Question

M. J., a 26-yr-old single female, is admitted to the hospital with right lower quadrant pain...

M. J., a 26-yr-old single female, is admitted to the hospital with right lower quadrant pain rated as 8 on a scale of 0 to 10; 10 to 12 watery, blood-streaked stools in the past 24 hours; and a low-grade fever. she has a 7-yr history of inflammatory bowel disease.

subjective Data

patient relates the following:

  • she has been hospitalized four times in the past year.
  • she is not currently working because of the illness and has no income.
  • she has no health insurance.
  • her boyfriend has lived with her for 2 years.
  • she does not want her boyfriend to visit because she thinks he has enough problems of his own.
  • she has been in bed for the past week because of pain, weakness, nausea, and malaise and has been crying and is depressed.

Objective Data

  • Height: 5 ft in (168 cm)
  • weight: 104 Ib (47.3 kg)
  • Hemoglobin: 10.5 g/dL (105 g/L)
  • Hematocrit: 30 %
  • Temp: 100 F (37.8 C)

Discussion Question:

1. patient-centered care: Describe an approach that the nurse could use to assess M.J's perception of her situation. include several specific questions to be used by the nurse?

2. priority Decision: what are the priority nursing interventions that can be implemented for M.J to enhance hr adaptation to stress?

3.priority Decision: based on the assessment data provided, what is the priority nursing diagnosis? are there any collaborative problems?

4. priority Decision: what is the priority nursing diagnosis for M.J. on admission?

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Answer #1

1. Patient-centered care

The nurse could use an approach of

  • Respect M.J by addressing her values, preferences, and culture.
  • Provide physical comfort to M.J to adapt to the current situation.
  • Support her emotionally.
  • Try to involve friends or relatives to support her.
  • Provide coordination of care by involving all team member in clinical care.
  • Provide continuity of care to improve her wellness and outcome.

2. Priority Decision:

The priority nursing interventions that can be implemented for M.J to adapt to stress

  • Assess the level of stress and anxiety
  • Provide emotional support to the client.
  • Instruct the patient to adapt to the relaxation techniques.
  • Promote positive coping strategies.
  • Educate about various stress management techniques.

3. Priority Nursing Diagnosis:

Electrolyte imbalance related to watery stools as evidenced by the loss of fluids.

Collaborative problems related to this are hypovolemia, malnutrition, hyponatremia, poor appetite, fatigue, and shock. Further patient does not have health insurance or proper income to pay from her pocket.

4. Priority Nursing diagnosis on admission

Acute pain related to increased bowel movements as evidenced by pain scale, verbalization of patient.

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