acute foot pain resulting from an infected wound.
**History of Present Illness:** Tina describes the onset of foot pain as sudden and severe, accompanied by redness, swelling, and warmth around the wound site. She notes increased pain with movement and difficulty bearing weight on the affected foot. Tina reports no improvement with home remedies and expresses concern about the worsening pain.
**Past Medical History:** Tina has a history of diabetes mellitus type 2, which predisposes her to poor wound healing and increased risk of infection. She also mentions a previous episode of foot ulcers requiring medical intervention.
**Medications:** Tina is currently taking metformin for her diabetes management.
**Social History:** Tina lives alone and is responsible for managing her diabetes and foot care independently.
**Family History:** Tina’s family history includes diabetes mellitus and cardiovascular disease.
**Review of Systems:** Tina reports symptoms related to her foot pain, including limited mobility, difficulty ambulating, and discomfort with weight-bearing activities.
**SMART Goals and Evidence-Based Nursing Interventions:**
**SMART Goal 1:**
– Specific: Tina will experience a reduction in pain intensity from 8/10 to 4/10 on the Numeric Rating Scale (NRS) within one week.
– Measurable: Pain intensity will be assessed using the NRS at regular intervals.
– Achievable: Implementing evidence-based pain management interventions tailored to Tina’s needs.
– Relevant: Managing pain is essential for Tina’s comfort, mobility, and wound healing.
– Time-Bound: To be achieved within one week.
**Nursing Interventions:**
– Administer analgesic medications as prescribed, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), to alleviate pain.
– Apply cold therapy to the affected foot to reduce inflammation and provide local pain relief.
**SMART Goal 2:**
– Specific: Tina’s wound will show signs of healing, including decreased redness, swelling, and exudate, within two weeks.
– Measurable: Wound healing progress will be assessed through visual inspection and measurement of wound size.
– Achievable: Implement evidence-based wound care interventions to promote healing and prevent infection.
– Relevant: Healing the wound is crucial for preventing complications and restoring Tina’s functional ability.
– Time-Bound: To be achieved within two weeks.
**Nursing Interventions:**
– Cleanse the wound using sterile technique and apply appropriate wound dressings, such as hydrocolloid or foam dressings, to promote a moist wound environment.
– Educate Tina on proper wound care techniques, including the importance of keeping the wound clean and dry, changing dressings regularly, and monitoring for signs of infection.
**Evaluation of Intervention Effectiveness:**
To determine if the interventions were successful, I will assess Tina’s pain intensity using the NRS and monitor changes in wound appearance, including decreased redness, swelling, and exudate. Improvement in Tina’s pain levels and wound healing progress will indicate the effectiveness of the interventions.
**Priorities for Tina within Tight Time Constraints:**
Assess Tina’s pain level and provide immediate pain relief measures.
Inspect the wound for signs of infection, such as redness, swelling, warmth, and purulent discharge.
Evaluate Tina’s mobility and ability to bear weight on the affected foot.
Review Tina’s medication regimen, focusing on adherence to diabetes management medications and potential interactions with analgesics.
**References:**
Berman, A., Snyder, S. J., & Frandsen, G. (2016). Kozier & Erb’s fundamentals of nursing: Concepts, process, and practice (10th ed.). Pearson.
National Institute for Health and Care Excellence. (2019). Diabetic foot problems: Prevention and management. https://www.nice.org.uk/guidance/ng19
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