Nursing Diagnosis case study
A 21-year-old woman presents to your practice with a number of complaints that have become increasingly problematic over the last several weeks. This patient is new to your practice. She has been having frequent headaches, has been having increasing difficulty getting out of bed in the morning, and feels that “something is terribly wrong” with her. She has gained more than 5 lbs. in the past month, which also upsets her. She thinks she has a thyroid problem. Her energy level is low and she has not enjoyed her usual activities for over a month. However, concurrently she has noticed feelings of anxiety when she leaves her house.
CC: “There is a history of thyroid problems in my family. I think that is what is wrong. And I need something for these headaches I keep having.”
Her physical exam is essentially normal except for the noted 5-lb. weight gain over the past month. Vital signs are all within normal limits. The patient seems rather distracted and has difficulty following directions in some situations.
- What other subjective and objective data may be important for you to gather to more effectively diagnose this patient’s problem/s? What other laboratory tests and/or imaging might be appropriate for this patient?
- What screening tools are available and how valid and reliable are they? Which ones would be important for you to use with this patient?
- How would you manage this patient (plan of care)? Would you treat her headaches?
- Identify some community resources available for the patient.
Is this your assignment or some part of it?
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