Introduction
The patient was a 30-year-old married woman with two children. The patients complained of dizziness, night sweats, and feeling tired. The patient does not smoke or use tobacco.
Gathering Data
General Overall Health State
The patients reported having gained 45 pounds during her pregnancy. She noted after her pregnancy 8 months ago she joined a fitness club where she works out twice a week and has managed to lose 5 pounds. She currently takes Rozerem on self-medication to curb fatigue. She is concerned with her condition of night sweats and fatigue, which she notes have been increasing.
Skin
The skin had blotches and blemishes. The skin on the feet was dry and had begun cracking. Since she is a light skinned person, her legs skin color turns pale blue whenever she exposes herself to the sun. She says she does not fail to use sunscreen.
Hair and Nails
The patient states that her nails feel nimble, especially. She had no problem with her hair, which she notes is still curly. Her SpO2 is 87 percent today.
Head
The patient has no history of head injury but reports mild headaches, which disappear after taking fatigue drugs or painkillers. The patients reported that she experiences memory loss and has in the recent occasion experienced difficulty in concentrating in complex activities.
Eyes
The patient's eyes are normal. The patients did not notice any changes in her eyes, such as blurred vision, redness, itchiness, and discharge. The patient's vision is 20/20.
Ear, Nose, Sinuses, Mouth, Throat, and Neck
The patient reported that she has recently stopped taking antibiotics to treat sinusitis, which had risen due to a cold. She reports that she no longer has a running nose and feels no discomfort. Though her throat is mildly sore, she does not have a hoarse voice. She states that she has no toothache and visits a dentist twice in the past 8 months. She states that she only had a stiff neck last week, which faded off by midday, which she attributes to a poor sleeping style that night.
Breast
The patients said that she did not experience breast pain and have breasts have not shown any abnormal signs. She noted that cancer does not run in her family, and they have had very few cases. She notes that in a recent free clinic by the local hospital, she underwent a breast cancer screening and was found to be okay.
Respiratory System
The patient has never been diagnosed with lung illnesses but notes that shortness of breath only occurs during exercise sessions.
Cardiovascular System
The patients noted that when she fills fatigued or dizzy, she experiences increased heartbeat. This shows an idiopathic heart pain and beating.
Peripheral Vascular System
The patients felt cold and in the hands and feet. She says that she often feels numb at the time but at the present moment did not feel the same. The patients also feel some tingling in the hands and feet.
Gastrointestinal System
The patient complained of irregular abdominal pain and diarrhea. The patient further stated she had had constipation and cramping and that her stool was bloody. She noted that she had developed hemorrhoids which disappeared by themselves after a week.
Urinary System
The patient reported experiencing a strong and frequent urge to urinate. Moreover, she notes that she sometimes has a burning sensation when urinating. The patient does notes that the smell of her urine has not changed. The patient noted that she had been treated of UTI during her second pregnancy and drinks a lot of water to avoid a second recurrence.
Female Genital System
The patient experience abnormal menstruation in that at times she period is lighter, and sometimes it is heavier. She, however, did not report the absence of menstrual periods. She states that on several occasions, her menstruation has been accompanied by a brown discharge as well as a lower back and abdominal pain.
Musculoskeletal System
She reported feeling pain in the legs, feet, arms, and hands. She states that her cold feet and hands throb, especially when they start to feel warm. She noted that when sitting or standing for long periods, the pain in the legs worsens. The feeling of fatigue also come during such incidences. She notes that when she exercises, the feeling wears off for some time. She notes that her family has no history of arthritis, nor has she ever suffered from it.
Neurological System
The patients noted that she experiences mood swings and feelings of being depressed just like before. She states that those feelings haven't worsened. She notes that when occupied by exercises, these feelings disappear.
Hematological System
The patients noted that when she was pregnant, she was anemic. She states the showed similar signs of fatigue and dizziness and shortness of breath, which waned off after medication. She notes that the current fatigue is heavier than the one she reported at the time.
Endocrine System
The patient did not report any complaints that would show a problem in the endocrine system.
Summary of the Key Findings
The patient is a mother of two and has given birth in the recent past. She has had a number of medical histories such as being anemic, experienced a cold, UTI, and abnormal heartbeat. The patient currently experiences dizziness, night sweats, shortness of breath pale skin, tingling, numbness, and pain in the feet and hands. She also experiences inconsistency in her menstrual periods. She also has a problem with urinating. From the assessment, it is obvious that her participation in the fitness center helps improve her condition. The patient's decision to drink water to avoid recurrence of UTI is also well informed and shows her regard for her health.
Nursing Diagnosis and Health Promotion Plan
The patient has symptoms that are close to hypertension. However, this is discounted on the basis that he is actively involved in exercises (CDC, 2018). This means that she would complain of a sharp chest pain which she does not. Moreover, she reports having mild depression and which could also worsen heart problems which are not the case.
The symptoms show a disturbance in the circulation of blood. Poor circulation of the blood is associated with memory loss and difficulty in concentrating. Moreover, it is associated with numbness and cold feet as evidenced in persons with diabetes and among smokers. Dokken, (2008) whose research sought to examine cardiovascular diseases beyond blood pressure, notes that abdominal pain, diarrhea, fatigue, joint pain as well as difficulties associated with standing and sitting can be linked to problems in the circulation o blood. The patient is diabetic.
In order to promote her health, her plan would involve several steps. First is the fact that she seemed to have gained a lot of weight during her pregnancy, which she needs to lose. She should, therefore, increase her weekly exercises. Moreover, she should consider resting more. To avoid the one position effects of standing and sitting, she should take short walks or jogging sessions. She can also improve her blood circulation by taking a healthy diet such as nuts, green tea, vegetable, and fruits (Fisher-Titus, 2019).
Conclusion
The patient should consider taking up the health promotion plan of exercising and better diet. She should follow up with her physician to access her development. Moreover, if symptoms persist, she should consider taking advanced tests to prevent the condition from developing into a chronic, life-threatening complication.
References
CDC. (2018, October 2). Effects of High Blood Pressure. Retrieved from https://www.cdc.gov/bloodpressure/effects.htm
Dokken, B. B., (2008). The Pathophysiology of Cardiovascular Disease and Diabetes: Beyond Blood Pressure and Lipids. Diabetes Spectrum, 21(3), 160-165. doi:10.2337/diaspect.21.3.160
Fisher-Titus. (2019). Foods That Improve Circulation. Retrieved from https://www.fishertitus.org/health/foods-that-improve-circulation
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