Patient’s history Essay Example for Free

Patients history EssayNursing Diagnosis 1 scant(p) nutritionDebbies nutrition is not adequate for her age, as well as her weight. Due to ghost nausea/vomiting, worked up distress she lost weight. Her weight is less ( 89 pounds) compared to her usual weight ( 1 hundred ten pounds). The assessment and management of weight is a major(ip) preoccupation in contemporary healthcare. Clinical interventions focus on on achieving energy balance deficit and are premised on claims that excess weight/fatness (body stack index (BMI) 25) is a significant direct cause of morbidity and mortality and,correspondingly, that weight loss in fat (overweight or obese) people give reduce risk and/or improve health unwrapcomes. (Aphramor, 2010). sought after publication 1Desired Outcome 2Nursing Intervention 1Refer Debbie to nutritionist.Debbie will have more cultivation regarding healthy eating within 2 weeks. She will realize the immensity of her diet and metabolism. Debbie realized the impo rtance of healthy nutrition and regimen. She gained weight in 2 months more than 10 pounds. She feels comfortable and happy.Nursing Intervention 2Pharmacological intervention, direction regarding medications.Debbie will control her weight excessively 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 mode come about up recall in doctors office after discharge within 2 weeks, day-to-day weights. Follow visit- tolerant weighs 12 pounds more, less nauseous, feels comfortable in her weight. RationalePatient education, more information regarding nutrition, talking, informality techniques, pharmacological. Given instructions regarding future appointments and plans on her treatment, daily weights, weight contro l.Nursing Diagnosis 2 educational deficitDebbie 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 subtract of their domain. The most important part of patient education is to prepareDebbie for independence in her care, increase the confidence and competence for self-management. (Bastable, 2006).Desired Outcome 1Desired Outcome 2Nursing Intervention 1Instructions 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 2Patient educationDebbie wi ll know information about her medications, route, dosage, side effects in 2 days. Teach back achieved regarding medications. Debbie states that she was dying(predicate) previously as she thought the will not remember all the information given. She is happy as she did everything correct. Evaluation methodAsked multiple cross questions, Debbie answers as educated, seems more interested in future education. Debbie do an organizer for her. The organizer contains medication regimen, few special considerations, reminders. RationaleDemonstrated Debbie how to do breast examination, catheterization. utilize 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 gr eat concern regarding her future. Effectivecommunication among restrain 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 1Desired Outcome 2Nursing Intervention 1Debbie 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 2Debbie will be seen by religious 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 methodGiven instructions on how to manage time and stress with different activities, planning activity and periods of rest. Asked questions regarding Debbies days, stress management. RationaleEducational packets, brochures, referrals provided.Multiple written stress tests used to find our patients emotional condition. Seems more relaxed and less anxious.ReferencesAphramor, 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 pear Learning. Yarbro, C., Wujchik, D., Gobel, B. (2010). Cancer Nursing Principles and Practice (7th ed.). Jones Bartlett Learning.