Question

  

nursing: concept map case study: Helen Henry is a 38 year old female who has just received the news from her PCP that she has lung mass. She is admitted to the hospital for further check up. Her mother died of lung cancer and she is very distraught and crying. She has no family in the area except her wife. They are self-employed and have no health insurance at this time. She is a small obese woman of 4' 11 and weighs 225 lbs, she smokes 2 packs of cigarettes stating, "I dont plan on quitting". However, she is complaining of difficulty breathing with shortness of breath when ambulating. A lung mass biopsy revealed that she has a cancerous tumor on the left lower lobe. The plan is to remove the mass and radiation therapy.

BP is 120/65, P 72, R 16 with a persistent cough but is unable to bring up her secretions, so at times she feels like she is choking, temperature 99.8, when the nurse assist Ms. Henry to the bathroom sh starts to experience shrotness of breath. Respiration 12, in addition she has difficulty ambulating, due to her weiht, and almost falls, the nurse immediately sits her in the chair and and administered 2 liters of nasal O2. Ms. Henry Ms. Henry feels a little better and states, "Its hard for me to get around I use a cane to get around when I am alone". Helen stated"she knows she has to lose weight also bushe loves to eat". "Besides I have lung cancer and my mother died, life is short". When the nurse sits with Ms. Henry she states, "my mother died when i was young, what am i going to do" she starts to get angry and tells the nurse to leave the room. The nurse returns 30 minutes later to check on Ms. Henry, the nurse observes Helen and her wife Jenny eating an entire pizza pie, with a 2 liter bottle of coke.

Write about what you just did and how you thought about it. Each Gordon’s Patterns set shall be a paragraph. Tell me about all the thinking you did to develop the associated nursing diagnoses for that data cluster set. Then, move on to the next data cluster and make that a new paragraph. Don’t assume I know anything about your thought process, because I don’t. Show me how you are thinking! How to begin…………….

Include ALL of the questions with the Answers of the questions:

1.Explain how the data clusters helped you to determine the Gordon’s Functional and Dysfunctional Patterns.

2.Using Gordon’s as a guide, which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph).

3.List the identified nursing diagnoses in the:  

                                           “Problem” Related to “_____ “ Evidenced by “____” format.

1.Which nursing diagnosis is most important to address with this client? Explain how this was determined.

2.Which nursing diagnosis is second most important to address with this client? Explain how this was determined.

3.Which nursing diagnosis is least important to address with this client? Explain how this was determined.

Complete the Nursing process by answering the questions below and including the information in the explanation paper:

1.What is the goal for the client to show that the priority problem is reduced or resolved?

2.What would a nurse (you) need to do for the client to help the client meet the goal?

3.How would you know that the client has met the goal?

Please use this Gordon's 11 Functional Health Patterns:

1. Health perception/health management 2. Nutritional-Metabolic 3. Elimination 4. Activity - Exersice 5. Cognitive- perceptual 6. sleep rest 7. Self perception/self concept 8. Role - relationship 9.Sexuality- reproductive 10 Coping/Stress Tolerance 11. Value - Belief (this 11 Gordon's functional health patterns can be found online).

Answer 1

Data clusters help to determine the subjective and objective signs and symptoms of the client and assess the caring needs of the patient based on Gordon's functional pattern. This model helps to develop a framework based on the health problems and the needs. It visualizes the patterned behavior and physiological responses of the client. Overall, Gordon's functional and dysfunctional health pattern helps to develop the nursing care plan.

2.

a. Health perception:

It is the collection of data related to the health pattern, lifestyle, well-being, and knowledge of health practices of the client. It also focused on the management of health, the need for modification, and continuity of care.

b. Nutritional/metabolic pattern:

It is related to her daily food intake, fluid intake, type of foods, metabolic needs, weight gain and the associated risk factors related to the nutrition.

c.Activity exercise pattern:

It is related to the Helen daily activities, leisure activities, self-care activities, and evaluation of his respiratory function and mobilization.

d. Self-perception, Self-concept pattern:

It is the client's own self-perception about her life and health condition and experienced emotions and anxiety, and the threat towards the life can be analyzed.

e.Coping - stress tolerance pattern:

Here, the patient stress level is assessed and coping strategies are evaluated to support the patient and to manage his health condition.

3.

• .Altered nutritional level more than the body requirements related to increased appetite as evidenced by weight gain.
• .Risk for falls related to decreased mobility as evidenced by limited activities.
• .Ineffective airway clearance related to lung impairment as evidenced by increased mucus production.
• . Activity intolerance related to loss of energy as evidenced by fatigue..
• . Risk for infection related to respiratory secretions as evidenced by the mucus production.
• Ineffective coping related to cancer as evidenced by the threatening about his length of life.
• Anxiety related to disability as evidenced by the activities.
• Knowledge deficit related to cancer treatment as evidenced by loss of hope of life.

1. The most important nursing diagnosis is

Ineffective airway clearance related to lung impairment as evidenced by the increased mucus production.

The client has an ineffective breathing pattern due to lung cancer which increases further with mobilization. The increased weight makes her lose her energy and become fatigue easily. The increased secretions make her cough continuously.

2. The second most important nursing diagnosis is

Ineffective coping mechanism related to disease condition as evidenced by loss of hope.

The client is thought about the past event of her mother condition and believe of the same thing will be happening to her. It is assessed by her emotions which also increase her anxiety and fear towards her life.

3. The least most important nursing diagnosis for this client is

Risk for infection related to respiratory secretions as evidenced by mucus production.

The client is unable to excrete the secretions which have the chance to get an infection if not treated properly in time.

1. The major goal for this client may include improving the breathing pattern, maintenance of patterned airway, attainment of optimal mobility, maintenance of adequate nutritional status, achieving of positive coping measures, and prevention of complications.

2. The nurse can help the client by

• monitoring the breathing pattern and ascultate of breath sounds.
• Make her sit at 30 - 40 degree.
• Administer the nebulizer.
• Chest percussion.
• Encourage effective coughing.
• Encourage to do activities within her limit.
• Tell about positive thinking and coping measures.
• Support her to mobilize according to her level of fatigue.
• Teach her to do self-care activities with frequent rest periods.
• Teach about the cancer treatment and the prognosis.
• Educate about the importance of healthy nutritional and weight reduction therapy.

3. The client goals are evaluated based on the outcomes of

• Improved breathing pattern and airway clearance.
• Improved mobility.
• Improved self-care activity.
• Reduced weight and maintained of adequate weight.
• Less anxiety by using appropriate coping strategies.
• Gained knowledge about cancer treatment and a sense of trust about life.