Abdominal surgery

Miranda, age 43 had abdominal surgery five days ago for a ruptured appendix. Her hospital stay has been lengthened for further investigation. Yesterday, she complained of weakness and had trouble getting out of bed. She has not been eating or drinking much for the past couple of days. Earlier today, a chest X-Ray confirms that Miranda has right lobe pneumonia. She tells the nurse that she is not surprised about her test result because she has been feeling unwell since the surgery. Miranda complains of dyspnea just after coming back to the unit. She states that “quite often, I am producing thick yellowish secretions which is very hard for me to cough up.” The nurse notes that Miranda’s cough is weak, she takes a sample of Miranda’s sputum to send for culture and sensitivity testing.

The RPN just entered Miranda’s room and assessed her vital signs as follows: BP – 132/82, Temp – 38°, Heart Rate – 101, O2 Saturation – 91%, Respirations – 23. When the nurse auscultates Miranda’s posterior chest she notes decreased breath sounds and the presence of popping sounds in the right lobe. The nurse notes that the skin around Miranda’s mouth is bluish in colour. Capillary refill is less than 3 second and skin turgor is good. Miranda told the nurse that she is willing to do what she needs to so that she can go home as soon as possible.

Selection of pertinent assessment data that is relevant to the case study need (different from cluster, pattern, gap, cue & inference, norm).

► Identification of data Cluster that is present in the case study. Clear analysis what the cluster mean to the patient and the nurse.

►Identification of data Pattern that is present in the case study. Clear analysis of what the pattern mean to the patient and the nurse.

► Identification of Data Gap that is present in the case study. Clear analysis of what the data gap mean to the patient and to the nurse.

► Identification of data Norm that is present in the case study. Clear analysis of what the data norm mean to the patient and the nurse.

►Identification of Cue and inference that is present in the case study. Clear analysis of what the cue and inference mean to the patient and the nurse.

► Selection of One (1) Priority Nursing Diagnosis that reflects the data analysis

► Write Two (2) Expected Outcomes (patient goals) which reflects the priority nursing diagnosis

► Write Two (2) Nursing Interventions (nursing orders) to address and achieve the expected outcomes/patient goals