NURSING PROCESS TEMPLATE: Assessment (Recognizing Cues) Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data. Analysis (Analyzing Cues) Which client conditions are consistent with the cues? Do the cues support a particular client condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? Subjective Data: • Jameela's report of feeling anxious for almost a year. ⚫ Difficulty sleeping and concentrating. • Increased feelings of irritability and fatigue. • Physical symptoms: nausea and diarrhea. • Persistent worries about work performance (forgetting clients) and health (diagnosis of cancer). • Reduced work hours due to anxiety Objective Data: • Age: 40s. Profession: Successful lawyer, indicating a high-stress occupation. • No notable medical history or trauma. Mental Health History: Duration of symptoms (almost one year). • Impact on daily functioning and work (cutting back hours). Most Important Client Data: Duration and persistence of anxiety symptoms. Physical symptoms that could indicate anxiety (nausea, diarrhea). Impact on occupational functioning (cutting back work hours). • Difficulty concentrating, which can affect job performance. Immediate Concerns: • The physical symptoms (nausea and diarrhea) may require further evaluation to rule out any underlying medical issues. The risk of worsening anxiety and its potential effects on Jameela's professional life and overall well-being. The possibility of anxiety leading to burnout or significant impairment in daily functioning. Consistent Client Conditions: • Jameela's symptoms are consistent with Generalized Anxiety Disorder (GAD), characterized by excessive worry about various aspects of life, including health and work performance. • The physical symptoms (nausea and diarrhea) can be associated with anxiety and stress responses. Supporting Cues for Client Condition: • Chronic anxiety over a year with physical manifestations supports a diagnosis of GAD. • Difficulty sleeping and concentrating aligns with common symptoms of anxiety disorders. • The occupational impairment indicates the severity of anxiety affecting her ability to function. Cues of Concern: Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most serious explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions. Planning (Generate Solutions) What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning-specific, measurable, attainable, realistic/relevant, time-restricted- Goal setting) Persistent worry about serious health issues (cancer diagnosis) raises the need for mental health support to address health-related anxiety. The increase in irritability and fatigue may suggest potential burnout or emotional exhaustion, which can affect both personal and professional life. Additional Information to Establish Significance: • A complete mental health assessment, including any history of anxiety or mood disorders in her family, could help clarify the situation. • Information about any coping mechanisms or strategies Jameela has tried, along with her social support system, would provide insight into her resilience and areas where she might need support. Lab tests to rule out other medical conditions that could be contributing to her physical symptoms. Generalized Anxiety Disorder (GAD) - Primary Diagnosis: o This condition manifests as excessive worry spanning multiple aspects of life, including health and work. Continuous symptoms lasting over six months and their associated functional impairments point to GAD being the leading explanation. ⚫Occupational Stress/Professional Burnout - Secondary Priority: 。 The demanding nature of her profession amplifies anxiety symptoms, with implications for her work-life balance and mental health. 。 Addressing workplace stressors and evaluating workloads is crucial to prevent further decline in mental health. Somatization of Anxiety - Tertiary Priority: 。 The physical symptoms are significant but largely seen as a byproduct of her anxiety. While these symptoms require attention, treatment focused on her anxiety is likely to alleviate them. Desirable Outcomes • Reduction in anxiety symptoms, enhancing overall life quality. Improved work performance and ability to manage professional responsibilities. • Resolution of physical symptoms associated with anxiety. • Interventions ⚫ Cognitive Behavioral Therapy (CBT): Focus on identifying and altering negative thought patterns that contribute to anxiety. • Lifestyle Modifications: Encourage regular physical activity, healthy eating, and sleep hygiene practices. • Relaxation Techniques: Introduce mindfulness, meditation, and breathing exercises to help manage panic and anxiety responses. • Medical Evaluation: Consider the use of medications, such as SSRIs, if symptoms remain severe or debilitating.

NURSING PROCESS TEMPLATE: Assessment (Recognizing Cues) Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data. Analysis (Analyzing Cues) Which client conditions are consistent with the cues? Do the cues support a particular client condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? Subjective Data: • Jameela's report of feeling anxious for almost a year. ⚫ Difficulty sleeping and concentrating. • Increased feelings of irritability and fatigue. • Physical symptoms: nausea and diarrhea. • Persistent worries about work performance (forgetting clients) and health (diagnosis of cancer). • Reduced work hours due to anxiety Objective Data: • Age: 40s. Profession: Successful lawyer, indicating a high-stress occupation. • No notable medical history or trauma. Mental Health History: Duration of symptoms (almost one year). • Impact on daily functioning and work (cutting back hours). Most Important Client Data: Duration and persistence of anxiety symptoms. Physical symptoms that could indicate anxiety (nausea, diarrhea). Impact on occupational functioning (cutting back work hours). • Difficulty concentrating, which can affect job performance. Immediate Concerns: • The physical symptoms (nausea and diarrhea) may require further evaluation to rule out any underlying medical issues. The risk of worsening anxiety and its potential effects on Jameela's professional life and overall well-being. The possibility of anxiety leading to burnout or significant impairment in daily functioning. Consistent Client Conditions: • Jameela's symptoms are consistent with Generalized Anxiety Disorder (GAD), characterized by excessive worry about various aspects of life, including health and work performance. • The physical symptoms (nausea and diarrhea) can be associated with anxiety and stress responses. Supporting Cues for Client Condition: • Chronic anxiety over a year with physical manifestations supports a diagnosis of GAD. • Difficulty sleeping and concentrating aligns with common symptoms of anxiety disorders. • The occupational impairment indicates the severity of anxiety affecting her ability to function. Cues of Concern: Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most serious explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions. Planning (Generate Solutions) What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning-specific, measurable, attainable, realistic/relevant, time-restricted- Goal setting) Persistent worry about serious health issues (cancer diagnosis) raises the need for mental health support to address health-related anxiety. The increase in irritability and fatigue may suggest potential burnout or emotional exhaustion, which can affect both personal and professional life. Additional Information to Establish Significance: • A complete mental health assessment, including any history of anxiety or mood disorders in her family, could help clarify the situation. • Information about any coping mechanisms or strategies Jameela has tried, along with her social support system, would provide insight into her resilience and areas where she might need support. Lab tests to rule out other medical conditions that could be contributing to her physical symptoms. Generalized Anxiety Disorder (GAD) - Primary Diagnosis: o This condition manifests as excessive worry spanning multiple aspects of life, including health and work. Continuous symptoms lasting over six months and their associated functional impairments point to GAD being the leading explanation. ⚫Occupational Stress/Professional Burnout - Secondary Priority: 。 The demanding nature of her profession amplifies anxiety symptoms, with implications for her work-life balance and mental health. 。 Addressing workplace stressors and evaluating workloads is crucial to prevent further decline in mental health. Somatization of Anxiety - Tertiary Priority: 。 The physical symptoms are significant but largely seen as a byproduct of her anxiety. While these symptoms require attention, treatment focused on her anxiety is likely to alleviate them. Desirable Outcomes • Reduction in anxiety symptoms, enhancing overall life quality. Improved work performance and ability to manage professional responsibilities. • Resolution of physical symptoms associated with anxiety. • Interventions ⚫ Cognitive Behavioral Therapy (CBT): Focus on identifying and altering negative thought patterns that contribute to anxiety. • Lifestyle Modifications: Encourage regular physical activity, healthy eating, and sleep hygiene practices. • Relaxation Techniques: Introduce mindfulness, meditation, and breathing exercises to help manage panic and anxiety responses. • Medical Evaluation: Consider the use of medications, such as SSRIs, if symptoms remain severe or debilitating.

Comprehensive Medical Assisting: Administrative and Clinical Competencies (MindTap Course List)

6th Edition

ISBN:9781305964792

Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Publisher:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Chapter5: The Therapeutic Approach To The Patient With A Life-threatening Illness

Section: Chapter Questions

Problem 6CR

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