Case Scenario # 3
The history describes your patient as a 38-year-old married woman, the mother of two children in the sixth and eighth grades. She works full-time as a paralegal professional. Her past medical history is listed as a tonsillectomy at age 8 years and a urinary tract infection at age 14 years (none since then). She has sought healthcare at this clinic for the last 2 years and had a comprehensive assessment when she entered the system. Her husband says that she has been fatigued for the last 2 weeks and that she gets short of breath on exertion. The patient’s reason for seeking care is “stabbing chest pain on my right side when I take a deep breath or cough.” Her height is 67 inches (170.2 cm), weight is 160 lb (72.7 kg), and she is alert and oriented. Her vital signs are temperature 102.2ºF (39ºC), pulse 120 beats per minute and regular, respirations 32 per minute and regular, blood pressure 152/80 mm Hg. She is coughing up moderate amounts of thick, yellow sputum. A pleural friction rub is present.
1. Construct a list of which data presented in the situation are primary data and which are secondary data. Determine which data are subjective and which are objective.
2. Develop the order in which you would collect your assessment information about the patient.
3. Using a functional health, head-to-toe, or body systems framework, cluster the data into meaningful groups.
4. Select which data are of priority and which data are irrelevant at this time.
5. Determine if you are able to make a nursing diagnosis at this time. If yes, identify the diagnosis. If not, explain why.