Subjective and Objective findings
Read the following case study. Then, work through the steps of analyzing the case study data. First, identify abnormal data and strengths in subjective and objective findings, assemble cue clusters, draw inferences, make possible nursing diagnoses, identify defining characteristics, confirm or rule out the diagnosis, and document your conclusions. Use the Diagnostic Reasoning page to guide your thinking and document your work. Propose nursing diagnoses that are specific to the client in the case study. Identify collaborative problems for the client. Finally, identify data, if any, which point toward a medical problem requiring a referral.
This case study assignment requires you to critically think as you go through the steps of the nursing process. This assignment is worth 10% of your Physical Assessment Grade and is to be submitted online through D2L’s assignment drop box. A 10 point per day grade reduction will occur for late assignments. Assignments will not be accepted 6 days beyond the due date & a grade of zero will be obtained. Students are expected to work on this independently, this is not a group assignment.
Instructions for Diagnostic Reasoning Guide
Subjective & Objective Data: In this section you will identify & list all subjective (what the patient reports) and objective (the reported assessment) found in the case study.
Cue clusters: Look for patterns, several cues form a cluster. Cues can be obtained from subjective & objective data to create a cue cluster. Cue clusters are used to formulate accurate, patient-specific nursing diagnoses. You are grouping your data looking for patterns (cue clusters) to make an appropriate nursing diagnosis.
Ex: Patient reports feeling weak, you assess an unsteady gait. These cues “go together” to form a cue cluster (pattern) to help you identify “Alteration in mobility related to generalized weakness as evidence by an unsteady gait” as an appropriate nursing diagnosis. In this section you would write: weakness & unsteady gait, because they “go together.”
Inferences: Conclusions drawn from facts/evidence. This is when you analyze the data obtained and come to a conclusion on what you suspect is going on with the patient.
Possible Nursing Diagnoses: In this section you will list possible nursing diagnoses for the patient in the case study. Ex: Alteration in mobility related to weakness, Risk for falls related to weakness.
Defining Characteristics: In an actual nursing diagnosis the defining characteristics are the identified signs and symptoms of the client (the as evidence by). “Risk for” nursing diagnoses do not have evidence because the “actual” problem did not occur yet. For the nursing diagnosis identified above, “unsteady gait” would be the defining characteristics.
Confirm or Rule-out Diagnosis: In this section you will put together the possible diagnoses and defining characteristics that you identified. For example, you would write “Alteration in mobility related to muscle weakness as evidence by unsteady gait.” You will then look at each full nursing diagnosis that you created and prioritize which two you feel are most appropriate (confirm) and eliminate one (rule out).
Collaborative Problems: Collaborative problems differ from nursing diagnoses in that they cannot be prevented or treated by nursing care alone. However, the complications of medical conditions can be reported and monitored by the nurse. In addition, the nurse can carry out provider-driven/prescribed interventions. In this section you will identify collaborative problems for the identified patient in the case study. These problems will be worded as: Risk for complications (RC), followed by the problem. EX: RC: Pathological Fracture
Potential Referral: In this section you will identify who (what other healthcare member) you would need to contact regarding the identified collaborative problem. EX: Orthopedic Doctor
Risk-For Diagnosis: In this section you will identify one “risk for” nursing diagnosis that the identified patient in the case study is at high risk for (based upon analysis of all information you identified on the Diagnostic Reasoning Guide.
Theresa J. is a 55-year-old Caucasian woman. She is a part-time secretary for a local businessman and is very active in her community. She is married and has two children. She presents at the nursing clinic this morning with a complaint of extreme shortness of breath. When entering the exam room, she appears very anxious and states that she has experienced this problem since yesterday afternoon.
Theresa J. does not have a previous diagnosis of asthma, allergies, or respiratory problems, but her brother and father have mild asthma. The client has smoked for 35 years but reports limiting her smoking to a pack every 2-3 days for the past 10 years. Before that she reports having smoked a pack per day. She worked in her office yesterday and reports having felt fine. She met friends at a local park for lunch but denies anything unusual about her daily activity. She states that she has experienced “tightness in my chest” increasing in severity since about 5pm yesterday. She denies any other associated symptoms such as pain or cough. Her discomfort made sleeping difficult last night, and she states that she has not eaten today because of her shortness of breath.
Theresa J. currently does not take any medications. She reports not having a regular exercise program and denies intolerance to activity until the onset of dyspnea. She reports having tried only rest to alleviate the problem and knows “nothing else to do but go to the doctor.”
Theresa J’s respiratory rate is 26 breaths/min and appears somewhat labored. The client seems somewhat apprehensive and experiences obvious dyspnea on exertion. Her anteroposterior diameter is within normal limits. The use of accessory muscles is noted, with respiration immediately after exertion. Expiration is somewhat labored and prolonged. Tactile fremitus is decreased, especially in the lower lobes, Percussion tones are resonant over all lung fields. Breath sounds are decreased, with prolonged expiration. Voice sounds are also decreased. Expiratory wheezes are noted throughout the lung fields, especially bilaterally in the lower lobes.
DIAGNOSTIC REASONING GUIDE
1. Identify abnormal findings
Subjective: The patient, Theresa has come into clinic with a complaint of extreme shortness of breath. She has been experiencing this since the previous afternoon
2. Identify Cue Clusters
3. Draw Inferences
4. List Possible Nursing Diagnoses (Minimum of 4)
5. Identify Defining Characteristics
6. Confirm or Rule out Diagnoses (minimum of 3)
7. Nursing Diagnoses that are Appropriate for the Client (Minimum of 2, cannot be a risk for problem)
8. Potential Collaborative Problems that May Require a Referral (minimum of 2)
9. Potential Referral
10. Identify One “Risk-For” Nursing Diagnosis