Question

h please i need help for this care plan. here is the scenario:Mary is a 60-year-old...

h please i need help for this care plan.

here is the scenario:Mary is a 60-year-old divorced Caucasian female who comes to the Valley View Therapy Center today with complaints of memory loss, insomnia, general fatigue. She was recently asked to “retire” in a company downsizing after having worked there for 30 years. Initially, she found retirement stimulating, but lately she’s been feeling, “not herself” with trouble sleeping, increased back pain, increased alcohol use and difficulty concentrating. She has been referred to this clinic by her primary provider, Dr. West for a full evaluation of her symptoms. Can you help Mary?

what will be , the subjective data, the objective data,the Medical diagnosis, the nursing diagnosis, the priority and the outcomes

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Answer #1

Subjective data:

The complaints verbalised by patient are

  • Memory loss
  • Insomnia
  • Fatigue
  • Back pain

Objective data:

The information collected from observing the patients are

  • Difficulty in concentrating
  • Alcohol use
  • Grimace of patient in pain

Medical diagnosis

  • Retirement syndrome
  • Depression

Nursing diagnosis

  • Ineffective sleeping pattern related to depression as evidenced by poor sleep,fatigue
  • Risk for self harm ,abuse related to Increased alcohol intake
  • Impaired memory related to the disease process as evidenced by difficulty in concentrating
  • Acute pain in the back related to poor self care

Priority care

  • to relieve pain and comfort the patient
  • Do a MSE to get the baseline data to provide care
  • Administer medication for sleep,pain
  • Provide psychotherapy to treat substance abuse
  • Provide cognitive therapy to regain concentration in daily work
  • Health educate about the general ageing process and their role in each stage to come out of depressed state
  • Provide motivational session
  • Envourge yo have a good nutritious dirt to get red of fatigue

Outcome

  • She should be able to concentrate on things and remember things
  • Pain should be relieved
  • Able to have a good sleep pattern
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