Nursing Assessment

The patient is a 25-year-old Filipino woman who is married with four children. She was born in the Philippines and moved to the United States at the age of 15. She works as a part time cashier at Kohls. The family is financially stable as her husband is an engineer for a prominent company. She has health care coverage from her husband’s employer as she only works part time and does not qualify for health insurance from Kohls. The client has not used health care systems regularly and has not had a regular doctor since she has been living in the United States. The patient finally sought medical help as she had been gaining weight and had not been feeling well.

The patient reported that she has not been feeling healthy as she has gained a lot of weight lately. She stated that she is unable to do things she used to enjoy and becomes fatigued easily. The patient has no allergies. The patient has been prescribed Ramipril as she has been found to have high blood pressure. The patient has also been diagnosed with hypothyroidism. The patient was last seen by a doctor two months ago. The patient reported that she was a healthy child and did not have any childhood illnesses. The patient stated that she had always been a healthy weight until recently. The patient did not report any past health screenings or assessments. The patient did report that she was hospitalized at the age of 17 and needed to have her appendix removed.

The patient reported a history of alcoholism on her father's side of the family however she stated that her family members never received treatment for it. The patient also reported a history of diabetes and high blood pressure in many members of her family. The patient also provided information on her pregnancies. The patient reported that all four children had been born naturally. She had received epidurals for all four pregnancies. All four children were also delivered full term. 

The patient reported that she belonged to a catholic church which she attended every Sunday with her family. Due to her recent weight gain, the patient has avoided going to church as she does not want to see her friends at church. The patient described her community as comprising of family members who mostly lived nearby and others belonging to her ethnic group. She also described her community as supportive and caring. The patient's grandmother recently passed away by killing herself which was unexpected by any of the family. The patient reported that this was a difficult time for her as she was very close to her grandmother and could not fathom why she would kill herself. The patient has shut down from family members and will not discuss the death with them or interact with them since the passing of her grandmother 2 months ago. The patient also reported having a healthy relationship with her husband who she has been married to for 6 years.

The patient lives in a four-bedroom home with her children and husband. The patient has lived in the home for five years which she owns. The patient completed her high school education. However, she did not pursue higher education as she chose to marry her husband and begin raising a family. The patient decided to begin working to provide extra income and also have interests outside of the home. The patient's mother provides assistance with caring for her children. The patient reported no drug use, tobacco use or alcohol consumption.

The patient’s symptoms included weight gain, fatigue, constipation, and weakness. The patient reported dry skin however she reported that she only occasionally used moisturizer and never used sunscreen as she felt she did not need it due to her dark skin color. The patient reported that her hair and nails were becoming thin and brittle. She was attempting to strengthen her hair through the use of thickening shampoo. She did not utilize anything to improve her nails. The patient reported that she had an increased tolerance to cold and she was attempting to avoid any situations in which she may be exposed to the cold. The patient reported that these symptoms have caused her to have a depressed mood and she has had difficulty sleeping. 

The patient did not report any concerns with her vision, head, ears, nose, throat or neck. The patient did not report any symptoms which would indicate problems with her neurological, respiratory, cardiac or any other symptoms. The patient has not had regular gynecological check-ups however a recent test did not show any abnormalities. The patient reported being active sexually however she reported no use of birth control or protection during sexual activity. The patient reported that she had tied her tubes after the birth of her fourth child.

The patient's actual diagnosis would be ineffective coping (Ackley & Ladwig, 2008). This is evidenced by the fact that the patient is having difficulty coping with the stressors in her life. The patient no longer enjoys the activities she used to enjoy as she no longer wants to attend church. The patient also avoids family and friends. The patient’s weak hair and fingernails could also be an indicator of stress in her system. The patient indicated depressed mood, lack of sleep and fatigue which may indicate depression which would need to be diagnosed by a doctor or psychologist.

The patient's wellness diagnosis would be readiness for enhanced coping. This is evidenced by the fact that the patient is finally seeking out assistance by coming to the nurse. Although the patient has ignored previous symptoms in the past she has come to terms with the fact that she needs to obtain medical assistance. The patient is also recognizing that she is not mentally well as demonstrated by her frequent discussion surrounding her depressed mood. This would indicate that she may be ready for therapy if suggested by the nurse to address the ineffective coping diagnosis. 

The patient would also be diagnosed with risk for violence: self-directed (Carpenito-Moyet, 2005). The patient is indicating that she may have symptoms of depression which left untreated could lead to suicidal thoughts. The patient reported hopelessness, depressed mood and a lack of sleep which could be suicidal indicators. The patient also had a close family member kill herself which increases the likelihood that the patient may make a suicidal attempt. Since the patient has not expressed suicidal thoughts or indicated a plan as of yet this would just need to be monitored until a referral could be completed for a therapist.

References

Ackley, B. J., & Ladwig, G. B. (2008). Nursing diagnosis handbook: an evidence-based guide to planning care. Mosby Elsevier.

Carpenito-Moyet, L. J. (2005). Nursing diagnosis: Application to clinical practice. Lippincott Williams & Wilkins.