Nursing Diagnosis Plan Assessment Analysis- Patient, Cm.,

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 breathing, and need for trips to the hospital.

Client's Strengths -- CM is coherent, verbal, has a strong sense of self and family, a positive outlook on life, and is able to express his symptoms and concerns in an educated and tangible manner. 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 -- The eating, exercise, and psychological log will be of great value in helping to assess CMs issues. When dyspnea occurs in unexpected situations it becomes pathological. However, in 85% of the cases, it may have a variety of causes: asthma, pneumonia, cardiac ischemia, lung disease, congestive heart failure, obstructive pulmonary disease, or psychogenic causes -- treatment of course depends on the underlying causes (Sarkar and Amelung, 2006).

Nursing Care Plan

Diagnosis- Because the symptoms are temporary and occasional, the log and testing workup should be thorough. It may be likely that some of CMs original issues are being aggravated, since other issues do not seem to present. Because patient already has COPD, the dyspnea may be exacerbation of her current condition.

Plan -- The first step in the plan will be to identify conclusively the source of CMs symptoms: 1) Fasting Glucose and Glycated hemoglobin (A1C) test; 2) Baseline and additional tests of heart and lung function to establish a database. More sophisticated testing if original tests are inconclusive.