Subjective Data
Client Complaints: The patient complains of dry cough, decreased appetite, shortness of breath, and low-grade fever. The woman also reports a slight sore throat.
HPI (History of Present Illness): According to the patient’s HPI, the woman has been suffering from a dry cough and decreased appetite for the past two weeks. Meanwhile, she does not report any cases of nausea or vomiting. The cough is particularly acute in the night time, while the sore throat mainly troubles her in the morning. The described symptoms have worsened within the past two days. The woman is concerned she might have heart problems or pneumonia.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations): The patient has refused to take the prescribed inhalers or to undergo the hospitalization and pulmonary function tests. When the symptoms worsen, she takes the prescribed antibiotics. The last chest investigation discovered emphysema. The woman reports an allergy to sulfa drugs; the associated reaction is rash.
Significant Family History: The patient has been single for the past 20 years. The woman has two daughters but they do not visit her often. She also has two sisters diagnosed with osteoporosis and breast cancer.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use): The woman receives a regular pension of $40,000 and uses the savings. She has her own house. Her lifestyle is reserved and stress-free. The major social activity is the patient’s visits to the church community. The patient does not have unhealthy habits except for smoking and is involved in sewing. She does not consider any other activities due to the low awareness of the community resources.
Description of Client’s Support System: The patient’s support system is composed of the primary care provider, her two daughters, and the church community members. The former two do not have time for frequent contacts.
Behavioral or Nonverbal Messages: The woman experiences depression due to the reserved lifestyle and rare social contacts. The self-efficacy perception is low and keeps decreasing.
Client Awareness of Abilities, Disease Process, Health Care Needs: The patient has low awareness of community resources and healthcare options. She aligns the present symptoms with heart problems and pneumonia though there is no medical evidence proving the assumptions. She does not take the prescribed medications, due in part to the fact they are not covered by the insurance, partially because of her poor awareness of their effect.
Objective Data
Vital Signs including BMI: BP: 130/72 left arm sitting regular cuff; T: 101 po; P: 100 and regular; R: 20, non-labored; Wt: 130#; Ht: 55”.
Physical Assessment Findings: White material on the buccal mucosa is discovered in the HEENT process. No lymph nodes are found. Lungs examination shows decreased breath sounds, dull to percussion right lower lobe, and increased anterior-posterior diameter to the chest wall. There is an end-expiratory wheeze in the right lower lobe. No rales or rhonchi are discovered. Heart examination shows that RRR is without murmur. Extremities examination shows 2+ pulses throughout; no edema is discovered.
Lab Tests and Results: CBC- WBCs 15, 000 with + left shift. The pulse oximeter reading is SAO2: 98%. The radiological studies show that CXR is the same as X-ray. EKG exhibits normal sinus rhythm.
Client’s Support System: From the financial perspective, it is the medical insurance. From the social standpoint, it comprises her daughters, the church and healthcare communities, and, potentially, her sisters.
Client’s Locus of Control and Readiness to Learn: The patient might have an external locus of control due to her spirituality and resistance to taking prescribed medications. Her readiness to learn might be evaluated as high as she appreciates her contacts with healthcare workers.
ICD-10 Diagnoses/Client Problems
Within the ICD-10 Diagnoses assessment, several problems should be distinguished:
F50 – eating disorders. The associated R/T is the decreased appetite.
F34 – persistent mood disorders (ICD-10-CM Codes, 2016). The associated R/T is the lowered self-esteem and continuous depression.
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources, and follow-up plans)
Nursing Diagnosis
According to NANDA Nursing Diagnosis List, several risks might be identified relevant to the preliminary assessments. Within the relations dimension, the condition can be characterized as social isolation (NANDA Nursing Diagnosis List, 2016). The associated R/T is the low level of social support. The diagnosis’s defining characteristics are the reported feeling of loneliness and low social activity.
Within the choice dimension, “the inability to adapt to a change in health status” can be pointed out as a “risk for” diagnosis ((NANDA Nursing Diagnosis List, 2016, para. 9). The associated R/T might be the poor patient’s awareness of the required health care procedures. The diagnosis’s defining characteristics are the woman’s addiction to smoking despite the consistent cough and her low social activity despite the worsening depressive moods. Finally, the ineffective family coping strategies, i.e. the lack of substantial support, might be pointed out as the potential “risk for” diagnosis (NANDA Nursing Diagnosis List, 2016).
The associated R/T is the low frequency of family reunions and poor communication between the patient and her children. The diagnosis’s defining characteristics are the patient’s dissatisfaction with the current family relations and the associated feeling of loneliness.
Patient Goals
The key goal of the proposed care plan resides in enhancing the patient’s socialization in a half-year period. The set goal comprises such objectives as raising the woman’s awareness of both community and healthcare resources and strengthening her relations with family members and other support agents. It is expected that the realization of this goal will allow for improved care delivery and help the patient adopt a healthy lifestyle framework that is one of the main targets promoted by AHRQ (Agency for Healthcare Research and Quality, 2016).
Nursing Intervention
A series of interventions is proposed to complete the target goal. First and foremost, it is proposed to intensify the primary care provider’s inclusion. Thus, the latter should support the patient more actively by giving regular visits and providing the essential clarification regarding the prescribed medications and the available resources. Second, it is proposed to involve the family members, i.e. the patient’s daughters to assist the woman in her socialization progress.
To this, the nursing community should contact the woman’s daughters and communicate the necessity for intense support to them. It is expected that the active participation of the family members will help the woman to overcome her emotional disturbances. Lastly, all the change participants, i.e. the nursing community, the primary care providers, and the family members, need to raise the patient’s awareness of the available community and health care resources to improve the quality of the care she receives.
Nursing Rationale
The effectiveness of the proposed interventions is evidenced by recent studies. Hence, in their research, Dickens, Richards, Greaves, and Campbell (2011) show that the socialization-related interventions, including the intensive inclusion of primary care specialists and family, help a patient to acquire a positive reinforcement and decrease the depressive moods, particularly in elderly people. Additionally, scientific studies reveal that patients who exhibit a satisfactory socialization level are more likely to make a shift to a healthy lifestyle as the surrounding communities provide them with up-to-date information regarding healthcare tendencies and options (Nicholson, 2012).
References
Agency for Healthcare Research and Quality. (2016). Living a healthy lifestyle. Web.
Dickens, A. P., Richards, S. H., Greaves, C. J., & Campbell, J. L. (2011). Interventions targeting social isolation in older people: a systematic review. BMC Public Health, 11(647), 1-20.
ICD-10-CM Codes. (2016). Web.
NANDA Nursing Diagnosis List. (2016). Web.
Nicholson, N. R. (2012). A review of social isolation: an important but underassessed condition in older adults. The Journal of Primary Prevention, 33(2), 137-152.