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

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

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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Case Study

Diagnostic Analysis 

284 APPENDIX DIAGNOSTIC REASONING GUIDES I) Identify abnormal findings and client strengths Subjective Data Objective Data 2) Identify cue clusters 3) Draw Inferences 4) List possible nursing diagnoses 5) Check for defining characteristics 6) Confirm or rule out dlagnoses 7) Document conclusions Nursing diagnoses that are appropriate for this client include: Potential collaborative problems inctude the following
Transcribed Image Text:284 APPENDIX DIAGNOSTIC REASONING GUIDES I) Identify abnormal findings and client strengths Subjective Data Objective Data 2) Identify cue clusters 3) Draw Inferences 4) List possible nursing diagnoses 5) Check for defining characteristics 6) Confirm or rule out dlagnoses 7) Document conclusions Nursing diagnoses that are appropriate for this client include: Potential collaborative problems inctude the following
CHAPTER 6 ASSESSING MENTAL STATUS AND SUBSTANCE ABUSE 33 Activity G CASE STUDY Read the following case study. Then, work through the steps of analyzing the case study data. First identify abnormal data and strengths in subjective and objective findings, assemble cue clusters, draw inferences, make possible nursing diagnoses, identify defining characteristics, confirm or rule out the diagnoses, and document your conclusions. Use the blank diagnostic analysis charts provided at the end of this book (also available on thePoint website) to guide your thinking. 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, that point toward a medical problem requiring a referral. Mrs. Carroll, a 54-year-old, sixth grade mathematics teacher, comes to a wellness screening and expresses concern that she has had difficulty recalling her students' names over the past semester. She also misplaces objects more frequently than in the past. Both her memory and misplacing things are getting worse. She has no history of stroke, meningitis, or head injury and no family history of Alzheimer's. Her brother had bipolar disorder. She is able to perform activities of daily living but it is getting more difficult to grade math papers at night. She tires more easily than in the past. She awakens two times a night but is able to return to sleep within 30 minutes. She reports having a good appetite and a daily well-formed bowel movement. She is active in her church community and walks 3 miles, four times a week. She enjoys quilting. Mrs. Carroll has positive relationships with her husband and two daughters. Mental status: Alert and oriented to person, place, day, and time. Clean and neat appearance. Has direct eye contact with pleasant cooperative disposition. Speech clear with moderate tone. Somewhat anxious over forgetting names and location of objects. Looking forward to retirement in 8 years. Able in room. Expressed clear, realistic and logical thought processes about the past and future. Recalls breakfast and past dates of family member's birthdays. Repeated four unrelated words after 5 minutes, one word after 10 minutes, unable to repeat any words after 12 minutes. Explained the meaning of common proverbs, explained what she would do in an emergency situation in her classroom. Correctly drew the face of a clock. Scored 28 on the Saint Louis University Mental Status (SLUMS) Examination. name familiar objects
Transcribed Image Text:CHAPTER 6 ASSESSING MENTAL STATUS AND SUBSTANCE ABUSE 33 Activity G CASE STUDY Read the following case study. Then, work through the steps of analyzing the case study data. First identify abnormal data and strengths in subjective and objective findings, assemble cue clusters, draw inferences, make possible nursing diagnoses, identify defining characteristics, confirm or rule out the diagnoses, and document your conclusions. Use the blank diagnostic analysis charts provided at the end of this book (also available on thePoint website) to guide your thinking. 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, that point toward a medical problem requiring a referral. Mrs. Carroll, a 54-year-old, sixth grade mathematics teacher, comes to a wellness screening and expresses concern that she has had difficulty recalling her students' names over the past semester. She also misplaces objects more frequently than in the past. Both her memory and misplacing things are getting worse. She has no history of stroke, meningitis, or head injury and no family history of Alzheimer's. Her brother had bipolar disorder. She is able to perform activities of daily living but it is getting more difficult to grade math papers at night. She tires more easily than in the past. She awakens two times a night but is able to return to sleep within 30 minutes. She reports having a good appetite and a daily well-formed bowel movement. She is active in her church community and walks 3 miles, four times a week. She enjoys quilting. Mrs. Carroll has positive relationships with her husband and two daughters. Mental status: Alert and oriented to person, place, day, and time. Clean and neat appearance. Has direct eye contact with pleasant cooperative disposition. Speech clear with moderate tone. Somewhat anxious over forgetting names and location of objects. Looking forward to retirement in 8 years. Able in room. Expressed clear, realistic and logical thought processes about the past and future. Recalls breakfast and past dates of family member's birthdays. Repeated four unrelated words after 5 minutes, one word after 10 minutes, unable to repeat any words after 12 minutes. Explained the meaning of common proverbs, explained what she would do in an emergency situation in her classroom. Correctly drew the face of a clock. Scored 28 on the Saint Louis University Mental Status (SLUMS) Examination. name familiar objects
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