Question

Read the scenario and complete the following: 1. any subjective and objective assessment data 2. Cluster the data 3. Formulate two (2) actual nursing diagnoses for this client A male client 68 years of age and was admitted to the aged care facility four days ago. He speaks little English. He refuses to take his medications and is spending a lot of time lying on his bed. When approached by a staff member he speaks rapidly and loudly. He has a reddened area at the base of his spine and his right elbow. He is overweight, has mild right-sided weakness from a stroke (Cerebral Vascular Accident - CVA), mobilizes independently with a cane and has a history of severe -sided shoulder pain. He has had no bowel movement since entering the facility

Answer 1

Subjective data:

• Right side weakness
• shoulder pain
• No bowel movement ×4 days

Objective data

• Anxious (speaking loudly and rapidly)
• Redenned area at the base of sound and elbow
• Refusing nature
• Lying on bed
• Obese

The patient seems to have constipation, risk for pressure ulcer,pain

Nursing diagnosis

• Chronic pain(in shoulder) related to disease condition as evidenced by verbalisation
• Impaired bowel movement related to oldage ,stress factor ,ne environment as evidenced by not passing stool since admission