Running head: TINA JONES HEALTH HISTORY NARRATIVE
Tina Jones Health History Narrative
Anna M. Medina
Professor Deborah Mathias
NUR 3700: Nursing Health Assessment
Metropolitan .State University of Denver
, TINA JONES HEALTH HISTORY NARRATIVE 2
Introduction
A complete health history based upon work in Shadow Health was completed on Tina
Jones, a twenty-eight year old woman. Ms. Jones came in through the emergency department for
an injury to her right foot. Utilizing interviewing and clinical skills, and clinical reasoning skills,
the ability to perform a health history was successful.
Health History
Finding Data and Reliability
Ms. Tina Jones is a pleasant twenty-eight year old African American woman. She is
seated upright in her hospital bed. She was admitted for further evaluations of her right foot
injury. She is the primary source of the history. She offers information freely. Her speech is
clear and coherent. She maintains good contact throughout the interview.
General Evaluation
Ms. Jones is alert and oriented. She appears to be in pain. She is well nourished. She is
well groomed, dressed appropriately, has good hygiene, and interacts appropriately.
Chief Complaint
Ms. Jones’s chief complaint is that “I hurt my right foot one week ago” They said I
needed to get admitted to the hospital.
History of Present Illness
Ms. Jones has an open wound to her right foot located on the plantar surface. She has
asthma and type II diabetes. She injured her foot by scraping the bottom of a stepping stool. She
states that she was barefoot at the time of the injury. She states that her current pain is 7/10, and
last received medication in the emergency department that seems to be helping. She states that
her pain is made worse when she stands, and is unable to bear weight on her right foot. She does
Tina Jones Health History Narrative
Anna M. Medina
Professor Deborah Mathias
NUR 3700: Nursing Health Assessment
Metropolitan .State University of Denver
, TINA JONES HEALTH HISTORY NARRATIVE 2
Introduction
A complete health history based upon work in Shadow Health was completed on Tina
Jones, a twenty-eight year old woman. Ms. Jones came in through the emergency department for
an injury to her right foot. Utilizing interviewing and clinical skills, and clinical reasoning skills,
the ability to perform a health history was successful.
Health History
Finding Data and Reliability
Ms. Tina Jones is a pleasant twenty-eight year old African American woman. She is
seated upright in her hospital bed. She was admitted for further evaluations of her right foot
injury. She is the primary source of the history. She offers information freely. Her speech is
clear and coherent. She maintains good contact throughout the interview.
General Evaluation
Ms. Jones is alert and oriented. She appears to be in pain. She is well nourished. She is
well groomed, dressed appropriately, has good hygiene, and interacts appropriately.
Chief Complaint
Ms. Jones’s chief complaint is that “I hurt my right foot one week ago” They said I
needed to get admitted to the hospital.
History of Present Illness
Ms. Jones has an open wound to her right foot located on the plantar surface. She has
asthma and type II diabetes. She injured her foot by scraping the bottom of a stepping stool. She
states that she was barefoot at the time of the injury. She states that her current pain is 7/10, and
last received medication in the emergency department that seems to be helping. She states that
her pain is made worse when she stands, and is unable to bear weight on her right foot. She does
