1: Further objective data I would want to obtain would be body weight, height, BMI, and potentially labs such as cholesterols and triglycerides. Subjective data that I would want to get from the patient would be family health history. When obtaining the family health history, the patient should “include as many genetic relatives as possible” (Weber & Kelley, 2018). Weber and Kelley also stated that “such thoroughness usually identifies those diseases that may skip a generation (2018). For example, is there a history of heart attack or diabetes, what about obesity, or hypertension? Further, I would ask about smoking status, ways patient copes with stress, and what her typical meals include. Past medical history from the patient is also an important piece of information, does she take any medications, has she had any major surgeries, or does she have any chronic illnesses?
2: Jane Delgado stated “Hispanics have specific predispositions and risk factors concerning heart disease” (2014) in her article discussing Hispanic health. She went on to explain that Hispanics are also at an increased risk for diabetes as well (Delgado, 2014). Aside from her race, risk factors Maria has for heart disease would be her level of stress and potentially her weight. Depending on what Maria’s diet consists of, she could also be at risk for high cholesterol. Her recent weight gain, lack of sleep, and consumption of caffeine are all concerning.
3: Some points of health promotion that could be utilized are educating Maria on the importance of self care. It should be explained that despite having a busy life, not taking time for relaxation and yourself can lead to long term health problems. I would also want to provide education on the importance of a healthy diet. It is possible that Maria may need a referral to a dietician or to go see her primary care physician. Aside from her diet and stress, her lack of sleep would be something to discuss. Sleep hygiene should be explained. Maria may also need referral to a counselor to help her manage her stress and busy lifestyle, maybe the college has one on staff?
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4: Imbalanced nutrition (more than body requirements) r/t increased caloric intake, sedentary lifestyle.
Stress overload r/t increased work, educational, and family responsibilities.
Weber, J., Kelley, J., (2018). Health Assessment in Nursing 6th ed., pg 23.
Delgado, J., (2011) Hispanic Health, National Alliance for Hispanic Health, 136(94).
What additional assessment data (subjective and/or objective) would you like to gather from Maria?
-Additionally, to the above information, I would ask Maria for any past family health history to see what she was at risk for. Also, it would be important to know subjectively of her daily routine. This can be done by having her use a journal for a week and noting her everyday lifestyle. At that point we could possibly work together to find time that she can use for herself to do stress relieving activities. Some objective data would include breath sounds, heart sounds, and checking for any edema.
What actual health concerns and risk factors have you identified?
-Having a lifestyle routine full of non-stop activity places anyone at risk for many things. For example, Maria’s BP is high at 148/90 which places her at risk for heart disease. With the increase in weight also increases many other risks. According to Hopskins medicine, inactivity may increase your chances of developing type 2 diabetes, depression, and/or anxiety.
What are some opportunities to promote health and wellness for Maria?
– Some ways that Maria can promote health and wellness is to find even thirty minutes out of each day for her own self-care. This can include doing something relaxing like reading, yoga, walking, or even just taking a bath. It is also very important to at least exercise at the minimum of three days a week for thirty minutes or more. With the use of the daily journal, it will give Maria a chance to really be able to schedule time for herself.
Write one nursing diagnosis for Maria (actual, wellness or risk), based on one of the health concerns or opportunities you have identified. (Please use one of the formulas outlined in the text and lesson!)
– Risk for decreased cardiac output r/t hypertension
Weber, J., Kelley, J., (2018). Health Assessment in Nursing 6th ed., 2-3.
After reading about Maria, I would like to obtain some more subjective data from her including both her personal and family medical history including any history of high blood pressure. What medications she takes both prescribed and OTC and if she smokes, consumes any alcohol or takes any illicit or recreational drugs. I’d like to ask her if she experiences any headaches, visual changes, or nausea due to consumption or decrease in consumption of caffeine. I would like to know if and how much water she drinks. Due to her excessive caffeine intake, I’d ask her if she has experienced any increased irritability, nervousness, or anxiety. I would ask what time of day she stops consuming caffeine. I’d ask if she has noticed any changes to her bowel or bladder habits such as urinary frequency, bladder weakness, loose stools and when her last bowel movement was. I would ask her to tell me more about what she typically eats in a day including snacks. I would ask her to describe her nightly routine regarding sleep, if she has trouble falling and/or staying asleep and if she is aware of any factors that may be interfering with her sleep. I would also like to ask her about her caregiver role, her spouse’s role, cultural/spiritual beliefs, and support systems. I would ask what her coping mechanisms are when dealing with stress. For objective data obtain her current height and weight to calculate her BMI using the standard adult body mass index (BMI) chart (Weber & Kelley, 2018). I would perform a head-to-toe assessment focusing on her overall appearance, eyes, mouth/mucous membranes, signs of fatigue, skin integrity/turgor and auscultate her heart, lungs, and bowel sounds.
Identifiable health concerns and risk factors are Maria’s sleep deprivation, increased resting heart rate and elevated blood pressure. I’m concerned about her excessive consumption of caffeine. I’m also concerned about her risk for caregiver stress and lack of sleep and inattentiveness to self-care. Opportunities for health promotion are many. I would encourage Maria to keep a separate food and sleep journal so she can physically see what she is eating and drinking in a typical day and last time she eats/drinks and can keep track of when she falls asleep, wakes up, and how rested she feels. I would also suggest using a phone app to record these things to offer a more convenient option. I would then educate Maria on the effects of caffeine on health, mood, weight and sleep. Sleep deprivation is a known side effect of caffeine consumption (O’Callaghan, 2018). Maria reports she uses caffeine to help her “stay awake” and although caffeine may increase performance, it is usually consumed by those who are fatigued and in turn disrupts their sleep pattern (O’Callaghan, 2018). I would encourage Maria to avoid or significantly limit her consumption of caffeine and if she is unwilling to stop drinking caffeine altogether, I would encourage her to stop drinking it at least 4-6 hours before bed to help ensure better sleep. I would also encourage her to stop eating at least 2-3 before bed to assist with weight loss and better digestion prior to sleep. I would encourage her to increase her consumption of water and stress the importance of proper hydration. I would encourage her to discuss her caregiver responsibilities and stress with her family and suggest involving them in sharing in some of tasks. Since her children are school-aged, they can assist her around the house by dividing chores and may enjoy helping her prepare meals also as a way of both how to destress and lightening her load by putting a spin on the task as quality family time. Educate the client about the importance of self-care and provide techniques for relaxation. I would encourage her to incorporate at least 20-30 minutes a day to exercise by walking, possibly after dinner with family and/or stretching prior to bed help her body wind down from the day before sleeping. The nursing diagnosis I would apply to Maria’s situation would be: Fatigue related to caregiver/student responsibilities and over consumption of caffeine as evidenced by patient appearance and verbal reports of dissatisfaction of health status and poor sleep pattern
O’Callaghan, F., (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Health Care Policy 11, 263-271.
Weber, J.R., & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Wolters Kluwer.