NR 305 Assessment for Health Promotion

NR 305 Assessment for Health Promotion

NR 305 Assessment for Health Promotion

I would want to collect more subjective and objective data from Maria. As for subjective, I would want to hear her describe her emotional state. (i.e. happy, stressed, sad) I would want to collect data regarding her personal health history and her family health history. It would also be helpful to know her values and beliefs in addition to her family relationships and support system. Lastly, I would want her to describe her daily routine, bedtime routine, and a typical eating routine. Additional objective data I would want to collect would be her current weight, blood work, including cholesterol and blood glucose, skin turgor, and reflexes.

I would identify her sleep deficit and caffeine use as immediate health concerns.  Her 14 lb weight gain is definitely a risk factor for heart and circulation issues.  I would also consider the amount of work that she assumes responsibility for is a risk to her sense of well being.

In order to promote health and wellness for Maria, we will first have to identify ways her family can contribute to lightening her stress load. Maria could meet with her family members and find ways to distribute the household work. This could allow her time for relaxation, studying or light exercise. We could also discuss teaching her family the recipes that she likes to cook. This would also provide quality time with her family, thus relieving the stress of feeling she has to do it all. We could explore technology to help her relax, such as apps on her phone for 10 minute meditations, or using the reading feature on her electronic school books to listen to her reading assignments while taking a leisurely walk.  Lastly, we could explore strategies to promote a more restful sleep. In my office setting, we often discuss sleep hygiene, which can help improve one’s psychological and physiologic well-being. (Jaffe & Engelke, 2018)

My nursing diagnosis for Maria would focus on her sleep deficit. Therefore, using the formula in our textbook, I

NR 305 Assessment for Health Promotion
NR 305 Assessment for Health Promotion

would write an actual nursing diagnosis. (Janet R. Weber Rn Edd & Kelley, 2018, Tables 5-1) My nursing diagnosis for Maria would be, Sleep Deficit, related to demands of household and schoolwork, as manifested by average sleep time of 5 hours, and patient’s dependence on caffeine to, “keep her going”, and “stay awake” throughout the day.

 

 

References

Jaffe, S., & Engelke, Z. (2018). Patient Education: Teaching Adult Patients Good Sleep Hygiene (Sleep Habits) Techniques (D. Pravikoff, Ed.). CINAHL Nursing Guide.

Janet R. Weber Rn Edd & Kelley, J. H. (2018). Health assessment in nursing (6th ed.). Lww.

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I imagine many of you can relate to Maria’s scenario in one way or another! I know I can. For that reason, it would be important to me to carefully consider the questions I ask and not assume I understand what she is going through. I look forward to reading your thoughts on this week’s discussion!

Please remember that this is a nursing assessment class so while mentioning the labs or consults is okay, this is not in our scope of practice to “order”… unless there are protocols in your facilities you might discuss. I am looking for nursing assessments and nursing interventions when asked.

Remember that this week, you may start posting for credit on Sunday 7/12. You need a minimum of two posts due Sunday 7/19 by 11:59 pm MT.

Here are a few tips:

  1. Per the rubric, you need to cite one class source and one outside source sometime within your posts.
  2. Also, your response should add new information to further the discussion rather than repeating what your peer stated or saying: “I agree”.
  3. Responses should be more than 60 words and should not contain a quotation that is more than 25% of your post. When you use too many quotations, this raises flags for plagiarism. You should have a maximum of one citation per every four sentences and a maximum of one direct quote per post.
  4. You also need to make sure you cite your references in your writing and not simple list them at the end (I hope this makes sense). See example below:

As stated by Professor Wills, be sure that you don’t simply list your references but also include them in your writing.

Following the tips mentioned above will help you maximize points. I look forward to more stimulating discussions!

Kind Regards, Professor Wills

Reference:

Professor Wills, Chamberlain College of Nursing

Additional subjective and objective data for Maria:

  1. Ask for an example of a 24 diet or food diary for her.  What exactly is eaten to get a better idea of the amount of daily calories and intake?
  2. How much coffee and diet cola is being ingested daily?  How much water intake?
  3. Any pertinent PMH I need to be aware of–medical diagnoses?
  4. Medications list including OTC meds.
  5. Details of mental health: what type of work does her spouse do?  How available is he to assist with family and home? Why exactly does everything seem to fall on her to be completed at home?  Religious beliefs?
  6. Sleep-Do you have difficulty falling asleep, staying asleep?
  7. Any routine for exercise?  Any recreational/leisure activities you enjoy?  Do you participate in any activities (physical) with your children?
  8. What do you do to cope with stress/anger?  What support system do you have in place?
  9. Obtain objective data by doing a complete head to toe assessment outside of the already provided vital signs.

 

Collecting subjective and objective data is a vital piece of the puzzle to be able to complete a nursing assessment. (Weber, Kelley, 2018)  Being able to obtain a complete health history means you are collecting as much subjective data about the patient as possible.  Obtaining the objective data requires a lot of practice on the nurses part to become proficient and accurate. (Weber, Kelley, 2018)

 

2) Actual risk factors and health concerns identified:

  1. Fatigue r/t only obtaining 5 hours of sleep every night and using caffeinated beverages throughout the day
  2. Stress/anxiety r/t multiple responsibilities of home/school
  3. Excessive caloric intake vs sedentary lifestyle r/t diet and inability to find time for exercise

 

3) Opportunities to promote health and wellness to Maria:

  1. Ask Maria to keep a food diary or use an app like myfitnesspal to track her intake daily to see if there is a pattern where things could be changed within her diet
  2. Give Maria information to be able to speak to a counselor pertaining to her stress levels to give her an outlet.  This can also possibly allow counseling to include her spouse so he understands she needs him as a support system and how to manage that.
  3. Try to encourage Maria to make a calendar for time management.  This will give her the opportunity to place everything in her life into a schedule, see where she could possibly make changes or make better use of all of her time to complete things efficiently for her and her family.  This could also give her the opportunity to have recreational/leisure time to then have an outlet for her stress/anxiety.
  4. Encourage Maria to find time to not only have quality time with her children, but possibly incorporate physical activity to give all of them energy, keep them moving and have that mental/emotional release.

 

Opportunities to promote health wellness can be difficult with minority groups such as Maria.  Research has shown that utilization by Mexican women for preventative services is huge.  (Mendias et al., 2001)  So due to her ethnic background she may be hesitant to recognize the need for holistic health services or even where to get the help she sounds like she truly needs.

 

4) Nursing diagnosis for Maria:

Imbalanced nutrition: more than body requirements r/t excessive intake in relation to metabolic need as evidenced by the patient stating she has had a 14 pound weight gain

 

References:

 

Weber, J., Kelley, J., (2018).  Health Assessment in Nursing 6th ed., 2-3.

 

Mendias, E., Clark, M., Guevara, E., (2001).  Women’s self-perception and self-care practice: implications for health care delivery. Health Care for Women International. 22(3). 299-312.  Retrieved from:  https://eds-a-ebscohost-com.chamberlainuniversity.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=10&sid=1e3683e7-5e66-4a5d-806c-3a37e6d47c7d%40sessionmgr4006Links to an external site.