Case StudyDiagnostic Analysis 284APPENDIX DIAGNOSTIC REASONING GUIDESI) Identify abnormal findings and client strengthsSubjective DataObjective Data2) Identify cue clusters3) Draw Inferences4) List possible nursing diagnoses5) Check for defining characteristics6) Confirm or rule out dlagnoses7) Document conclusionsNursing diagnoses that are appropriate for this client include:Potential collaborative problems inctude the following CHAPTER 6 ASSESSING MENTAL STATUS AND SUBSTANCE ABUSE33Activity G CASE STUDYRead the following case study. Then, work through the steps of analyzing the case study data. First identifyabnormal data and strengths in subjective and objective findings, assemble cue clusters, draw inferences, makepossible nursing diagnoses, identify defining characteristics, confirm or rule out the diagnoses, and documentyour conclusions. Use the blank diagnostic analysis charts provided at the end of this book (also available onthePoint website) to guide your thinking. Propose nursing diagnoses that are specific to the client in the casestudy. Identify collaborative problems, if any, for this client. Finally, identify data, if any, that point toward amedical problem requiring a referral.Mrs. Carroll, a 54-year-old, sixth grade mathematics teacher, comes to a wellness screening and expresses concernthat she has had difficulty recalling her students' names over the past semester. She also misplaces objects morefrequently than in the past. Both her memory and misplacing things are getting worse. She has no history ofstroke, meningitis, or head injury and no family history of Alzheimer's. Her brother had bipolar disorder. She isable to perform activities of daily living but it is getting more difficult to grade math papers at night. She tiresmore easily than in the past. She awakens two times a night but is able to return to sleep within 30 minutes. Shereports having a good appetite and a daily well-formed bowel movement. She is active in her church communityand walks 3 miles, four times a week. She enjoys quilting. Mrs. Carroll has positive relationships with her husbandand two daughters.Mental status: Alert and oriented to person, place, day, and time. Clean and neat appearance. Has directeye contact with pleasant cooperative disposition. Speech clear with moderate tone. Somewhat anxious overforgetting names and location of objects. Looking forward to retirement in 8 years. Ablein room. Expressed clear, realistic and logical thought processes about the past and future. Recalls breakfastand past dates of family member's birthdays. Repeated four unrelated words after 5 minutes, one word after10 minutes, unable to repeat any words after 12 minutes. Explained the meaning of common proverbs, explainedwhat she would do in an emergency situation in her classroom. Correctly drew the face of a clock. Scored 28 onthe Saint Louis University Mental Status (SLUMS) Examination.name familiar objects

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Subjective Data Objective Data 2) Identify cue clusters 3) Draw Inferences

Comprehensive Medical Assisting: Administrative and Clinical Competencies (MindTap Course List)

6th Edition

ISBN:9781305964792

Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Publisher:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Chapter5: The Therapeutic Approach To The Patient With A Life-threatening Illness

Section: Chapter Questions

Problem 5.1CS

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Plan, implement, and evaluate nursing care relatedto select nursing diagnoses for disturbances inself-concept.
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