Reverse Case Study and Plan of Care for Sequoia Rain

Reverse Case Study and Plan of Care for Sequoia Rain Song Scenario Overview: Sequoia Rain Song, a 54-year-old Native American cisgender female, presents for an annual wellness visit. She has experienced weight gain, fatigue, and concerns about her energy levels. She works as a guide at a Native American heritage museum, earns minimum wage, and is expecting her first grandchild. Her current health issues include hypertension and occasional fatigue. Nursing Diagnoses: Ineffective health maintenance related to insufficient resources Ineffective peripheral tissue perfusion related to hypertension Activity intolerance related to fatigue 1. Individual’s Data Health History: Surgeries/Hospitalizations: No surgeries or hospitalizations mentioned. Illnesses: Weight gain, fatigue, and hypertension. No chronic illnesses explicitly noted. Medications: Current Medications: Not provided. It’s important to verify if she is on antihypertensive medications or any other treatments. Physical Assessment Findings: Vital Signs: BP 138/84 mmHg, HR 90 bpm, RR 20 breaths/min, Temp 37.7°C. BMI: 28 (overweight). Laboratory Results: Elevated LDL cholesterol (160 mg/dL), low HDL cholesterol (40 mg/dL), elevated creatinine (1.2 mg/dL), and ALT (48 units/L). Social Determinants of Health (SDOH) and Culture: Economic Stability: Minimum wage job may limit access to health resources and nutritious food. Healthcare Access: Regular wellness visits but limited details on preventive care (e.g., immunizations). Dietary Habits: Not specifically mentioned but could be contributing to weight gain and cholesterol issues. Support System: Widowed with two adult children; potential support but may face challenges related to her economic situation. Living Environment: Not specified; could impact overall well-being indirectly. Cultural Considerations: Cultural beliefs and practices may influence health behaviors and access to care. Health Literacy Needs: Understanding of hypertension management, cholesterol control, and impact of lifestyle changes on overall health. 2. Physiologic or Psychological Response Ineffective Health Maintenance Related to Insufficient Resources: Physiologic Response: Limited resources may result in poor management of chronic conditions, leading to worsening health. Psychological Response: Stress and anxiety about health management and financial constraints. Ineffective Peripheral Tissue Perfusion Related to Hypertension: Physiologic Response: High blood pressure can impair blood flow to tissues, increasing the risk of cardiovascular complications. Psychological Response: Concern about potential long-term effects of hypertension and its management. Activity Intolerance Related to Fatigue: Physiologic Response: Fatigue affects physical activity levels and can lead to further deconditioning and poor health. Psychological Response: Frustration and decreased motivation due to impact on job performance and daily life. 3. Evidence and Presenting Complaint Subjective Data: Weight Gain: Indicates potential metabolic or lifestyle issues. Fatigue: Impairs job performance and overall quality of life. Worry About Health: Concerned about health status and future responsibilities with the upcoming grandchild. Objective Data: Vital Signs: Elevated BP. Lab Results: High LDL, low HDL, slightly elevated creatinine and ALT. Physical Assessment: Overweight (BMI of 28). 4. Assessment Prioritization Medical Health History Findings: Elevated Blood Pressure (138/84 mmHg): Indicates the need for hypertension management. Social Health History: Economic Stability (Minimum Wage): May limit access to health resources and necessary medications. Physical Assessment: BMI of 28: Indicates overweight, contributing to hypertension and possible other health issues. 5. Interventions and Outcomes 1. Elevated Blood Pressure: Intervention: Initiate lifestyle modifications (dietary changes, increased physical activity) and consider antihypertensive medication if needed. Regular monitoring of BP. Outcome: Achieve BP < 130/80 mmHg within 6 months. 2. Economic Stability: Intervention: Refer Sequoia to a social worker for assistance with financial resources, community health programs, and support services. Outcome: Enhanced access to resources and improved ability to manage health conditions within 3 months. 3. BMI of 28: Intervention: Develop a weight management plan including nutritional counseling and an exercise program tailored to her ability. Outcome: Achieve a 5-10% reduction in body weight over 6 months. 4. Fatigue: Intervention: Evaluate potential causes of fatigue (e.g., anemia, sleep disorders) and recommend gradual increase in physical activity and stress management techniques. Outcome: Improved energy levels and job performance within 3 months. 5. Cholesterol Levels: Intervention: Implement dietary changes to reduce LDL cholesterol and increase HDL cholesterol; consider lipid-lowering medication if necessary. Outcome: LDL < 100 mg/dL and HDL > 60 mg/dL within 6 months. 6. Clinical Reasoning Nursing Theory: Orem’s Self-Care Deficit Theory can guide the approach to empower Sequoia in managing her health through education and support. Experience and Knowledge: Utilize evidence-based practices for managing hypertension, weight, and cholesterol. Clinical Guidelines: Follow recommendations from the American Heart Association and similar organizations for hypertension and lipid management. Screening Tools: Use tools like the Framingham Risk Score to assess cardiovascular risk and guide treatment. 7. Health Literacy Needs Impact: Ensuring Sequoia comprehends her health conditions, the importance of lifestyle changes, and how to utilize healthcare resources effectively is crucial for successful management. 8. Impact of SDOH Economic Stability: Financial limitations could impede access to necessary medications, healthy food, and regular healthcare. Healthcare Access: Limited financial resources may result in less frequent visits or delayed care, affecting overall health outcomes. 9. Incorporating the Individual into Care Planning Strategies: Engage Sequoia in goal-setting, provide culturally sensitive education, and involve her family for support and motivation. 10. Interprofessional Team Members Physicians: For hypertension and cholesterol management. Social Workers: To address financial and resource-related challenges. Dietitians: For nutritional counseling and weight management. Physical Therapists: To develop an appropriate exercise plan to improve physical activity and energy levels. Rationale: Each team member plays a critical role in addressing different aspects of Sequoia’s health and well-being, ensuring a comprehensive approach to care. 11. Communication Strategies for Holistic Care Strategies: Utilize interdisciplinary team meetings, shared electronic health records, and regular updates to keep all team members informed and coordinated. Rationale: Ensures integrated care and addresses all aspects of Sequoia’s health, promoting a holistic and patient-centered approach. References American Heart Association. (2023). Hypertension management guidelines. National Institute for Health and Care Excellence (NICE). (2023). Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. U.S. Preventive Services Task Force. (2023). Screening for hypertension in adults. Centers for Disease Control and Prevention (CDC). (2023). Health and economic costs of chronic diseases. Maughan, D. (2022). The impact of socioeconomic status on health outcomes. McDonald, M. (2022). The role of dietitians in managing cholesterol and weight. Williams, L. (2023). The importance of health literacy in chronic disease management. This plan aims to provide a comprehensive, culturally sensitive approach to managing Sequoia’s health, addressing both immediate and long-term needs while considering her socioeconomic and cultural context.

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