Debbie’s Medical History: Diagnostic Analysis Essay

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According to Achterberg, Pot, Kerkstra and Ribbe (2006), a diagnostic analysis of Debbie’s medical history indicates five symptomatic factors or defining characteristics which demonstrate her nursing needs in the context of Watson’s theory of human care. Combining PES, NANDA, and NOC, and NIC diagnosis show that Debbie is addicted to smoking 2 packets of cigarettes a day, suffers constant abuse by her husband, is poorly educated, unemployed, lacks sustained income which is the direct cause of her poverty and nutritional problems, and has been diagnosed with c/o pelvis illness. Nursing is a career for preserving the dignity and wholeness of humanity with a mission to preserve and protect the wholeness of humanity (Achterberg, Pot, Kerkstra & Ribbe, 2006).

According to Achterberg et al, (2006), the PES (problems, etiology, and signs and symptoms) based on the defining characteristics of the problems indicate depression and nutritional problems. The etiological or causes of the problem include are depressive episodes, anhedonia, and her mood, which are the risk factors which underpin her suicidal symptoms. The PES and NANDA (Nursing Diagnosis: Definitions and Classification) show that the factors are related to the constant abuse by her husband. The symptoms include discharge of a watery fluid with a foul smell as evidenced from the worries about who will take care of her boys, which is a clear indication of the intention to commit suicide (Tomey & Elsevier, 2006). The next problem is the discomfort she is experiencing. According to the NIC (Nursing Interventions Classification), the etiological cause or evidence is the foul smell and her smoking history. The signs and symptoms include the vaginal discharge she is experiencing. The NANDA diagnoses for the problem are based on a list of approved nursing diagnoses, which in this case is the results of the papanicolaou smear, which indicate class V stage2 squamous cell carcinoma cervical cancer (Alligood et al., 2006). According to Watson’s theory of caring for the human being, there is evidence of poor nutrition which is caused by lack of a stable and sustained income, which calls for immediate intervention (Funnel, Koutoukidis & Lawrence, 2009).

The diathesis of the etiological factors and the symptoms reinforce the need to integrate NANDA’s Taxonomy II framework elements of health promotion, awareness, management into Debbie’s treatment, holistic management plan, transpersonal relationships and a caring moment which is based on structured reminiscence for the young lady. According to NANDA, this case requires a combination of risk, actual, and wellness diagnosis. The NIC (nursing interventions classification) and linking PES, NOC, NANDA, and NIC provides the nurse’s intervention based on the nursing knowledge include listening to the patient to include, giving encouragement, discussing parental care, encouraging the patient to cope, establishing a trusting relationship, monitoring the risk of suicide, and introducing milieu therapy for depression. The two nursing interventions and the evaluation methods are based on NOC (nursing outcomes classification) and NANDA, and include pain management, Analgesic administration, and heat/cold application.The outcomes will be evaluated using the Nursing Outcomes Classification (NOC) scale which is rated between five and one and the Hamilton Rating Scale for Depression. With the proposed treatment plan, a score of five shows a positive response and a score of one shows the need for further diagnosis and intervention for the patient (Shepherd, Weston, Peersman & Napuli, 1999).

References

Achterberg, W., Pot, A. M., Kerkstra, A. & Ribbe, M. (2006). Depressive symptoms in newly admitted nursing home residents. Int J Geriatr Psychiatry, 21(12):1156–1162.

Alligood, M. R., Tomey, A. M. & Elsevier, M (2006). Nursing Theory: Utilization & Application. Mosby Elsevier, New York.

Funnel, R., Koutoukidis, G. & Lawrence, K. (2009).Tabbner’s Nursing Care Theory and Practice 5E, Lusia Cacotti, New Zealand.

Shepherd, J., Weston, R., Peersman, G. & Napuli, I. Z. (1999). Interventions for encouraging sexual lifestyles and behaviours intended to prevent cervical cancer (Cochrane Review). In The Cochrane Library, 4 (1): 1-5.

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