Maria’s vitals today are as follows; T 98.6, R 20, HR 88, BP 148/90 Using the lesson and text as your guide, answer the following questions. What additional assessment data (subjective and/or objective) would you like to gather from Maria? What actual health concerns and risk factors have you identified? What are some opportunities to promote health and wellness for Maria?

Maria’s vitals today are as follows; T 98.6, R 20, HR 88, BP 148/90 Using the lesson and text as your guide, answer the following questions. What additional assessment data (subjective and/or objective) would you like to gather from Maria? What actual health concerns and risk factors have you identified? What are some opportunities to promote health and wellness for Maria?

Write one nursing diagnosis for Maria (actual, wellness or risk), based on one of the health concerns or opportunities you have identified. (Please use one of the formulas outlined in the text and lesson!)

With regard to additional assessment data, first, I would repeat Maria’s blood pressure to confirm that this number is accurate; then I would ask Maria about her previous weight and measure her current height and weight. If she was underweight in the past, a 14-pound weight gain, over the course of one year, may not be a problem. However, if this recent weight gain puts Maria near or in the overweight category, then her health may be at risk. I would ask Maria about family medical history, her own past and current medical history, surgical history, allergies, immunizations, current medications, and any current symptoms. I would then perform a head-to-toe assessment with a focus on any areas where Maria is experiencing symptoms. I would also ask about Maria’s current psychological state: How does she feel about her current schedule? Is she overwhelmed or anxious? In addition, I would gather information about Maria’s current support system: Is her spouse supportive, and would it be possible for her spouse to help with some of Maria’s responsibilities at home? I would also gather more detailed information about Maria’s eating habits: when she eats (times of day), what she eats (home-cooked meals or fast food), how often she eats, etc.

If Maria’s blood pressure is indeed accurate, then Maria is clearly hypertensive at this time. Her increased blood pressure could be related to increased stress and/or increased consumption of caffeine. A family history of hypertension could also put Maria at risk. If Maria’s weight gain continues, she could be at risk for developing a nutrition imbalance; this can put her at risk for heart disease, diabetes, and impaired physical mobility. In addition, if Maria does not find a way to manage her stress and get more sleep, this will contribute to the aforementioned health concerns and could lead to other health concerns and burn out.

Maria’s increased systolic blood pressure, consumption of multiple caffeinated beverages per day, recent weight gain, hectic schedule, insufficient amount of sleep, and lack of stress relief all provide opportunities to promote health and wellness. After establishing Maria’s preferred learning style and drawing on any knowledge she may currently have on these subjects, I would provide Maria with information that she can understand and apply to her life. Keeping in mind the importance of proper verbal and non-verbal communication, I would present this information in a non-judgmental manner with a focus on helping Maria achieve optimum health (Weber & Kelley, 2018). I would teach Maria about the risks and complications associated with hypertension and how it can be managed or prevented. I would council Maria about the importance of adequate water intake and a balanced diet; I would also educate Maria about the dangers of increased caffeine and sugary drink consumption and how these can worsen hypertension and put her at risk for other health issues. If possible, I would refer Maria to a registered dietitian or nutritionist. I would try to help Maria understand the importance of stress management by showing her how stress has impacted her health so far and how it can continue to affect her future health if it is not addressed. I would also provide Maria with suggestions for time management, and perhaps a weekly schedule template, so that Maria can plainly see how her time is spent and where it may be possible to include more time for self-care and sleep. I would also encourage Maria to talk with her spouse and other family members, if possible, so that she can share what she is going through and perhaps get some help from them.

Quite a few nursing diagnoses can be applied to Maria’s case. I have decided to focus on stress management, as I have found this to be an area that is frequently overlooked or under-addressed. By no means am I prioritizing this area of diagnosis over any other, this is merely the one I chose to use. The diagnosis I chose is as follows: Stress Overload r/t increase in educational responsibilities compounded with household responsibilities AMB decreased hours of sleep and stated inability to find time to relax and de-stress.

References:

Weber, J.R. & Kelley, J.H. (2018). Health Assessment in Nursing (6th ed.). Wolters Kluwer.