Case Study:
Read the following case study. Then work through the steps of analyzing the case study data.
1. First identify subjective and objective findings;
2. Assemble cue clusters;
3. Make possible nursing diagnoses;
4. Identify defining characteristics;
5. Confirm or rule out the diagnoses; and
6. Document your conclusions.
Use the table below to collect subjective and objective data provided to guide you. 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, which point toward a medical problem requiring a referral.
Alice K. is a 50 year old divorced woman, with a medical diagnosis of carcinoma of the sphenoid sinus and nasal pharynx. She has been referred by the physician to the hospital's home health service for weekly skilled nursing visits by an RN. She lives in her own home and is currently being cared for by her younger sister. Alice has two grown sons. One son lives close by; the other lives in another state. Ms. K is currently being treated with radiation therapy, which she receives three times weekly. She states that she is experiencing some pain across the bridge of her nose (2 on a scale of 0 to 5, with 5 being the worst). She uses cold compresses to help relieve the pain. These small oral ulcers approximately 3 to 5 cm wide are noted on the left buccal mucosa. Ms. Kenedy reports that she has no difficulty swallowing, but the sores are painful when she eats, especially when she eats citrus fruits. She uses a soft-bristled tooth brush and brushes her teeth gently after eating, and she tries to avoid irritating food . The findings in the rest of the oral examination are within normal limits. The nasal examination reveals a slightly reddened color of the nose, with the tenderness noted across the bridge of the nose. There is no conclusion of either nostril. The nasal septum is intact, with no ulcers or perforations. The nasal mucosa is red and slightly swollen. Both frontal and maxillary sinuses transilluminate; the frontal sinus area is slight tender to palpitation. Ms. K's sister has taken over most of the housekeeping responsibilities. She says that she is currently able to keep up with everything but is concerned about she will be able to care for her sister as her condition worsens.
1.
subjective data:
objective data:
2. Assemble cue clusters
3. Make possible nursing diagnoses
4. Identify defining characteristics
5. Confirm or rule out the diagnoses
6. Document your conclusions