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Questions for Case Study 1. List the subjective data? 2. List the objective data? 3. What Assessment Data from the objective
urpose: To review the nursing process and evaluate students ability to construct a nursing diagnosis Case Study: Mrs. Jean H
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Answer #1

1.Subjective data(verbalized by patient)

  • No appetite
  • Poor sleep on the night
  • Want to pray
  • Anxious

2.Objective data (observed and all simple procedures to diagnostic tests)

  • Tearful
  • Exhausted
  • Feeling sinful
  • Overweight
  • Surgical dressing
  • BP:146/86mmHg

3.Assessment

  • Anorexic
  • Inadequate sleep
  • Elevated blood pressure

4.Nursing Diagnosis intervention and outcomes

  • Anxiety related to disease condition as evidenced by verbalisation, elevated blood pressure,crying, inability to sleep,poor intake of food, disturbed thoughts regards spirituality
  • Intervention
    • Assess the patient knowledge regarding the disease condition, baseline information to plan for care
    • Support the patient psychologically by counseling, support therapy,social interaction, this helps to diver her mind
    • Inform disease may be due hereditary, life style,environment, diet ,etc., and find hope in God
    • Ensure that patient feels hope that her disease is not because of her any sinful activity in the past
    • Meet the patient's dietary requirements as this may lead to detoriating in patient's health
    • Provide calm and quite environment to encourage sleep
    • Provide warm sponge bath at bed time to enhance circulation and promote sleep
  • Outcome
    • Able to sleep adequately
    • Overcome her anxiety and trying to lead a quality life
    • Able to pray
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