Nursing Diagnosis Handbook - A Case Study Example

History of Present Condition

Elizabeth Wein is a 103-year-old patient is a Caucasian female was born in Cuthbert, GA on 2/17/1914. The patient was admitted on 10/31/2016 at St. Josephs hospital. Information is obtained from the patient as well as her chart indicates that she has had hypertension for three months. The patient stated that she has been experiencing severe headaches for the last one week, which prompted to the hospital on 2/25/2016.

Health Care Plan

Nursing Diagnosis, you identified for your patient:

Hypertension

Assessment Priority

Nursing Diagnose Goals/OutcomesList at least 2(Must be time-sensitive, measurable, & realistic) Interventionsr/tOutcomesAt least 2-3(Must be specific, realistic, and measurable) RationaleMust use APA format references for rationale Evaluation of Goal/Outcome(Met or Not Met. What might you change?)

Subjective data: Irregular heart beat

Objective data: patient has difficulty in breathing

Problem: hypertension

Related to: muscle weakness, severe headaches and swollen right leg.

AMB/AEB: Imbalanced nutrition The patient will:

1. The blood pressure will return to normal level after medication.

2. Report any changes in the patients heart rate. The nurse will:

1. Investigate the irregular heart rate of a patient and determine its cause.

2. The nurse will also take urine samples from the patient regularly.

3. Check the patient every three hours to determine whether blood pressure is reducing.

1. Regular inspection will ensure early identification of impending problems (Ackley & Ladwig, 2014).

2. A validated health assessment tool will be used to identify whether the patient is at risk of developing immobility related complications (Ackley & Ladwig,

2014)

1. The current nurse will continue with regular checkups.

2. Further tests to ensure there are no other complication that might compromise treatment of hypertension.

Health Care Plan 2

Assessment PriorityNursing Diagnose Goals/OutcomesList at least 2(Must be time-sensitive, measurable, & realistic) Interventionsr/tOutcomesAt least 2-3(Must be specific, realistic, and measurable) RationaleMust use APA format references for rationale Evaluation of Goal/Outcome(Met or Not Met. What might you change?)

Subjective data:

Lower back pain and in the legs.

Objective data: Resident has difficulty in mobility in lower extremities.

Problem: Spinal stenosis and CHF

Related to: muscle weakness at ankles due swollen feet

AMB/AEB: sciatic-like pain The patient will:

1. Report on whether the swollen right leg would shrink to its normal size.

2. Report whether pain reduces after medication or not. The nurse will:

1. Regularly check on the patients pain level.

2. Take weekly weight of the patient to ensure that she is not putting more.

3. Use a risk assessment tool to evaluate risk factors associated with immobility. 1. The cause of swollen feet should be checked before administration of appropriate interventions (Ackley & Ladwig, 2014).

1. Determining whether the patient will need corrective surgery

2. Ensure there is round the clock checkup of the patient by the original nurse who treated the patient.

Spinal stenosis and CHF

Reference

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed.). Maryland Heights, MO: Elsevier.