Reference no: EM133197244

Sharon Higgins (Adult)

Patient presented to the office for a routine flu shot but became very agitated. Upon assessment, the patient looks very tired and has bags under her eyes. Made referral for RN to come speak to patient while patient is still in the office. Patient states she has been experiencing severe fatigue and seems very stressed. Patient is located in room 3 awaiting the RN.

Patient intake was conducted by LPN who brought to my attention the fact that the patient requires a more in-depth assessment. Patient is awake and alert. Assessment findings: No abnormalities with eyes, nose, mouth. Bilateral lungs are clear, heart rhythm regular. Gait steady, good circulation and strength to bilateral arms and legs. Per conversation with patient, she came into the office for her flu shot and became "a basket case" as she states she is very stressed from work and taking care of her family. She states that her mind races at nighttime and she is not able to sleep. She says she tries to sleep but just can't. She has been getting nauseous and hasn't been able to eat. She has tried taking naps but they make her feel worse. She says she tries to go to bed around midnight and gets up at 5am. In total she says she gets 2-3 hours but the quality of sleep is 1/10 on a scale of 1-10, with 10 being the best quality.

She is in charge of her family along with her husband. They have three children, 7, 9, and 11 who all have busy schedules. She states they have a master calendar to keep track of all the activities and events going on. She states her family tells her how to make things easier for her but no one steps into help her.

I suggested that she mark time off for herself on the master calendar but she was very adamant that "there simply isn't time for her to have time for herself and that's what moms do."

Question: 

 Use your critical thinking and nursing judgment to develop a concept map specifically for your patient using the following criteria (refer to the rubric in Canvas for specific requirements): 

1. Identify the medical sleep problem you think the patient is experiencing 

2. Identify a potential NANDA diagnosis that is appropriate for the patient 

3. Identify at least 3 risk factors that contribute to the medical and nursing problems identified 

4. Identify at least 3 signs/symptoms that are appropriate for the chosen medical and nursing problem 

5. Identify one (1) outcome that is: 

• • Patient-centered (makes sense for your patient)
• • _Measurable (can be easily measured; no ambiguous terms like increase/decrease) 
• • _Time limited (has a reasonable time frame) 

6. Identify at least 3 potential complications (i.e. what can the problem cause?) 

7. Identify at least 3 nursing interventions that move the patient towards achievement of the outcome