Based On The Health History Information, Identify The Following: Essays Examples
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Directions: Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 250 points, with 10 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language.
1: Analyze Assessment Data:
A. Areas for focused assessment (30 points)
Provide a brief overview of those areas of strength and weakness noted from Milestone 1: Health History.
The client has recently experienced problems with abnormal vaginal bleeding. As it was the primary reason for seeking care, reproductive system would be the first area for the focused assessment.The weaknesses which predispose to the sex hormone imbalance and gynecological problems, are the client’s age (perimenopause) as a separate risk factor, the family history of gynecologic problems from maternal side (mother diagnozed with uterine fibroid approximately at the same age), and hyperestrogenism (1200 pmol/L). However the client’s strengths are absence of history of any abnormal bleeding (menorragia or dysmenorrhea) and relatively good reproductive profile (regular periods, no abortion or miscarriages, regular sexual life) which are probably indicative of some occasional hormone imbalance the reason of what should be sought for. Another area for focused assessment is neurology given the fact the client experiences migraines regularly 1-2 times per month. The great workload pressure and the high levels of work stress, with the family history of cardiac events, the borderline cholesterol level (240 mg/dL ) and the client’s life style (smoking which can exacerbate the symptoms of migraine), are weaknesses; meanwhile, absence of any other complaints and no history of neurologic abnormalities in the past are strong points.
B. Client’s strengths (30 points)
Expand on areas identified as strengths related to the person's overall health. Support your conclusions with data from the textbook.
Both the client self-perception of her strengths and the nurse’s critical summary of the initial and focused assessment should be considered. As the client’s interview shows, she considers having no major health problems her main strength. Another strong point, per the client’s perception, is a holistic approach to her own self, with her care about the balance of healthy body, healthy mind and healthy spirit. Critical summary of the interview information shows however that client does not always manage to strike this balance. Her key strengths are definitely a focus on the healthy life habits (dietary supplements, naturopathic medicine, medicines as last resort, attempts to manage a healthy diet (fresh, hydration, glass of wine 1-2 times a week). Objective data show that Ms.TB does not experience any problems in majority of health areas (musculoskeletal, urinary, skin, respiratory, gastroenterology, etc.) which, given her high levels of stress and unstable lifestyle (frequent business trips) are indicative of her high endurance limits and rather good health status. Another strong point is the client’s intention to take measures to make her life healthier, and her readiness to cooperate with the nurse in pursuing this goal.
C. Areas of concern (30 points)
Expand on areas previously identified as abnormal and those that place the person at a health risk. Support your observations with data from the textbook.
The nurse should evaluate the risks, associated with client’s family history and state of health, environmental and occupational risks, and the risks connected to client’s beliefs and\or cultural considerations. The family history places the client at a moderate\high risk of cerebrovascular diseases (ischemic heart disease in grandmother, clinically manifest cerebrovascular disease in father; peripheral arterial disease in mother and younger brother) enhanced by the client’s job position (senior management position with frequent stresses) and health habits (smoking). That can be the reason of a slight increase in cholesterol up to borderline level.The moderate family risk of metabolic syndrome (diabetes mellitus and obesity from paternal side, mild hypertension from both sides) is increased due to the client’s sudden weight gain and her lifestyle – frequent travel, sedentary way of life, little physical activity (in spite of her attempts to have it), high level of stress at job, and smoking. The occupational risks are rather high and connected with the nature of work (audit), high level in managerial hierarchy (increased responsibility levels, hard work, sleep patterns violations, unstable life schedule, complex work assignments, problems with keeping a balanced diet). The absence of normal work-life balance contributes to her anxiety and can lead to depression (the factor which aggravates the risk is the client’s history of post-partum depression). The primary risk connected to client’s behaviors\patterns is smoking which enhances the cardiovascular risk she has. No other cultural risks which could add to the existing health problems exist.
D. Health teaching topics (30 points)
Identify health education needs. Support your statements with facts from the Health History and information from your textbook.
The client is concerned about her weight gain which she treats as “unusual”. That indicates Ms. TB may be unaware of the complex association of underlying reasons leading to her metabolic problems. She needs to learn more about pathophysiology of metabolic changes which she undergoes to be able to manage and to effectively decrease risks associated with them. Also, she pays no particular attention to her diet focusing her attentioon more on fitness and physical activity. Ms. TB may need to learn more about the importance of nutrition for keeping stable weight, blood sugar and cholesterol level and in such way to reduce risks of cerebrovascular disease and metabolic syndrome. Due to her frequent migraines which she prefers to treat only symptomatically (Tylenol) she has to learn more about alternative non-pharmacological ways of reducing her anxiety and tension during the periods of high workload.
2: Nursing Care Plan
Next, plan your care based on your analysis of your assessment data:
A. Diagnosis (30 points)
Write one nursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility.
Ineffective Self-Health Management diagnosis as an umbrella term reflects all the problems the client experiences. The inability of the client to keep regular physical activity and stable healthy diet leads to increased cholesterol levels. The absence of understanding of the reasons of weight gain without any additional attempts to compensate for it, accompanied by a sudden hormone disbalance (hyperestrogenism) can dramatically increase the risk of obesity and raise blood sugar level if the same dietary habits are kept to and no action is taken. Poor sleep patterns can contribute to blood sugar level increase. Finally, several attempts of smoking cessation which failed aggravate the situation. The sum of all three risk factors –physical inactivity, tobacco use and poor diet overweight the benefits of the client’s regular support of the body function by dietary supplements\herbal medicine and result in ineffective self-health management.
B. Plan (30 points)
Write one goal and one measurable expected outcome related to your nursing diagnosis. Explain why this goal and outcome is a priority. Include cultural considerations for this client.
The goal is to incorporate the measures to return to the weight which has been stable for the client for the last 10 years (121.4lb) and to further maintain this weight. The outcome of the nursing care plan should be the client’s ability to describe the impact of bad and healthy life habits on her weight, to identify the measures to keep her weight stable and to understand why she should apply them regularly. This goal is especially important for the client as weight gain was identified by her as a concern, and a wish to reduce it to the normal level was expressed. Due to the client social position (high managerial level, constant work with people in job and active “presence” in the church community), it may affect her self-esteem and her own perception of herself as a woman. She also may be concerned how weight gain will influence her sexual relations with her husband. In health terms, this step would be a priority as in important measure to prevent and to mitigate the metabolic changes (increased catabolism, probably impaired glucose tolerance, lipids’ metabolism abnormalities) at the early stage and thus to reduce a risk of metabolic syndrome. The understanding of all the underlying mechanisms of these changes by the client will let her get control over her weight and her overall metabolic health thus “managing the manageable”.
C. Intervention (30 points)
Write as many nursing orders or nursing interventions that you need in order to achieve the outcome. Provide the rationale for each intervention listed.
First intervention should definitely be a diet pattern change. Though the nature of the client’s job does not allow keeping strictly to some particular diet, the basic principles of healthy nutrition can be implemented. These can perfectly be combined with the client’s regular use of dietary supplements. The changes include a diet rich in fruits and vegetables with especial focus on whole-grain, high-fiber foods, high content of oily fish (twice a week) and limited intake of sodium and saturated fat. Second intervention will be a recommended increase in physical activity adjusted to her work pattern: about 60 minutes of at least moderate intensity physical activity (aerobic exercise) 3-4 times a week (at home, outdoors or at gym). Third intervention should be smoking cessation to prevent associated metabolic and cardiovascular hazards. Finally, the interventions aimed at anxiety reduction (as anxiety can also contribute to sugar level increase and thus weight gain) can be recommended (e.g. acupuncture or aromatherapy) when required. Additional gynecologic screening\metabolic tests will clarify the background information and will give hint where to move and what areas to focus at. All these interventions have the same rationale providing the client with the possibility to maintain the optimal weight balance by combination of physical activity, diet, and behavioral style. The outcome of the fourth intervention (anxiety reduction) can additionally improve the client’s neurologic status reducing the number of migraine episodes.
D. Evaluation (30 points)
You will not carry out your care plan so you cannot evaluate the effectiveness of your nursing interventions. Instead, comment on what you would look for in order to evaluate your effectiveness.
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