2.9 Spotlight Application

Client Profile:

• Name: Sarah Johnson
• Age: 45 years old
• Gender: Female
• Occupation: Office Manager
• Medical History: Hypertension, Obesity (BMI 32), Prediabetes, Family history of heart disease

Presenting Problem: Sarah Johnson, a 45-year-old office manager, presents to the clinic with complaints of frequent headaches, fatigue, and difficulty concentrating. She shares she has been feeling stress with recent staff turnover in the office. She has also been experiencing shortness of breath while climbing stairs and feels generally unwell. Sarah’s vital signs on admission reveal an elevated blood pressure of 150/90 mmHg.

Clinical Judgment Measurement Model

• Recognizing Cues: The nurse observes the client’s elevated blood pressure and identifies her symptoms of headaches, fatigue, difficulty concentrating, and shortness of breath as potential signs of an underlying health issue. The nurse also notes Sarah’s report of increased stress levels.
• Analyzing Cues: The nurse interprets these findings in the context of Sarah’s medical history, including her hypertension, obesity, prediabetes, and family history of heart disease.
• Prioritizing Hypotheses: The nurse recognizes that these risk factors suggest a need for further assessment and intervention. Priority problems include ineffective health maintenance, including risk for cardiovascular disease and imbalanced nutrition.
• Generate Solutions: The nurse plans health teaching for addressing Sarah’s specific modifiable risk factors and how she can manage them to reduce her risk for disease (diet, exercise, stress management).
  • The nurse establishes SMART outcomes such as:
    • The client will identify three stress management techniques they are willing to implement by the end of the teaching session.
    • The client will accurately describe how to make a meal plan using the MyPlate model by the end of the teaching session.
    • Within four weeks, the client will regularly participate in 150 minutes of moderate level exercise a week.

• Take Action: The nurse provides health teaching on diet, exercise, and stress management and consults with a dietician to develop a nutrition plan.
• Evaluate Outcomes: The nurse assesses to determine if the client has achieved the established SMART outcomes by the time frames indicated.

The nurse also uses the nursing process to perform a comprehensive assessment, provide health teaching on healthy lifestyle choices, and collaborate with the health care team to develop a care plan tailored to her needs.

Nursing Process

• Assessment:
  • Physical Assessment:
    • Blood pressure measurement reveals hypertension.
    • Calculation of BMI confirms obesity.
    • Examination of general appearance indicates fatigue.

• • Psychosocial Assessment:
    • Explore Sarah’s stressors related to her job and personal life.
    • Assess her social support system and coping mechanisms.

• • Health History:
    • Gather detailed information about Sarah’s dietary habits, physical activity, and sleep patterns.
    • Review her current medications and adherence to prescribed treatments.

• Diagnosis: Based on the assessment findings, the nurse identifies the following nursing diagnoses:
  • Ineffective Health Management related to lack of knowledge and motivation.
  • Risk for Unstable Blood Pressure related to hypertension, obesity, and family history.
  • Imbalanced Nutrition: More Than Body Requirements related to poor dietary choices.
  • Ineffective Coping related to high stress levels.
  • Knowledge Deficit related to risks of uncontrolled hypertension

• Outcome Identification: The nurse establishes SMART outcomes in collaboration with Sarah, considering her cultural beliefs, values, and preferences, as described under the “Generate Solutions” bullet of the previous “Clinical Judgment Measurement Model” subsection:
  • The client will identify three stress management techniques they are willing to implement by the end of the teaching session.
  • The client will accurately describe how to make a meal plan using the MyPlate model by the end of the teaching session.
  • Within four weeks, the client will regularly participate in 150 minutes of moderate level exercise a week.

• Planning: Collaborative goals and interventions are established with Sarah and the health care team:
  • • Health Promotion: Teach Sarah about the importance of a balanced diet, regular exercise, and stress management.
    • Blood Pressure Control: Collaborate with the physician to adjust medications and recommend lifestyle modifications.
    • Dietary Improvement: Refer Sarah to a dietician for a personalized nutrition plan.
    • Stress Reduction: Suggest stress-reduction techniques such as mindfulness and relaxation exercises.
    • Follow-Up: Schedule regular follow-up appointments to monitor progress and adjust interventions as needed.

• Implementation: The nurse implements the following interventions:
  • • Provides health teaching on healthy eating, portion control, and the DASH (Dietary Approaches to Stop Hypertension) diet.
    • Reinforces teaching regarding diet developed by the dietician.
    • Assists Sarah in setting achievable exercise goals and recommends a local fitness program.
    • Teaches stress-reduction techniques and suggests resources for counseling if needed.
    • Works with the health care team to adjust medications and monitor blood pressure regularly.

• Evaluation: The nurse assesses Sarah’s progress toward the established SMART goals during regular follow-up appointments and finds:
  • The client will identify three stress management techniques they are willing to implement by the end of the teaching session: MET. Sarah is participating in meditation and journaling and seeking counseling.
  • The client will accurately describe how to make a meal plan using the MyPlate model by the end of the teaching session: MET. Sarah accurately describes making a meal plan using the MyPlate model.
  • Within four weeks, the client will regularly participate in 150 minutes of moderate level exercise a week. PARTIALLY MET, progressing toward goal. Sarah is regularly participating in 120 minutes of exercise per week after four weeks. Sarah reports a transportation barrier to the gym on the weekends. An alternative walking plan on weekends is established.

• Additional assessment reveals Sarah has also achieved:
  • Improved blood pressure control within the recommended range.
  • Weight reduction as per the BMI chart.
  • Reported reduced fatigue and improved concentration

Using the Clinical Judgment Measurement Model and the nursing process, the nurse identified the client’s health issues, developed a comprehensive care plan, and evaluated the outcomes. Sarah Johnson is on her way to making healthier lifestyle choices, reducing her risk of cardiovascular disease, and improving her overall well-being. Regular follow-up and ongoing support will be crucial to maintaining her progress and preventing future health complications.