Nursing Diagnosis and Care

1: Analyze Assessment Data:

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Based on the health history information, identify the following: A. Areas for focused assessment (30 points)

Provide a brief overview of those areas of strength and weakness noted from Milestone 1: Health History. From the conversation with JAW on her medical history she is in denial about the occurrences that is happening in her life which is making her non-compliant about taking her medications as prescribed. It appears that taking her medications will make her an unfit mother in the presence of her children according to JAW. Being a hospital corpsman in the Navy she is well aware of the ramifications about taking medications especially the ones that will help her overcome these issues.

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. JAW is in good shape according to military regulations. She runs at least three times a week which is keeping her physically in shape thereby not subjecting her to hypertension, any cardiac diseases, or joint problems at the present. I asked JAW was she uncomfortable talking to me about her health history and the issues that are related to her and me being her best friend. Her health patterns are excellent compared to others because she does follow the rules and conforms to the Navy standards. She also watches what she consumes to stay compliant with the nutritional needs as part of her physical fitness regimen.

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. JAW has anxiety and depression concerns. Her failed two marriages and raising her three children as a single mom are causing her some undue stress in her life and it could possibly lead to some bad decisions about her life choices. Stress can sometimes motivate or enhance a person performance and JAW chooses to run to help her escape what she is experiencing in her life. Fitness influences some qualities such as mental alertness and emotional stability because it is known that the body affects what it does to the mind. If she would take her medications as prescribed it could help her take control of the amount of bad or negative thoughts she may be having as far as her marriages and being a single parent. She has to be willing to verbalize that she has a problem and that she needs help which will be the first step to understanding what the underlying cause of her unresolved uncertainties is truly.

D. Health teaching topics (30 points)

Identify health education needs. Support your statements with facts from the Health History and information from your textbook. JAW does not have any pertinent health issues that require immediate attention but the issues that she does have can manifest into something major because she does have a diagnosis of anxiety and depression. The emotional reactions to stress may include difficulties sleeping, inability to concentrate, or in her case anxiety and depression. There are many support groups out there for JAW to join such as single parents and marriage counseling to name a few to help her overcome her problems. She can also schedule some sessions with a psychologist to talk through her problems and try and devise a plan to move forward with her life. At this point I would strongly suggest that she does seek some type of counseling because her masking the stress in her life will not help her cope.

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 individual coping related to situational crisis as evidence by anxiety, depression, and alteration in lifestyle.

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. Goal: JAW will verbalized the ability to cope effectively with anxiety by instituting three new stress-reducing skills by April 30, 2014. Outcome: JAW will be able to identify the stressful situations in her life and adjust changes suited for her and her children. African Americans are very hesitant to seek outside help to solve their problems because they are regarded as private people and JAW doesn’t want anyone to know that she feels might jeopardize her career.

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. 1). Inter: Provide information regarding different ways to deal with the current situations that promote anxiety feelings and the feeling of being depressed. RAT: With this information it provides JAW an opportunity to learn new coping skills. 2). Inter: Teach importance on how to balance life.

RAT: A life out of balance adds immensely to stress and anxiety. The changes affects adequate sleeping patterns, family time, quiet time, and overall enhancements of quality of living. 3). Inter: Refer to outside resources, including support groups, psychotherapy, and community recreation involvement. RAT: People have a tendency to benefit from the support of other people with similar problems and the resources available will help keep her life in balance and monitor her stress levels. 4). Inter: Encourage JAW to identify and verbalized feelings and perceptions.

RAT: The process of identifying feelings that remain underlying and drive behaviors enables the clients to begin taking control of their lives. 5). Inter: Teach JAW the physiologic actions of taking antidepressants and how it alleviates symptoms of anxiety and depression. RAT: Many depressed people resist taking medication because they fear becoming “addicted” to the drug. However antidepressants are not addictive drugs and providing her with the information about the drug’s physiologic action helps with adherence.

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. I would inquire about rather JAW has started her medication regiment and if she has any questions in regards to how it will affect her as far as her family and her career. Did she make the time to seek a physiologist to help her and her family overcome these difficult times of being just the four of them and also a psychiatrist to continue to prescribe the necessary medications? JAW will be able to discuss 3 coping techniques that she utilizes to help her feel more in control over her current situation. She will also be able to share the support system of people she can talk to when she is faced with a crisis. The way she has adjusted to her new life will ensure that she has become compliant with the medication regime and have sought the appropriate to help her overcome these issues so she can move forward.

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