1. What additional assessment data (subjective and/or objective) would you like to gather from Maria?
2. What actual health concerns and risk factors have you identified?
3. What are some opportunities to promote healt
...
1. What additional assessment data (subjective and/or objective) would you like to gather from Maria?
2. What actual health concerns and risk factors have you identified?
3. What are some opportunities to promote health and wellness for Maria?
4. 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!)
1. What additional assessment data (subjective and/or objective) would you like to gather from Maria?
First I would assess for any past medical history, family history, and current medications that Maria is taking. If multiple
people in her family have a history of thyroid problems, diabetes, or metabolic conditions, Maria may need to consider
being evaluated for these conditions to help determine if they are leading to weight gain. Researchers are discovering that
many health problems can be genetically connected (Weber & Kelley, 2018, p. 23). I would evaluate objective data such
as height and weight to help identify her current BMI. I would determine what her healthy body weight is as well. I would
also ask Maria what she eats at each meal daily. I would assess how she drinks her coffee, if she uses flavored creamer
or adds sugar, this may cause increased calorie intake, which may lead to weight gain. I would ask what types of cultural
foods Maria and her family generally eat to determine if they are fried, high in carbohydrate intake, or poor nutritional
value. I would discuss portion sizes, along with what Maria eats typically for lunch. If she is eating fast food or foods from
the school café, she may be eating more calories than she usually ate before starting the nursing program. I would also
assess for any edema, given her increased blood pressure.
I would also assess Maria’s normal daily routine in further detail. Are there any areas in which she can use to complete
physical activity? Is it possible that she could park further away from the entrance to increase her daily steps? By also
evaluating her daily routine, I may be able to identify areas in which she can raise her activity and burn calories. I would
assess what her physical activity level was before the entrance of the nursing program. If Maria has had a significant
decrease in activity, this may be leading to weight gain as well. I would further evaluate Maria’s sleep pattern, including if
she is having trouble falling asleep or staying asleep, and if she feels rested in the morning after sleeping. I would
determine how late in the day she is consuming caffeinated beverages and recommend not drinking them later in the day.
I would ask if Maria has any family or friend support that she can rely on occasionally to help with childcare and household
tasks.
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