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Nursing Diagnosis Plan
Assessment Analysis- Patient, CM., is a 60-year-old female African-American, married and a factory worker. CM is complaining about difficulty breathing, dyspnea. She indicates she is completely compliant with her medication regimen, naps and sleeps 7 hours a day. She is active, has a positive attitude, and regularly exercises. She does admit that sometimes she waits to seek medical attention, believing she should trust in God for minor issue. She does not take OTC or herbal medications and her immunizations are up-to-date. She denies use of alcohol, tobacco, or illicit drugs. Her pharmaceutical regimen consists of control of heart issues (aneurysm, artery disease, COPD, vein thrombosis, hypertension, aortic aneurysm; arthritis, seizures, and diabetes). She is emotionally stable, plans to continue working for at least 7 more years, and has a positive attitude.
Areas for Focused Assessment- CM has visited the hospital four times in the last two weeks. Preliminary examination shows no headache, pain, wheezing, or cardiovascular issues. The concern remains focused on her recent difficulty in...
She has strong motivation to stay healthy, seems happy, and has strong spiritual beliefs. She is covered by insurance plans, keeps herself clean and neat, and has strong self-worth.
Areas of Concern- Primary concerns are the symptoms that indicate may indicate blood sugar (diabetes issues), anxiety, or potential medication side-effects. Because of the history, medications, and frequency of issues, first steps would be to evaluate CM. with a fasting glucose test and other indicators of diabetic concern. Nurse/Physician should probe more to get a better longitudinal understanding of the dyspnea spells and try to match with certain times of day, length of time from eating, eating diary, and overall longer term testing of blood sugar levels. While there were no indications of psychological stress, further probing is necessary.
Health Teaching Topics…
REFERENCES
Treatment with Daliresp. (2012). Forest Pharmaceuticals. Retrieved from: http://www.daliresp.com/TreatmentWithDALIRESP.aspx?WT.srch=1&guid=363952239
Sarkar, S. And Amelung, P. (2006). Evaluation of the Dyspneic Patient in the Office. Primary Care. 33 (3): 643-57.
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