Purpose of the Assignment
1. Assist students in clustering assessment data when developing a nursing diagnosis.
2. Develop students’ ability to write client-based outcomes when planning care.
Course Competencies·
Explain components of multidimensional nursing care for clients with musculoskeletal disorders.
Instructions
Using the template below, write 3 NANDA-I approved nursing diagnoses in a proper format based on the client case provided below. Write one SMART client-centered goal for each nursing diagnosis. Consider the client’s medical history and medications.
Kacie Benson, a 19-year-old woman, is a client on your unit due to a skiing accident. She is unconscious and may or may not regain consciousness. She is on complete bedrest. She requires frequent repositioning to maintain correct body alignment and attention to her ROM. She responds to painful stimuli with slight non-purposeful withdrawal. No spontaneous movements are noted. The recent lower extremity ultrasound showed no evidence of venous thrombosis, and she continues on low molecular weight heparin injections. Her fluid and electrolyte balance is being maintained by a tube feeding at 60 mL per hour continuously. She is incontinent of stool and has an indwelling Foley catheter. Her heels are reddened, but otherwise, her skin is intact. Use at least two scholarly sources to support your nursing diagnoses.

Answer:

Complex

Explanation:

This is a very complex question

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A 59-year-old African American female is admitted at midnight with a diagnosis of Chest Pain. She complains of a squeezing type pain across her chest and into her left jaw area. Although she cannot remember exactly when the pain began, she does remember having indigestion and being nauseas after dinner the night before, around 7:30 p.m. Vital signs are: Blood Pressure-200/110; Pulse-128 beats per minute; Respirations- 26 per minute; Temperature-99.8; Saturation of Oxygen-86% on room air; pain level 9/10. During your initial assessment, she is rubbing her mid-chest, grimacing and is diaphoretic. The pain has been occurring intermittently throughout the evening and night. Her color is pale except around her lips which are bluish. Cardiac auscultation reveals a rapid regular rhythm. She has never had this pain before. Lungs sounds are crackles in both bases with clear upper lobes. She is afraid she is going to die. Per standing orders, a nurse administers Nitroglycerine 0.4mg sublingually; applies cardiac electrodes for continuous cardiac monitoring; obtains an electrocardiogram; places a peripheral intravenous catheter with saline lock; positions patient in low Fowlers.

On assessment one hour later, vital signs are Blood Pressure-180/95; Pulse-108 beats per minute; Respirations- 22 per minute; Temperature-99.0; Saturation of Oxygen-90% on 2 liters per minute; Pain level 8/10. She says her chest pain hasn’t changed. Heart and lung sounds are unchanged. Color is pale without previous blue changes. EKG displays ST elevation in leads II, III, and AVF. The MD has decided not to perform a cardiac catherization, and has admitted the patient to the ICU with a cardiology consult.

Required:
a. Is the type of pain this patient is having typical or atypical of cardiac type of chest pain?
b. What other types of pain would indicate a cardiac type problem but would not be specifically in the chest area?
c. Describe how women often present with cardiac problems and how they are different from men.
d. What health history information would the nurse assess for this patient?
e. What abnormals are present in the patient's vital signs (first set)?

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c) Battery

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replace worn out blood cells
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ОВ.
Crunches
OC. Yoga
OD.
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ОА. .
She should give only a small portion of her snacks to the dog.
ОВ.
She should mix her snacks in a soft drink for the dog.
Ос.
She should mix a few pieces of her snacks in the dog's feed.
OD. She should prevent the dog from eating any of her snacks.
O E. She should give the dog water after sharing the snacks.

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