Patient’s history Essay Example for Free

Patient’s history Essay Nursing Diagnosis 1: Inadequate nutrition Debbie’s nutrition is not adequate for her age, as well as her weight. Due to frequent nausea/vomiting, emotional distress she lost weight. Her weight is less ( 89 pounds) compared to her usual weight ( 110 pounds). The assessment and management of weight is a major preoccupation in contemporary healthcare. Clinical interventions focus on achieving energy balance deficit and are premised on claims that excess weight/fatness (body mass index (BMI) 25) is a significant direct cause of morbidity and mortality and, correspondingly, that weight loss in fat (overweight or obese) people will reduce risk and/or improve health outcomes. (Aphramor, 2010). Desired Outcome 1 Desired Outcome 2 Nursing Intervention 1 Refer Debbie to nutritionist. Debbie will have more information regarding healthy eating within 2 weeks. She will realize the importance of her diet and metabolism. Debbie realized the importance of healthy nutrition and regimen. She gained weight in 2 months more than 10 pounds. She feels comfortable and happy. Nursing Intervention 2 Pharmacological intervention, education regarding medications. Debbie will control her weight also by controlling her nausea using the prescribed medication for nausea. She will receive information on how to use the medication, frequency, dosage, side effects in 2 days. After one week Debbie has more information regarding her medications, realized that medication helps her to control nausea and takes as ordered. Evaluation method Follow up visit in doctor’s office after discharge within 2 weeks, daily weights. Follow visit- patient weighs 12 pounds more, less nauseous, feels comfortable in her weight. Rationale Patient education, more information regarding nutrition, talking, relaxation techniques, pharmacological. Given instructions regarding future appointments and plans on her treatment, daily weights, weight control. Nursing Diagnosis 2: Educational deficit Debbie needs more information regarding her care. She needs education related to medications, self-catheterization, breast self-examination. Patient education is a central the practice of nursing and should be in part of their domain. The most important part of patient education is to prepare Debbie for independence in her care, increase the confidence and competence for self-management. (Bastable, 2006). Desired Outcome 1 Desired Outcome 2 Nursing Intervention 1 Instructions on how do self breast- examinations and self- catheterization, warning signs/symptoms. Debbie will be able to do breast self-examination herself in one week, will be able to perform intermittent self-catheterization. Two weeks passed. Debbie states how she performs breast self-examination, what she needs to look out for. She states how often she does the examination and demonstrates what positional changes she needs to do. Nursing Intervention 2 Patient education Debbie will know information about her medications, route, dosage, side effects in 2 days. Teach back achieved regarding medications. Debbie states that she was anxious previously as she thought the will not remember all the information given. She is happy as she did everything correct. Evaluation method Asked multiple cross questions, Debbie answers as educated, seems more interested in future education. Debbie made an organizer for her. The organizer contains medication regimen, few special considerations, reminders. Rationale Demonstrated Debbie how to do breast examination, catheterization. Used a kit and plastic body to demonstrate. Used the board to give important information regarding medication. Debbie demonstrates what she does at home to do the catheterization, breast self-examination, questions given, answered properly as was educated. Nursing Diagnosis 3: Emotional distress. Debbie is experiencing emotional distress, anxiety. As stated in case study she is tearful, has great concern regarding her future. Effective  communication among nurse and patient/family can improve care and relieve suffering. The diagnosis and treatment for cancer is a major challenge and it affects all aspects of life. By therapeutic communication, providing information, encouraging optimistic outlook, teaching how to reduce stress patient care will have better outcomes. (Yarbro, Wujchik, Gobel, 2010). Desired Outcome 1 Desired Outcome 2 Nursing Intervention 1 Debbie will get used to controlling her stress by daily walks, relaxation techniques, music, spending time with family in 2 weeks. Debbie states she feels better spending time with family, resting, being in the park, meeting friends when feeling lonely and anxious. Nursing Intervention 2 Debbie will be seen by spiritual care in 2 days. Debbie states that her conversations with spiritual care makes her feel more relaxed, she reads books, has prayers at her bedside. Evaluation method Given instructions on how to manage time and stress with different activities, planning activity and periods of rest. Asked questions regarding Debbie’s days, stress management. Rationale Educational packets, brochures, referrals provided. Multiple written stress tests used to find our patient’s emotional condition. Seems more relaxed and less anxious. References Aphramor, L. (2010, July). Validity of claims made in weight management research: a narrative review of dietetic articles. Nutrition Journal, 9(). Bastable, S. B. (2006). Essentials of Patient Education. : Jones Bartlett Learning. Yarbro, C., Wujchik, D., Gobel, B. (2010). Cancer Nursing: Principles and Practice (7th ed.). : Jones Bartlett Learning.