Coping-Stress tolerance pattern case study - need help with that

I can't give you any opinions if you don't post any of your diagnoses, outcomes/goals and interventions. I need to see your interventions in order to tell if your goals are appropriate.

when care planning the first thing that must be done is an assessment. assessment consists of:

• a health history (review of systems)
  
• performing a physical exam
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition
  
• reviewing the signs, symptoms and side effects of the medications they are taking
  

with a scenario the assessment information has been supplied for you and for this particular one some things need to be extracted. this patient is diabetic, had a bk amputation (complication of the diabetes?) and the scenario seems very intent on wanting you to think he was drunk on the first visit. since the scenario also clearly mentions that the patient is a native american, i think that is an important piece of assessment information.

ineffective coping related to vulnerability secondary to amputation as evidence by substance abuse, inability to cope with the current situation.

but then, i see this. . .subjective data * pt states his leg hurts * pt uses herbal potions on his leg

objective data * 55 year old male * diabetic * native american * left below knee amputation performed 10 days ago * pt is stressed * pt has difficulties with accepting his current situation.

• substance abuse
  
  
• inability to cope with the current situation - restatement of the nursing diagnosis and not evidence
  
  

outcome and goals

*pt will accept his situation by time his wound heal.

*pt will accept the assistance provided by the nurse at the end of her visit.

nurse interventions

* will provide informations about the treatment, and prognosis.

* will provide an atmosphere of acceptance

* will appraise adjustment to change in body image

* will encourage the patient with behavior change,

* will encourage the patient to be more assertive in providing care to his amputated leg.

* will discuss the problem of alcohol abuse,

rationale for nursing interventions - none of these are appropriate rationales (reasons) for why you are performing the specific nursing interventions.

* pt doesn't demonstrate cooperating with the nurse,

* pt doesn't verbalize acceptance of his situation,

* pt doesn't let the nurse to do the dressing on his leg

outcomes not met

* pt refuses the assassinate in dressing change on his leg - no relevance to this diagnosis

* pt states, he doesn't need any help.

i would construct this diagnosis differently and use different evidence to prove it's existence: ineffective coping r/t disturbance in pattern of tension release and inadequate level of control aeb became angry when talked to about following a diabetic menu plan and began shouting that he doesn't need anyone coming to see him.

outcome: client will answer visiting nurses questions without becoming angry and asking her to leave.

goal: client will talk calmly about how he has been dealing with his current dietary situation.

interventions:

• ask the patient what he does to relieve his tension when he feels stressed
  
  • rationale: having the patient describe what works effectively helps him to use previous experience in adapting to present situations.
    

  [*]assess current ability to deal with stressors and persons available to help in his life

  • rationale: data collection is necessary to formulation of a plan of action.
    

  [*]note what specific subjects triggers patient to angry outbursts and avoid these topics.

  • rationale: identifying triggers help to target areas where skills are weakest.
    

  [*]use active listening and therapeutic communication skills to talk with patient about his diabetes, diet and amputation wound.

  • rationale: a safe environment provides the client with opportunities to open up and reveal information.
    

  [*]refer the patient to social services, if appropriate.

  • rationale: nurses are managers of patient care and provide a link between the client and other services that are needed.