As professional nurses, it is our responsibility to gather data for the health care team. It is often our role to present the data in an organized manner for the analysis and interpretation. Diagnostic reasoning is “the process of analyzing health data and drawing conclusions to identify diagnoses.” While it is not our role to determine medical diagnoses, it is our role to determine “the human response to actual or potential health problems and life processes” (Defining the knowledge of nursing and NANDA).
Often we are called to quickly cluster like data which leads to the identification of clinical problems and helps to focus on accurate solutions. It is through our assessment of patterns of signs and symptoms that we can prioritize our interventions and promote health in our patients.
Upon successful completion of this discussion, you will be able to:
Integrate nursing knowledge and evidence-based practice by the analysis of a clinical case study.
Implement effective communication with health team members.
Textbook: Physical Examination & Health Assessment
The Heart and Vascular System Assessment
File: Case Study Template
Review the case study below. Organize the data utilizing the Case Study Template.
Jane is a 69-year-old African American female presenting to her primary physician office. Jane complains of a “racing heart” and shortness of breath. Jane has a history of anxiety attacks, hypertension and hypercholesterolemia, gout and 4 ½ years ago had a two-vessel coronary bypass after suffering an anterior wall MI. She had a double mastectomy 2 years ago for breast cancer, stage 2 and completed radiation 1½ years ago. She states she has been having problems sleeping through the night for the past month and has been sleeping with 3 pillows; she has also been experiencing fatigue and weakness throughout the day and believes she may be gaining weight since her shoes and pants are getting tight. She says she will not go to the hospital since she is still paying from her last surgery.
The nurse notes her Temp is 98.6 F, Pulse is 94 (irregular), Resp 20, Denies pain. BP 125/80. Weight is 215 lbs (up 9 pounds since her last visit one month ago). She appears to be anxious and slightly diaphoretic. She is alert and oriented answering the phone throughout her assessment, asking her family and friends to pray for her as she is sure she is dying. Current medications: Allopurinol, Atorvastatin, Baby ASA, and clopidogrel. She states she stopped smoking when she had her “heart attack,” although when she gets anxious she may “sneak 1 or 2 cigarettes” but “no more than a pack a week.”
Review the rubric to make sure you understand the criteria for earning your grade.
In your textbook, Physical Examination & Health Assessment, read:
Chapter 20: Heart and Neck Vessels
Chapter 21: Peripheral Vascular and Lymphatic System
Chapter 11: Pain Assessment
Use the Case Study Template and prepare to discuss the following prompts:
What focused assessments would you perform on Jane? What cues are you looking for and why? (Utilize at least one scholarly reference for rationale.)
What problems would you deduce? What do you believe is happening to Jane? How severe is the problem? (Prioritize according to labels on page 5 of the text.)
Utilizing NANDA diagnostic labels, identify 3 nursing diagnoses.
Based on the data, develop 3 goals. (Goals must be SMART.)
What recommendations do you have? What are some probable interventions you would recommend based upon the assessment data and goals? Define the assessment data and evidence-based prior knowledge upon which you are basing your recommendations. (You must have at least 3 recommendations and use at least 2 scholarly references.)
Research and select at least two current scholarly sources to support your explanations and insights. Wikipedia is not permitted, as it is not a peer-reviewed, scholarly source.
Whether written or spoken, interactions are expected to:
clearly and thoroughly address the prompt with meaningful information that shows critical thinking.
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