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Nursing Diagnosis Term Paper

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A nursing diagnosis is part of a nursing process where clinical judgment about a patient based on the potential health issues, portrays the next cause of intervention. Also, the nursing process focuses on fostering the patient’s comfort and relief with the dependent interventions provided by the medical personnel. In this regard, to determine the appropriate plan of nursing care for the patients, an analysis of three case studies was significant. The case studies are for hypertension, pneumonia, and diabetes patients.

Case Study 1: Hypertension Patient
Scenario: A 64 years old male adult walks into the emergency section (ER) complaining of a painful headache. On the onset of experiencing this symptom, the patient took a blood pressure test from home, and it read 210/110. The patient’s medical history is as follows: he had a transient ischemic attack (TIA) in 2010, Hyperlipidemia, two cardiac attacks in 2014, diabetes type 2, and hypertension.

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Nursing Diagnosis: The client’s diagnosis demonstrated a reduced cardiac output triggered by a rise in peripheral vascular resistance. The blood pressure (BP) of 220/115 gives evidence to this scenario. Besides, the patient complains of headache and blurred vision, which is also another symptom of hypertension (Zanchetti, 2018). However, the patient admits of not taking Clonidine as it makes him dizzy. Other measurements taken include

Objective and subjective data: Objective data is that the patient came to the hospital complaining of a headache as the blood pressure level read 201/110. He admits not taking Clonidine as it made him dizzy. The subjective data is that the patient has a history of TIA in 210/110 and two cardiac stents in 2014. The patient takes the following medication, Metformin 150mg, Liptor 20mg, Plavix 75mg, Coumadin 2mg, and Clonidine 2mg daily. On arrival at the hospital the VS is at HR 85, O2 Sat 96% on RA, and BP 220/115. In addition, his blood sugar reads RR 16.

Nursing intervention: During patients care, the nurse will continuously access the blood pressure (BP) in one hour up until the molecular dynamics (MD) parameters stabilize. According to Zanchetti (2018), molecular dynamics simulations determine the physical and mechanical properties of nano-materials. Finally, the nurse will educate the patient on how to consult a doctor during medication.

Patient goal outcome and evaluation: The patient’s blood pressure will be SBP 120 to 130 and DBP of between 80 and 95 within the next twenty hours. In addition, the patient will report the absence of headache and blurred vision in the next twelve hours. Furthermore, the patient will acknowledge the advice of not stopping medication before consulting a doctor.

Case Study 2: Pneumonia Patient
Scenario: Mary, a 34-year-old executive and a part-time college student begin to feel cold on return from work one day. All night, the alternates between shivers and sweats, hence she does not go to work the next day. She then develops dull aching chest pains as she begins to cough. Her fever continues, and she starts to cough rust-colored sputum the next day necessitating her to seek medication from a family nurse.

Nursing diagnosis: The patient diagnosis exhibit ineffective breathing pattern, which relates to the chest pains and an inflammatory process that relates to hyperthermia (Pletz & Rhorde, 2016). In addition, the patient lacks knowledge about pneumonia. In addition, the patient admitted to not knowing pneumonia.

Objective and subjective data: The objective data is that the patient describes the chest pain to increase as she moves around. Her cough rises in frequency, and her sputum is a rusty brown fluid. The subjective data is that the blood pressure (BP) reads 116/74, R 26, body temperature is 38.7°C, and her skin is warm with no signs of cyanosis. The respiration is shallow, and the respiratory excursion is equal. A STAT CBC indicates a WBC of 18,900/ mm3. In this regard, the patient’s sputum is taken for further analysis together with the chest X-rays.

Nursing intervention: The nurse makes a diagnosis of acute bacterial pneumonia caused by pneumococcal (Pletz & Rhorde, 2016).

Nurses Intervention: The Nurse Prescribes Penicillin V 500mg Every Six Hours for the Next Ten Days
Patient goal outcome and evaluation: the expected result is that the patient will maintain a normal pulmonary function, the coughs and chest pain will reduce and eventually end, the patient will report normalization of body temperature, and the patient will take her medication as prescribed. In addition, the patient will have to implement the access to knowledge and understanding about pneumonia attacks, assist in developing and complying with the medication schedule, and avoid the use of cough suppressants to facilitate proper rest.

Case Study 3: Patient with Type 2 Diabetes
Scenario: Simon is a retired 69-year-old man with a history of type 2 diabetes of five years. In addition, he has also shown symptoms of hyperglycemia for the past two years. He previously had blood glucose records recording a value of 118/127 mg/dl, which is a sign of borderline diabetes (Abdulfattai & Obateru, 2012). The patient has had previous attacks of nocturia, which relates to his diet of Italian pastries and other pasta meals.

Nursing diagnosis: the patient diagnosis shows hemoglobin (AIC) of 7% which has never been less than 8%. The blood pressure is up by BP: 150/70 mmHg. His blood pressure is usually at 130/80 mmHg in both cases of renal and cardiovascular health tests.

Objective and subjective data: The objective data is the rise in blood pressure, but there is no other complaint from the patient. On further analysis the subjective results are as follows, the patient has uncontrolled type 2 diabetes at AIC 7%, obesity BMI 32.4 kg/m2, hyperlipidemia, peripheral neuropathy, and elevated urine microalbumin levels. In addition, he undergoes limited exercises, high carbohydrate intake, and no SMBG program. He takes all his medication but does not have proper knowledge of diabetes.

Nursing intervention: During the intervention, the nurse will administer medication targeting glucose control without necessarily contributing to weight gains. The administration of thiazolidinediones by the nurse will adequately address the issue of insulin resistance. However, these drug associates with weight gain in some patients (Abdulfattai & Obateru, 2012). To reduce the postprandial elevations caused by increased carbohydrate intake, the nurse will administer sulfonylurea.

Patient goal outcome and evaluation: the goal was that, after one month, the patient would report an improvement in the levels of insulin, hemoglobin, and the subsequent body weight. The patient agreed for a referral to a nutritionist to help him with the diet. The patient acknowledged having little knowledge of nutrition and general diabetes condition and hence decided to consult medical experts. By following the doctor’s instructions, the expectation is that the patient’s blood pressure will reduce because of controlled body weight.

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References
Abdulfattai, O., & Obateru, O. (2012). Type two diabetes: A review of current trends. Oman
Medical Journal, 27(4), 269–273.
Pletz, M., & Rhorde, G. (2016). Advances in the prevention, management, and treatment of community-acquired pneumonia. Journal of Medicine, 5(2).
Zanchetti, A. (2018). Mechanisms, diagnosis and therapy of hypertension. Journal of
Hypertension, 36(2), 205-207.

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