Mrs. Smith is an 88- year-old female who lives alone in her home. She walks with a walker. Last night Mrs. Smith needed to go to the bathroom. She got out of her bed and walked to the bathroom without using her walker. In the morning her daughter came to the house to check up on her. She found her mom on the bathroom floor. She called the ambulance and her mom was taken to the emergency room. In the emergency room, the patient states, “she lost her balance in the bathroom when she was washing her hands and fell to the floor.” According to the daughter, her mom has lost her balance many times but never fell. She doesn’t always use her walker in the house. Her daughter also states, “She needs help getting dressed, taking a shower and making her meals.” Mrs. Smith states her pain is an 8 out of 10 on numeric scale of 0 to 10. She also states the pain constant, worse with movement, and radiates down her leg. Her legs feel weak. The nurse performs an assessment on the patient. She is unable to stand in and apply weight to her legs. The patient is weak in the upper extremities and lower extremities. She is unable to lift her legs off the bed. She is unable to turn from on her side without assistance. She is unable to pull her body up in the bed.
- What subjective data and objective data do you notice in this case study? Please list the subjective and objective data.
- Cluster the data together that is similar and explain the significance of the data.
- Analyze the data by applying Maslow’s Hierarchy of Need? Why is this data significant?
- Create three nursing diagnoses for this patient. Problem- focused nursing diagnosis has three components: Problem, Etiology and Symptoms). What are some reasons you choose each nursing diagnosis?
- List three outcomes for each nursing diagnosis. Outcomes must be specific, measurable, attainable, realistic and timed.
- What nursing actions are you going to choose for each nursing diagnosis? Please think about the patient holistically. This should be a fairly comprehensive list. Include all necessary interventions related to each nursing diagnosis, must be measurable and specific. Provide rationales for each intervention.