On the basis of the following assessment information, work through the steps of analyzing the data

QUESTION

On the basis of the following assessment information, work through the steps of analyzing the data. 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 nursing diagnosis, and document your conclusions. Use the blank diag- nostic analysis charts provided at the end of this book to guide your thinking. You may want to write on the chart or use separate paper. Propose nursing diagnoses that are specific to the client in the case study. Identify collaborative problems, if any, for this client. Finally, identify data, if any, that point toward a medical problem requiring a referral. Mrs. Vera Wagner is a 60-year-old white woman who emigrated from Germany to the United States at the age of 18. She has come to her primary care physician’s office with her daughter. She tells you, “My daughter made me come here because I have had bad stomach pains for about 6 weeks.” After you ask about the character, onset, location, duration, severity, and pattern of the pain as well as associated symptoms (COLDSPA), such as what relieves the pain and what functions are affected by pain, you learn the following information. The pain is aching epigastric pain, fairly continuous, and worse at night. It radiates to her back when she lies down. The pain gets progressively worse, is not affected by eating, and interferes with her daily function (it prevented her from attending her grand- son’s birthday party; it also wakes her up at night). Additionally, Mrs. Wagner admits to loss of appetite, mild nausea, heartburn, and fatigue. For the past several months she has felt full soon after beginning a meal. She tells you that she was afraid to tell her doctor this because “He always says I worry too much.” A review of Mrs. Wagner’s chart discloses that she had four normal vaginal deliveries, several blad- der and kidney infections, a total abdominal hysterectomy at age 50 for uterine fibroids, cholecystec- tomy at age 55, two episodes of deep vein thrombosis in the past few years, allergy to penicillin, and stomach sensitivity to medicines (e.g., aspirin). Four years ago she had gastric endoscopy and upper gastrointestinal (GI) barium swallow studies for complaints of heartburn and difficulty swallowing. The results revealed delayed esophageal peristalsis. Mrs. Wagner takes estrogen and calcium daily (in the form of Tums) as recommended by her physi- cian as a source of hormone and calcium after surgical menopause. She tells you that she has recently started to take acetaminophen once—sometimes twice—daily in the hope that this will relieve her pain. She has had mild temporary relief as a result. Mrs. Wagner’s family history reveals that her mother died at age 58 from “liver problems after hav- ing half her stomach removed.” Mrs. Wagner says she does not smoke, drink, or use drugs. She says that she has eaten the same diet all her life. “I eat good German food, a lot of potatoes and meats. My children tell me I should eat more vegetables and drink more water, but I don’t like fruits and vegeta- bles and I’d rather drink coffee.” In response to your question about exercise, you learn that Mrs. Wagner walks to the post office every day, and “I pick up after my husband around the house—does that count?” You comment that Mrs. Wagner looks upset, and she tells you that she is very concerned about her pain. “I have always been strong and healthy, and now I am getting old and sick. It is depressing.” Your physical assessment reveals a firmly palpable left supraclavicular node, approximately 2 cm in diameter, nonmobile, and nontender, as well as the following abdominal findings: abdomen round and symmetric, hysterectomy scar, striae, umbilicus in the midline without inflammation or hernia- tion, slight midline pulsation in the epigastrium. Soft bowel sounds are heard in all four quadrants; no audible bruits. Generalized tympany percussed throughout; span of liver dullness is 13 cm over the MCL, splenic dullness at the 10th intercostal space (ICS), MAL. The abdomen is soft and tender to palpation in the epigastrium; the liver edge descends 2 cm below the right costal margin (RCM) on deep inspiration; no splenomegaly is noted. 1. Identify abnormal findings and client strengths ( subjective data and Objective data) 2. Identify cue clusters 3. Draw inferences 4. List possible nursing diagnoses 5. Check for defining characteristics 6. Confirm or rule out diagnoses 7. Documentation conclusion ( nursing diagnosis that are appropriate for this client and potential collaborative problems)

ANSWER

Abnormal Findings and Client Strengths

Abnormal Findings (Subjective Data):
Aching epigastric pain that is fairly continuous and worse at night.
Radiates to the back when lying down.
Progressively worsening pain not affected by eating.
Loss of appetite, mild nausea, heartburn, and fatigue.
Feeling full soon after beginning a meal.
Recently started taking acetaminophen for pain relief.

Abnormal Findings (Objective Data):
Firmly palpable left supraclavicular node, approximately 2 cm in diameter, nonmobile, and nontender.
Soft and tender epigastric region upon palpation.
Liver edge descends 2 cm below the right costal margin on deep inspiration.
No splenomegaly noted.

Client Strengths (Subjective Data and Objective Data):
No history of smoking, drinking, or drug use.
Daily physical activity (walking to the post office).
Takes estrogen and calcium daily as recommended by her physician.

Cue Clusters

Epigastric pain that worsens at night and radiates to the back.
Progressive worsening of pain not affected by eating.
Loss of appetite, mild nausea, heartburn, and fatigue.
Feeling full soon after starting a meal.
Recently started taking acetaminophen for pain relief.
Firmly palpable left supraclavicular node.
Soft and tender epigastric region.
Liver edge descends 2 cm below the right costal margin on deep inspiration.

 Inferences

The client’s presenting symptoms, such as aching epigastric pain, difficulty swallowing, loss of appetite, and fatigue, may indicate gastrointestinal issues or potential problems with the liver or other abdominal organs. The palpable supraclavicular node raises concerns about possible lymphatic involvement.

Possible Nursing Diagnoses

Acute Pain related to aching epigastric pain and radiating pain to the back.
Imbalanced Nutrition: Less than Body Requirements related to loss of appetite and feeling full soon after starting a meal.
Fatigue related to ongoing symptoms and sleep disturbance due to pain at night.
Anxiety related to the fear of worsening health and the recent diagnosis of abdominal issues.
Ineffective Coping related to the client’s feelings of depression and being “old and sick.”

Check for Defining Characteristics

For each nursing diagnosis, it is essential to check for defining characteristics or signs/symptoms that confirm the presence of the diagnosis. For example, for the nursing diagnosis of Acute Pain, the defining characteristics would include the client’s report of aching epigastric pain, radiating pain to the back, and worse pain at night.

Confirm or Rule Out Diagnoses

Further assessment and diagnostic tests may be needed to confirm or rule out specific nursing diagnoses. For example, laboratory tests, imaging studies, and additional history taking may be required to establish a definitive diagnosis.

Documentation Conclusion

Based on the data provided, potential nursing diagnoses for this client could include Acute Pain, Imbalanced Nutrition: Less than Body Requirements, Fatigue, Anxiety, and Ineffective Coping. Additionally, the palpable supraclavicular node and other abdominal findings warrant further investigation and may indicate a need for a medical referral to explore potential lymphatic or abdominal issues. Collaborative problems could also be identified based on further assessment and diagnostic findings. The documentation should be comprehensive and reflect the process of analyzing data to arrive at nursing diagnoses and potential collaborative issues.