Question

Case Scenario

C.R. is a 52-year old Hispanic, Spanish-speaking male who is newly-diagnosed with Hypertension (diagnosed 2 months ago). He presents to the ED with Hypertensive Crisis. C.R. is 65 inches and weights 280 lbs. BP is 195/120. Temperature is 37.2 C/98.9 F. Pulse is 70 beats per minute, respiratory rate is 20 breaths per minute. O2 saturation is 92%. Patient states, “I have a really bad headache, my vision is blurry and my chest hurts”. His wife is with him and tells the nurse she brought him to the ED because he was complaining of these symptoms and that he appeared very confused. He reports he has had a lot of nausea over the last 2 days and vomited 3 times; also has had decreased urinary output. Patient is currently A/O x 3 (alert/oriented to person, place, time & situation). Patient reports he has been working very hard this week at his job (patient is a janitor at a school and works 60 hrs/wk). Patient has no significant medical history. He had an appendectomy 10 years ago.

(Assessment) Gather your objective and subjective data from this case to interpret

1. Specify which data is objective and which is subjective
2. Which assessment data is pertinent to the overall plan of care?

(Nursing Diagnosis) 3. Formulate one appropriate nursing diagnosis (3 parts). Don’t forget to relate it to factors from your assessment, and provide evidence (i.e. related to, as evidenced by).

(Planning) 4.) Plan your nursing interventions/outcomes both long and short-term (include client education, community resources, etc.). Make your interventions/goals “realistic” and “measurable”

(Implementation) 5.) How will you implement your nursing interventions (how will you teach your client, do a learning styles assessment)? Don’t forget to assess his health literacy level.

(Evaluation) 6.) Evaluate whether they worked (patient is getting ready to be discharged, how will you evaluate whether your teachings worked, ex: Teach Back Method)?

Answer 1