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Nursing Assessment and Patient Interview

Data Gathered

The patient analyzed in the case study at hand is a 21-year old female, whose major complaint is that she has been feeling weak and unwell for rather a long period of time. First and foremost, it can be concluded from the information provided by the woman that she is far from leading a healthy lifestyle. The patient reported having only one meal and smoking up to two packs of cigarettes per day. Furthermore, she also admitted occasional use of street drugs. Thus, the data obtained can be summarized as follows:

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  • the patient does not have a balanced diet;
  • not only the nutrition but also the amount of sleep is hardly sufficient since the patient admits rummaging through trash to find something she could sell, which is likely to be done at night;
  • the patient is a heavy smoker;
  • although the woman does not reveal any signs of drug addiction, she does not miss an opportunity to use them when someone shares with her, which can develop into an addiction in a short while;
  • the patient is aware of the mess in her life but cannot find the way out; this may lead to frustration and depression.

Questions to Ask

In order to help the patient, it is crucial to obtain all the related information about his/her condition. In the given case, the following questions can be asked to clarify the picture (Boss, Bryant, & Mancini, 2016):

  • How long has the patient been feeling the lack of energy?
  • Was the change connected with any particular event or stress?
  • Is it accompanied by other symptoms, such as insomnia, muscle soreness, loss of appetite, etc.?
  • Does the patient feel depressed?
  • Does she feel relief smoking or taking drugs?
  • What diseases did she have as a child and as an adolescent?
  • Were there any serious complications?
  • Is she willing to change her lifestyle to achieve health improvements?

Planning How to Assist the Client

First, it is necessary to eliminate the possibility of any serious physical conditions. The patient must be screened for cancer, HIV/AIDS, and hepatitis, which may cause her chronic fatigue (since she occasionally takes drugs). If the patient’s problem is not physical, it would imply that the patient’s state is connected with certain socio-psychological issues. In this case, the task of a nurse is to find out as much as possible about the facts of the woman’s background that might have led her to this condition. Otherwise, the assistance will hardly be productive (Jaremko & Meichenbaum, 2013). Since the woman is unable to stop the mess in her life (despite admitting it), the reason may be connected with some stressful events she experienced in childhood or adolescence. She may have quit her studies or lost some of her close people, which switched on the mechanism of adaptive responding (Feige, Morimoto, & Polla, 2013). Thus, as a nurse, I can provide her with the support and care she needs, including psychological help. In this case, the patient may better recover receiving the attention she needs rather than medications.

Potential Strategies to Assist the Client to a Better Life

The following strategies should be considered to assist the client in achieving a better life (Morton, Fontaine, Hudak, & Gallo, 2017):

  • The client must receive drug treatment in case some conditions are discovered.
  • The client must undergo therapy if it turns out that she experiences stress, frustration, or depression.
  • She must start sticking to a healthy diet since the lack of proper nutrition makes her feel weak.
  • The patient should quit smoking and taking drugs since these detrimental habits aggravate her condition.
  • She must be assisted in finding a job to be able to solve her financial problems that produce a negative impact on her general state.

References

Boss, P., Bryant, C. M., & Mancini, J. A. (2016). Family stress management: A contextual approach. Thousand Oaks, CA: Sage Publications.

Feige, U., Morimoto, R. I., & Polla, B. (2013). Stress-inducible cellular responses. Basel, Switzerland: Birkhäuser.

Jaremko, M., & Meichenbaum, D. (2013). Stress reduction and prevention. Berlin, Germany: Springer Science & Business Media.

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Morton, P. G., Fontaine, D., Hudak, C. M., & Gallo, B. M. (2017). Critical care nursing: a holistic approach. Philadelphia, PA: Lippincott Williams & Wilkins.

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StudyCorgi. (2020, December 9). Nursing Assessment and Patient Interview. Retrieved from https://studycorgi.com/nursing-assessment-and-patient-interview/

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"Nursing Assessment and Patient Interview." StudyCorgi, 9 Dec. 2020, studycorgi.com/nursing-assessment-and-patient-interview/.

1. StudyCorgi. "Nursing Assessment and Patient Interview." December 9, 2020. https://studycorgi.com/nursing-assessment-and-patient-interview/.


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StudyCorgi. "Nursing Assessment and Patient Interview." December 9, 2020. https://studycorgi.com/nursing-assessment-and-patient-interview/.

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StudyCorgi. 2020. "Nursing Assessment and Patient Interview." December 9, 2020. https://studycorgi.com/nursing-assessment-and-patient-interview/.

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StudyCorgi. (2020) 'Nursing Assessment and Patient Interview'. 9 December.

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