Question

Mr. Robert Mason, an 81-year-old is a new admission from the local hospital to your long-term care facility. After Mr. Mason’s last bout with pneumonia and congestive heart failure, his wife of 59 years has decided that she is no longer able to care for him at home. Mrs. Mason states, “He has just gotten too weak and can’t help me care for him. I am so afraid he will fall and hurt himself. I am so worn out trying to care for him myself. I have to bathe him and remind him to eat; sometimes I’ve had to feed him myself or he won’t eat. He can be so forgetful. I hope I am making the right decision for him, because he never wanted to go into a nursing home.” From the database obtained at admission, you note that Mr. Mason’s medical diagnoses include early-onset dementia. You explain to Mr. and Mrs. Mason that you will be completing a comprehensive assessment to gather additional information to help establish a plan of care for Mr. Mason.

When you ask Mr. Mason to rate his current state of health, he responds, “My health is fair. I am doing just fine but I am being treated like I can’t take care of things”. Mr. Mason tells you that he used to work as a manager at the utility company. He retired 15 years ago. Now he likes to watch television to pass the time. He says he used to like reading the morning newspaper but “it seems like it’s just gotten too long to read”. When asked about his morning routine he says “I am just fine getting up and doing for myself. I don’t like it but my wife insists that she help me with my bath.” Mrs. Mason says, “He gets washed up on his own every morning and I give him a total bath once a week.” Mrs. Mason also verbalizes a concern that her husband is not eating enough because he leaves food on his plate at every meal. She says he has lost weight. Mr. Mason states, “I get enough to eat; you always put too much food on my plate.”

As you progress with the assessment, you note that Mr. Mason is sitting upright in a chair at his bedside. His facial expressions are appropriate to the conversation. He is aware of his surrounding but needs reminding that he is now at the long-term care facility and not still at the hospital. When Mr. Mason stands up you observe that his posture is slightly stooped forward. As he walks to the weigh scale, you observe his gait to be unsteady. His weight is 62.1 kg and his height is 1.9 meters. Your assessment of his vital signs reveals:

• Blood pressure (sitting): 160/86 right arm; 158/84 left arm
• Apical pulse: 86 beats per minute and regular
• Respirations: 24 per minute, regular and unlabored
• Oxygen saturation: 92% on room air
• Temperature (oral): 36.5° C

Apply clinical reasoning to critically think through the case study data to determine the priority needs of Mr. Mason so that a plan of nursing care can be developed.

a) Explain the difference between a cue and an inference; and the difference between subjective and objective data. Use the case study as a source for examples of each of the underlined terms and include these examples in your response.

b) Select a nursing diagnosis from Box 13-4 (Fundamentals textbook, p.198). that fits the case study database. Explain why you selected the diagnosis by presenting the clinical criteria and interpretation that help confirm the specific health problem is applicable to Mr. Mason.

c) Using a two-part format, state the nursing diagnosis that is applicable to Mr. Mason.

d) Refer to Table 14-2 (Fundamentals textbook, p. 216) and identify classes of nursing interventions that you would consider in developing the plan of care specific to the nursing diagnosis identified in part c).

e) Identify factors that should be considered when determining the specific interventions that should be implemented in the plan of nursing care to resolve Mr. Mason's problem and achieve the client-centered goal and expected outcome.

Answer 1

a) Explain the difference between a cue and an inference; and the difference between subjective and objective data. Use the case study as a source for examples of each of the underlined terms and include these examples in your response.

A cue is a fact (data). Cues are significant data that influence your conclusions about the client's health status or that influence the choice of nursing diagnoses. Inferences are conclusions (judgments, interpretations) that are based on the data.

Here in the present case study the cues are loss of memory, dependent on another person,too weak, and elevated blood pressure of 160/86 right arm; 158/84 left arm.

Inference is the patient have dementia and hypertension.

Objective patient data involves measurable facts and information like vital signs or the results of a physical examination.

In the case study objective data are elevated blood pressure of 160/86 right arm; 158/84 left arm, Loss of memory, too weak, lack of control over self care activities.

Subjective data means description of an event rather than from a physical examination. Based on or influenced by personal feelings, tastes, or opinions.

From the case study subjective data includes

The patient bystander said that “I have to bathe him and remind him to eat; sometimes I’ve had to feed him myself or he won’t eat. He can be so forgetful”.

b) Select a nursing diagnosis from Box 13-4 (Fundamentals textbook, p.198). that fits the case study database. Explain why you selected the diagnosis by presenting the clinical criteria and interpretation that help confirm the specific health problem is applicable to Mr. Mason.

The patient have the history of dementia, pneumonia and congestive cardiac failure. Hence the nursing diagnosis are

Dementia

• Risk for trauma related to disorientation or confusion.
• Risk for self-directed or other-directed violence related to delusional thinking.
• Chronic confusion related to alteration in structure/function of brain tissue.
• Self-care deficit related to cognitive impairment.
• Risk for falls related to cognitive impairment.

Pneumonia and congestive cardiac failure.

• Ineffective Airway Clearance related to pneumonia
• Impaired breathing pattern related to respiratory distress secondary to cardiac failure.

c) Using a two-part format, state the nursing diagnosis that is applicable to Mr. Mason.

• Self-care deficit related to cognitive impairment.
• Risk for falls related to cognitive impairment.
• Risk for trauma related to disorientation or confusion

d) Refer to Table 14-2 (Fundamentals textbook, p. 216) and identify classes of nursing interventions that you would consider in developing the plan of care specific to the nursing diagnosis identified in part c).

Self-care deficit related to cognitive impairment.

• Assess the patient’s strength to accomplish ADLs efficiently and cautiously on a daily basis using a proper assessment tool, such as the Functional Independence Measures
• Determine the specific cause of each deficit (e.g., visual problems, weakness, cognitive impairment).
• Consider the patient’s need for assistive devices
• Recognize choice for food, personal care items, and other things.
• Monitor impulsive behavior or actions indicative of altered judgment.

Risk for falls related to cognitive impairment.

• Assess the patient environmental factors that known to increase the risk for fall.
• For patients at risk for falls, provide signs or secure a wristband identification to remind healthcare providers to implement fall precaution behaviors.
• Move items used by the patient within easy reach, such as call light, urinal, water, and telephone.
• See to it that the beds are at the lowest possible position. If needed, set the patient’s sleeping surface as adjacent to the floor as possible.
• Provide heavy furniture that will not tip over when used as support when patient is ambulating. Make the primary path clear and as straight as possible. Avoid clutter on the floor surface.

Risk for trauma related to disorientation or confusion

• Assess patient’s behavior and cognition systematically and continually throughout the day and night as appropriate.
• Evaluate extent of impairment in orientation, attention span, ability to follow directions, send/receive communication, appropriateness of response.
• Orient patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result.
• Avoid/limit the use of restraints.

e) Identify factors that should be considered when determining the specific interventions that should be implemented in the plan of nursing care to resolve Mr. Mason's problem and achieve the client-centered goal and expected outcome.

The factors responsible for selecting the nursing interventions are the patient have loss memory and lack of ability to do the self care activities. He is so weak and high risk for fall.

The patient bystander verbalised that, “I have to bathe him and remind him to eat; sometimes I’ve had to feed him myself or he won’t eat. He can be so forgetful”.

These denotes that the patient have dementia. So by implementing these interventions it helps to achieve the desired outcome within expected time period.