Chapter 4 (Nursing Process)

Box 4: Scenario C:

Subjective data:

“I am so short of breath.”

“My ankles are so swollen I have to wear my house slippers.”

“I am so tired and weak that I can’t get out of the house to shop for groceries.”

“I’m afraid to get out of bead because I get so dizzy.”

Objective data:

Bilateral basilar crackles in the lungs

Bilateral 2+ pitting edema of the ankles and feet

Increase weight of ten pounds in three weeks

Furosemide use (a medication that eliminates excess fluid from the body)

Serum potassium level of 3.4 mEq/L

Oxygen saturation 91% on room air

Respiratory rate 28 breaths per minute

Secondary data:

Daughter reports, “We are so worried about mom living at home by herself when she is so tired all the time!”

Care Plan Activity Answers:

The client, Mark S., is a 57-year-old male who was admitted to the hospital with “severe” abdominal pain that was unable to be managed in the Emergency Department. The physician has informed Mark that he will need to undergo some diagnostic tests. The tests are scheduled for the morning.

After receiving the news about his condition and the need for diagnostic tests, Mark begins to pace the floor. He continues to pace constantly. He keeps asking the nurse the same question (“How long will the tests take?”) about his tests over and over again. The client also remarked, “I’m so uptight I will never be able to sleep tonight.” The nurse observes that the client avoids eye contact during their interactions and that he continually fidgets with the call light. His eyes keep darting around the room. He appears tense and has a strained expression on his face. He states, “My mouth is so dry.” The nurse observes his vital signs to be Temperature 98 degrees F, Pulse 104, Respiratory Rate 30, and Blood Pressure 180/96. The nurse notes that his skin is diaphoretic and cool to the touch.

1. Group (cluster) the objective and subjective data.

Objective Data:

• 57 years old
• Paces the floor
• Avoids eye contact
• Fidgets with call light
• Eyes dart around room
• Temp 98 degrees F
• Pulse 104
• Blood pressure 180/96
• He is diaphoretic
• Skin is cool to touch
• Appears tense
• Strained expression on face

Subjective Data:

• Male
• Severe abdominal pain
• “I’m so uptight that I will never be able to sleep tonight.”
• “My mouth is so dry.”

*Note that “male” is subjective data in this case because the client identifies as a male and reports that he is a male. Without a clear definition, sex is what the client reports.

2. Create a problem-focused nursing diagnosis (hypothesis).

Anxiety related to need for diagnostic testing as manifested by increased heart rate, pacing the floor, avoiding eye contact, diaphoretic and cool to the touch skin, appearing tense, dry mouth, and states, “I’m so uptight I will never be able to sleep tonight.”

This is an actual nursing diagnosis because the client is experiencing and exhibiting symptoms of anxiety.

3. Develop a broad goal and identify an expected outcome in “SMART” format.

Goal: The client will have reduced anxiety.

Expected Outcome in SMART format: The client will verbalize effective coping mechanisms to decrease his feelings of anxiety in the next two hours.

4. Outline three interventions for the nursing diagnosis with associated rationale. Cite an evidence-based source.

Potential interventions include:

• Use a calm, reassuring approach.
• Explain all procedures, including sensations likely to be experienced during the procedure.
• Seek to understand the client’s perspective of a stressful situation.
• Provide factual information concerning diagnosis, treatment, and prognosis.
• Encourage verbalization of feelings, perceptions, and fears.
• Provide diversional activities geared toward the reduction of tension.
• Control stimuli, as appropriate, for client needs.
• Instruct the client on the use of relaxation techniques.
• Administer prescribed medications to reduce anxiety as appropriate.

Source: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 144-147.

5. Imagine that you implemented the interventions you identified. Evaluate the degree to which the expected outcome was achieved.

The client verbalized effective coping mechanisms to decrease anxiety in the next two hours. Outcome was met.

Answers to interactive elements are given within the interactive element.