The comprehensive health assessment of Tina Jones, a 28-year-old African American female, was conducted at a primary care clinic. This assessment aimed to gather pertinent subjective and objective data to evaluate her current health status, specifically addressing her chief complaint of a "scraped foot" that has been slow to heal. Ms. Jones presents with a complex medical history including Type 2 Diabetes, Asthma, and Polycystic Ovary Syndrome (PCOS). This documentation utilizes the SOAP note format to organize findings, formulate nursing diagnoses, and develop a patient-centered plan of care focusing on wound management and chronic disease optimization.
Ms. Jones presented to the clinic reporting a right foot injury sustained approximately one week ago after tripping on a step. She describes the injury as a scrape that is "stinging" and seems to be healing slower than expected. She rates the pain as a 3/10 currently but notes it increases with pressure. She has been cleaning it with hydrogen peroxide and covering it with a band-aid but has seen minimal improvement. She denies any drainage or fever but expresses concern given her diabetic history.
Ms. Jones has a significant medical history including Type 2 Diabetes Mellitus, diagnosed at age 24, and Asthma, diagnosed in childhood. She also reports a history of Polycystic Ovary Syndrome (PCOS). She lives with her mother and sister and works at a copy center. She denies tobacco or illicit drug use but reports occasional social alcohol consumption. Financially, she expresses some concern about the cost of medications.
Medications:
Allergies:
General: Denies fatigue, weight changes, or fevers.
Respiratory: Reports occasional wheezing triggered by dust or cats; shortness of breath with exertion.
Cardiovascular: Denies chest pain, palpitations, or edema.
Endocrine: Reports polydipsia and polyuria; denies heat/cold intolerance.
BP: 128/82 mmHg (Right arm, sitting)
HR: 78 bpm (Regular)
RR: 16 bpm (Unlabored)
Temp: 37.2°C (99.0°F)
O2 Sat: 98% on Room Air
BMI: 29 (Overweight)
General Appearance: Ms. Jones is alert and oriented x3. She appears her stated age and is in no acute distress. She is well-groomed and maintains eye contact.
Respiratory: Chest expansion is symmetrical. Breath sounds are clear to auscultation anteriorly and posteriorly. No wheezes, rhonchi, or crackles heard upon exam today. No use of accessory muscles noted.
Cardiovascular: S1 and S2 heart sounds are audible and regular. No murmurs, gallops, or rubs detected. Capillary refill is < 3 seconds in upper extremities.
Integumentary: Skin is warm and dry. On the plantar surface of the right foot, there is a 2cm x 1cm abrasion. The wound bed is red with defined edges; no purulent drainage or significant induration is noted. Surrounding tissue is slightly erythematous. Sensation is intact in bilateral feet, though she reports a "tingling" sensation occasionally.
Impaired Skin Integrity related to altered circulation and sensation secondary to Type 2 Diabetes Mellitus, as evidenced by a 2cm abrasion on the right plantar foot that is slow to heal. The delay in wound healing is a common complication in diabetic patients due to hyperglycemia and potential peripheral neuropathy (Ackley et al., 2023).
1. Cellulitis: While there is erythema, the lack of systemic signs like fever, significant warmth, or spreading redness makes this less likely at this stage. However, it remains a risk requiring monitoring.
2. Tinea Pedis: The wound is distinct and traumatic in origin; the appearance is not consistent with the classic fungal scaling or interdigital maceration typical of athletes' foot (Jarvis, 2023).
The priority is managing the foot wound to prevent infection, given Ms. Jones's diabetes. Uncontrolled blood glucose levels can impair neutrophil function, slowing the healing process. Furthermore, the location on the plantar surface increases the risk of pressure injury and further trauma.
Cleanse the right foot wound with mild soap and water (discontinue hydrogen peroxide as it can damage granulating tissue). Apply a sterile, non-adherent dressing daily. Inspect the wound for signs of infection such as increased redness, warmth, or drainage.
Educate Ms. Jones on the importance of daily foot inspections using a mirror if necessary. Emphasize proper footwear to offload pressure from the injury site. Review the correlation between blood glucose management and wound healing, encouraging adherence to her Metformin regimen (Bickley, 2021). Discuss signs of infection that warrant immediate return to the clinic.
Return to clinic in 1 week for a wound check and to review lab results. If symptoms worsen (fever, spreading redness), present to the clinic or urgent care immediately.
Completing this comprehensive assessment on Tina Jones highlighted the interconnectedness of her chronic conditions and her acute presentation. Initially, I focused heavily on the foot injury, but as the interview progressed, I realized the critical need to address her diabetes management as the root cause of her slow healing. A gap in my data collection was a more detailed nutritional assessment; understanding her diet would have better informed the diabetes education plan (Shadow Health, 2024).
My clinical reasoning improved as I moved from simply documenting findings to connecting the "tingling" sensation she mentioned with potential diabetic neuropathy. In future practice, I will be more proactive in performing full sensory foot exams for all diabetic patients, regardless of their chief complaint, to detect early signs of neuropathy. This simulation reinforced the value of a holistic approach, ensuring that acute issues are treated within the context of the patient's overall health profile.
Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnosis handbook: An evidence-based guide to planning care (13th ed.). Elsevier.
Bickley, L. S. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Jarvis, C. (2023). Physical examination and health assessment (9th ed.). Elsevier.
Shadow Health. (2024). Tina Jones comprehensive assessment. Elsevier.
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