Ackley & Ladwig: Nursing Diagnosis Handbook: A Guide to ...



Ackley: Nursing Diagnosis Handbook, 10th EditionProblem-Based and Critical Thinking Exercise: Use of the Nursing ProcessCase Study - Mr. Spole (Acute Myocardial Infarction)Case Scenario“What’s happening? I just had a bad case of indigestion, and now I’m in here. They tell me I had a serious heart attack. How can that be? I’m only 42 years old, and I’m in great shape.” Mr. Spole was angry; he had always been in complete control of his life, and now here he was in the coronary care unit, hooked up with gadgets, and everyone treated him differently. When he looked into his wife’s eyes, he saw raw fear. He kept trying to tell her everything would be fine. He would go back to work, their two children would be well taken care of, and life would go on―just as soon as he got out of here.Nursing Assessment Including Client StoryMr. Spole is a 42-year-old man who started and owns his own previously successful construction company. Now, business is down, and he is scrambling to support his family of a wife and two teenage children. He works 12-hour days and eats on the run, mostly fast food. His motto is, “Work hard; play hard.” He is admitted to the coronary care unit for an acute myocardial infarction (AMI). He developed severe indigestion, nausea, and chest pressure at work. His secretary called 911 without his permission. Vital signs are blood pressure: 100/88 mm Hg; temperature: 98.8° F; pulse: 118 beats per minute (bpm); and respirations: 22 breaths per minute. Apical pulse is 120 bpm and regularly irregular; peripheral pulses are very weak. Mr. Spole still has chest pressure, but when asked about the presence of pain in the critical care unit, he denies having pain. He keeps telling everyone that he is fine and plans to leave the hospital in the afternoon. He had been working on a bid for a large project that he needed to keep his company afloat. “I’ve got to get out of here,” is what his nurse heard over and over.ASSESSIdentify the significant symptoms by underlining them in the above nursing assessment.List the symptoms (those you have underlined) that indicate the client has a health problem.Group the symptoms that are similar.DIAGNOSESelect possible nursing diagnoses for this client.Review the list of nursing diagnoses in Section II of Ackley and Ladwig: Nursing Diagnosis Handbook: A Guide to Planning Care.(The information can be copied and pasted from the EVOLVE site into the area below.)Possible nursing diagnoses:________________________________________________________________________________________________________________________________________________________________________________________________Validate the possible nursing pare the signs and symptoms (i.e., defining characteristics) that you have identified from your client assessment with the defining characteristics for the nursing diagnosis that you have selected. In addition, read the diagnosis definition and determine whether this diagnosis fits this client. This information is found in Section II of the Ackley and Ladwig text.Validated nursing diagnoses include:(The information can be copied and pasted from the EVOLVE site into the area below.)________________________________________________________________________________________________________________________________First Nursing DiagnosisWrite a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the “related to” (r/t) factors.The label is the title of the nursing diagnosis as defined by the North American Nursing Diagnoses Association (NANDA).An r/t statement describes the factors that may be contributing to or causing the problem that resulted in the nursing diagnosis.(The information can be copied and pasted from the EVOLVE site into the areas below.)NANDA label: _________________________________________________Related to (r/t) factors: __________________________________________The complete nursing diagnostic statement is:______________________________________________________________PLANClick here to access the Ackley and Ladwig care plan constructor for assistance in formulating a care plan: an outcome to help Mr. Spole resolve the symptoms (i.e., defining characteristics). Refer to Section III of the Ackley and Ladwig text.Outcome: _______________________________________________________Write or select appropriate nursing interventions. Nursing interventions:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Second Nursing Diagnosis1.Write a nursing diagnostic statement for the second nursing diagnosis by combining the nursing diagnosis label with the r/t factors.The label is the title of the nursing diagnosis as defined by NANDA.An r/t statement describes factors that may be contributing to or causing the problem that resulted in the nursing diagnosis. (The information can be copied and pasted from the EVOLVE site into the areas below.)NANDA label: ___________________________________________________Related to (r/t) factors: ____________________________________________The complete nursing diagnostic statement is:________________________________________________________________PLANWrite an outcome to help Mr. Spole resolve the symptoms (i.e., defining characteristics). Refer to Section III of the Ackley and Ladwig text.Outcome: _______________________________________________________Write or select appropriate nursing interventions. Nursing interventions:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________IMPLEMENTThe next step in the nursing process is to provide the nursing care using the nursing interventions.EVALUATEAfter the nursing interventions are implemented, the results of the care should be evaluated by determining whether the outcome was met. If the outcome was met, then the care plan is resolved. If the outcome has not been met, then further assessment should be made to answer the following questions:Was the correct nursing diagnosis chosen?Was the outcome appropriate?Were the interventions appropriate in this situation?What other interventions might have been helpful?Changes in the nursing diagnosis, outcomes, and interventions should be made as needed. The continued use of critical thinking will ensure appropriate nursing care.Click here to access the Ackley and Ladwig care plan constructor for assistance in formulating your care plan: EVOLVE ................
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