Community Health Planning, Implementation and Evaluation
Community Nursing Class
Diabetes mellitus type 1:
Assessment:
History: When collecting data, ask the caregiver about:
– The child’s symptoms leading up to the present illness
– Ask about the child’s appetite.
-Weight loss or gain.
– Evidence of polyuria or enuresis in a previously toilet-trained child,
– Polydipsia.
– Dehydration.
– Irritability and fatigue.
Include the child in the interview and encourage him or her to contribute information.
Physical exam:
– Measure the height and weight and examine the skin for evidence of dryness or slowly healing sores.
– Note signs of hyperglycemia.
– Record vital signs, and collect a urine specimen.
– Perform a blood glucose level determination using a bedside glucose monitor.
-Urine dipstick test. For ketones in the urine, the child should be tested using urine dipstick test.
Diagnosis:
1-Deficient Knowledge related to absence or deficiency of cognitive information as evidence by new diagnosis of IDDM
2-Compromised Family Coping related to Inadequate or inaccurate information as evidence by Anxiety and guilt
3-Risk for Injury as evidence by sweating, shakiness, nervousness, lightheadedness, weakness, nausea, moodiness, pale skin, loss of consciousness
4- Imbalanced nutrition: less than body requirements related to insufficient caloric intake to meet growth and development needs as evidence by patient BMI of 16.
Planning:
The major nursing care planning goals for diabetes mellitus type 1 the child.
– Client will verbalize understanding of IDDM.
– Client and parents will demonstrate appropriate blood-glucose monitoring insulin administration, dietary management, and exercise plan.
– Client and parents will identify signs and symptoms of hypoglycemia and hyperglycemia and correct response
– Family will explore feelings regarding the child’s long-term needs.
– Family will determine appropriate support systems and coping skills
– Family will show learning about and managing hypoglycemia and hyperglycemia, insulin administration, and exercise needs for the child.
– Client’s blood glucose levels will maintain between 60 mg/dL and 120 mg/dL.
– Client will maintain adequate nutrition.
Nursing Interventions
-The nurse will assess parents and child understanding of disease and ability to perform procedures and care, for educational level and learning capacity, and for developmental level.
-The nurse will provide a quiet, comfortable environment; allow time for teaching small amounts at a time and for reinforcement, demonstrations and return demonstration; start educating one day following diagnosis and limit sessions to 30 to 60 minutes.
-The nurse will instruct parents and child in insulin administration including drawing up insulin into the syringe, rotating vial instead of shaking, drawing clear insulin first if mixing 2 types in the same syringe, injecting SC, storing insulin, rotating sites, adjusting dosages, reusing a syringe, and needle, and disposing of them
-The nurse will include as many family members in teaching sessions as possible.
– The nurse will assess family coping mechanisms and its effectiveness, family dynamics and expectations related to long-term care, developmental level of family, response of siblings, knowledge, and use of support systems and resources, presence of guilt and anxiety, overprotection and overeating behaviors.
– The nurse will assist family to establish short- and long-term goals for the child and to involve the child in the activities of the family; include the participation of all family members in care routines.
– The nurse will encourage family members to verbalize feelings, to tell how they handle the chronic needs of the family member, and to define coping patterns that support or inhibit adjustment to the problems.
– The nurse will assess for signs and symptoms of hyperglycemia; Monitor serum glucose level, urine for glucose and ketones, pH and electrolyte levels. Also assess for symptoms of hypoglycemia.
-The nurse will administer insulin subcutaneously as prescribed, increase dosage depending on the glucose levels; rotate injection sites, minimize food intake during an infection or illness and modify the dosage of insulin during an illness.
– The nurse will promote exercise program compatible with insulin regimen; instruct to increase carbohydrate intake prior a strenuous activities.
– The nurse will encourage a diet with calories that balance with the energy requirements and paired with the type and action of insulin, and snacks between meals and at bedtime as appropriate.
-The nurse will ensure adequate and appropriate nutrition to maintain the blood glucose at near normal levels; the food plan should be well balanced with foods that take into consideration the child’s food preferences, cultural customs, and lifestyle.
-The nurse will prevent skin breakdown. Teach the caregiver and child to inspect the skin daily and promptly treat even small breaks in the skin; encourage daily bathing; teach the child and caregiver to dry the skin well after bathing, and give careful attention to any area where skin touches skin, such as the groin, axilla, or other skin folds; emphasize good foot care.
Evaluation
Goals are met as evidenced by:
The child/ caregiver:
•Maintained adequate nutrition.
•Promoted skin integrity.
•Prevented infection.
•Regulated glucose levels.
•Learned adjust to having a chronic disease.
•Learned about and managing hypoglycemia and hyperglycemia, insulin administration, and exercise needs for the child
Breast cancer.
Assessment:
During the history:
It is crucial to know if the nurse admitting learns that the patient her mother, two of her aunts, and one sister had been diagnosed with breast cancer. Her mother and one of the aunts died before age 45. . Risk factors include age 65 and above, two first-degree relatives diagnosed with breast cancer at an early age, high breast tissue density, and factors that affect circulating hormones like late menopause, long-term use of hormonal replacement therapy, and obesity.
Physical assessment findings
Breast cancer may present as a palpable breast mass, breast pain, lymph node swelling, or skin changes, such as dimpling or redness. Evaluation of a breast abnormality usually starts with a clinical breast examination and mammography or ultrasonography, with MRI considered for some patients. The next step is a needle biopsy or surgical excisional biopsy. To determine if the cancer has spread, the patient may undergo additional tests, such as X-ray, computed tomography (CT), a bone scan, and fluorodeoxyglucose (FDG) positron emission tomography (PET) integrated with CT (FDG-PET/CT).Breast cancer screening includes mammography, clinical breast examination (CBE), and breast self-examination (BSE). It is important that patients understand what these examinations are all about, how they are performed, and their limitations.
Diagnosis:
1- Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs related to hypermetabolic state associated with cancer as evidence by body weight 20% or more under ideal for height and frame, decreased subcutaneous fat/muscle mass.
2- Acute Pain related to side effects of various cancer therapy agents as evidence by patient verbalize pain and alteration in muscle tone; facial mask of pain.
3- Situational Low Self-Esteem related to threat of death; feelings of lack of control and doubt regarding acceptance by others; fear and anxiety as evidence by Not taking responsibility for self-care, lack of follow-through.
Planning:
– The patient will demonstrate stable weight/progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition.
– The patient will verbalize understanding of individual interferences to adequate intake.
– The patient will anticipate in specific interventions to stimulate appetite/increase dietary intake.
– The patient will verbalize understanding of body changes, acceptance of self in situation.
– The patient will begin to develop coping mechanisms to deal effectively with problems.
– The patient will demonstrate adaptation to changes/events that have occurred as evidenced by setting of realistic goals and active participation in work/play/personal relationships as appropriate.
– The patient will report maximal pain relief/control with minimal interference with ADLs.
– The patient will follow prescribed pharmacological regimen.
– The patient will demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
Nursing Interventions
– The nurse will monitor daily food intake; have patient keep food diary as indicated.
– The nurse will measure height, weight, and triceps skinfold thickness (or other anthropometric measurements as appropriate). Ascertain amount of recent weight loss. Weigh daily or as indicated.
-The nurse will assess skin and mucous membranes for pallor, delayed wound healing, enlarged parotid glands.
– The nurse will determine pain history (location of pain, frequency, duration, and intensity using numeric rating scale (0–10 scale), or verbal rating scale (“no pain” to “excruciating pain”) and relief measures used. Believe patient’s report.
– The nurse will evaluate and be aware of painful effects of particular therapies (surgery, radiation, chemotherapy, biotherapy). Provide information to patient and SO about what to expect.
– The nurse will encourage use of stress management skills or complementary therapies (relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and therapeutic touch).
– The nurse will review anticipated side effects associated with a particular treatment, including possible effects on sexual activity and sense of attractiveness and desirability (alopecia, disfiguring surgery). Tell patient that not all side effects occur, and others may be minimized or controlled.
-The nurse will encourage discussion of concerns about effects of cancer and treatments on role as homemaker, wage earner, parent, and so forth.
– The nurse will acknowledge difficulties patient may be experiencing. Give information that counseling is often necessary and important in the adaptation process.
Evaluation
Goals are met as evidenced by:
-Patient has no signs of physical complications and is looking forward to being at home with her family as temporary caregivers.
-Together, patient and family decide to try a healthy diet and buy a new cookbook.
– Patient met with a Reach to Recovery volunteer, who brought her a temporary prosthesis and booklets about post mastectomy exercises, chemotherapy, and breast reconstruction. The volunteer also referred her to a local breast cancer support group.
-Patient has talked about her concerns related to breast reconstruction.
-Patient pain has stay 2/10 in pain scale.
– Patient shows better more and is interested in learning skills to take her of herself.
-Patient had an improved of 10 % of body weight.
Cushing Syndrome.
Assessment:
The Assessment will focus on the effects on the body of high concentrations of adrenal cortex in respond to changes in cortisol and aldosterone levels.
Health history: The history includes information about the patient’s level of activity and ability to carry out routine and self-care activities.
Physical exam: The skin is observed and assessed for trauma, infection, breakdown, bruising, and edema. Others are:
– Skin fragile.
– Truncal obesity with small arms.
– Rounded face (appears like moon).
– Reproductive issues amenorrhea and ED in male (due to adrenal cortex’s role in secreting sex hormones).
– Ecchymosis
– Elevated blood pressure.
-Striae on the extremities and abdomen (Purplish).
– Sugar extremely high (hyperglycemia).
-Excessive body hair especially in women and Hirsutism (women starting to have male characteristics).
-Electrolytes imbalance: hypokalemia.
– Dorsocervical fat pad (Buffalo hump).
Mental function: The nurse assesses the patient’s mental function including mood, responses to questions, awareness of environment, and level of depression.
Diagnosis
1- Risk for infection related to impaired immune response.
2-Disturbed body image related to altered physical appearance, impaired sexual functioning, and decreased activity level as evidence by change in social behavior and refusal to discuss or acknowledge being.
3-Disturbed thought processes related chemical changes in the brain from high cortisol as evidence by to mood swings, irritability, and depression.
Planning.
– The client will identify interventions to prevent risk for infection.
-The client will display an absence of infection as evidenced by normal body temperature and normal white blood cell count.
-The client will verbalize feelings about the changes in appearance, sexual function and activity level.
-The client will demonstrate enhanced body image and self-esteem as evidenced by ability to look at, touch, talk about, and care for actual and perceived altered body parts and functions.
-The client will exhibit normal thought process and improve mentation
Implementation:
– The nurse will assess frequently for subtle signs of infections
– The nurse will avoid unnecessary exposure to people with infections.
– The nurse will strict medical and surgical asepsis when providing care.
– The nurse will stress proper hand washing techniques
– The nurse will assess for any changes in personal appearance caused by the cortisol excess.
– The nurse will reassure the client that the physical changes are a result of the elevated hormone levels and most will resolve when those levels return to normal
– The nurse will encourage the client to verbalize feelings about the body image changes
– The nurse will promote coping methods to deal with the client’s change in appearance
– The nurse will explain to client and family the cause of emotional instability.
– The nurse will encourage client to discuss feelings and concerns.
– The nurse will provide a positive and caring environment for the client.
– The nurse will repeat instructions as necessary using clear, simple language and short sentences.
Evaluation:
Expected patient outcomes may include the following:
– Decrease risk of injury.
– Decrease risk of infection.
– Increase ability to carry out self-care activities.
– Improve skin integrity.
– Improve body image.
– Improve mental function
References
American Cancer Society. Breast Cancer. 2013. www.cancer.org/cancer/breastcancer/detailedguide/index. Accessed November 22, 2018.
Dirksen, S. R., Lewis, S. M., Heitkemper, M. M., Bucher, L., & Lewis, S. M. (2014). Clinical companion to Medical-surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Elsevier.
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Mosby, an imprint of Elsevier.
Mary A. Nies, Mary A., McEwen, Melanie (2015). Community/Public Health Nursing. Promoting the Health of the Populations. (6th ed).
