The following is a paper that I wrote assessing a family, formulating nursing diagnoses and then using problem solving skills to develop a plan of care.

            The family that I decided to assess was a family of two. They live in the city limits of Murfreesboro. The family consists of a female, A.S., 25, and a male K.B., 31. The two are not married, but they plan on marriage as soon as they have the money. The house that they live in is a one story house that has siding and was built in the early 90’s. The houses that surround their home are all in good condition and were built in the late 80’s- early 90’s. The inside of the home was well furnished with furniture. The television was on when I arrived and the couple seemed to be watching a television show before I arrived. I saw a laptop in the living room and I also noticed the room was cool. The place was clean and neat. They had a small dog that stayed on the inside, and two larger dogs that stayed in the back lawn. The woman was well groomed, and seemed to be in good health. The man was slightly overweight, but he seemed to be in good health.

            The two assessment tools that I decided to assess the couple with were Beck’s Depression Inventory and Individual Spiritual Assessment. A.S. scored an 11 on the Beck Depression Inventory, which indicates mild mood disturbances. K.B. received a score of 4, which indicates that the ups and downs are normal. A.S. had more 1 and 2 responses on the depression scale than K.B. For example, she marked I don’t enjoy things the way I used to and I have greater difficulty in making decisions than before. The spiritual assessment was similar for the couple. Both of them have God as a source of spiritual strength. The only major difference in the spiritual assessments was A.S. attends church more frequently than K.B. Another assessment tool that I used assessed environmental risks. This assessment tool was called a Windshield Survey. The windshield survey assessed the couples’ neighborhood, and did not identify any micro- or macro environmental risks.

            The major health need I identified by assessing the couple with the Beck Depression Inventory and The Spiritual Assessment was depression management for A.S. I also observed that K.B. was slightly overweight, so I decided I needed to do healthy eating education for the couple.

The nursing diagnosis I formed after evaluating A.S. was situational low self-esteem related to recent unemployment as evidenced by verbalization that she is unemployed and can’t use her degree to get a job. The plan of care that I developed for A.S. was for depression management. I talked with her about what could be causing her high score on Beck’s Depression Inventory. She said that she had recently become unemployed, and that the degree she graduated with a year ago had been a waste of time because she can’t find a job. She also mentioned a couple of small arguments that the couple have about every week. After talking with her about the depression, I formed a plan of care I thought would help her. The plan of care consist of writing in a journal daily about thought and feeling to help identify any negativism in her life. I also told her to use positive self talk about her degree and unemployment. A Support services that I spoke to A.S about was The Guidance Center in Rutherford County. I told her she could call them if she ever thought she needed to talk with someone. However, sometimes there is a waiting list of patients, so I also talked with her about support groups that are available in Murfreesboro. The care plan that I formed for A.S. focused on tertiary prevention.

The nursing diagnosis that I formed for K.B. was altered nutrition: more than body requirements related to decreased activity and unhealthy eating as evidenced by sedentary lifestyle and observation of client being overweight. The plan of care that I developed for K.B. was for weight management. I first talked with him and asked him what he thought should be done for his weight. He mentioned the gym and eating healthy. He mentioned he does have a gym membership with Olympus. Considering the two concepts he addressed, I formed a plan that included going to the gym at least three times a week and doing cardiovascular exercises for at least 30 minutes each time. I assessed his knowledge on heart rate, and he understands how to calculate beats per minute. I also talked with him about healthy food choices, and referred him to the website MyPyramid.gov.  Support services that I spoke with K.B. about was the various websites that will help him make healthier food choices, such as MyPyramid.gov. The care plan I formed for K.B. focused on tertiary prevention.