Reference no: EM133585378

History of Present Problem: Jody Foster is a 28-year-old Caucasian woman who presents to the emergency department complaining of right-sided rib pain, neck pain, and headache after being physically assaulted by her husband. Last evening her husband came home intoxicated and became angry when their 12-month-old son began to cry. He punched her in the face, chest, then began to choke her by squeezing her neck for about a minute. She began to feel dizzy, but did not lose consciousness. She admits that this is not the first time she has been assaulted by her husband, but acknowledges that it has gotten worse lately. Her right cheek is swollen with a large abrasion. She has left lateral neck pain, but no cervical spine tenderness. Her headache is on the left side of her head that has been continuous since she was assaulted. She rates it as a 9/10 and a "throbbing" sensation. She has increased pain in her right chest when she takes a deep breath. She has no other neurologic complaints. The CT of her head is normal, and x-rays revealed no facial or rib fractures. What data from the histories is important and RELEVANT; therefore it has clinical significance to the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: The Dilemma Begins... Current Concern: Jody has no family in the community and no close friends who can assist her. She refuses to press charges against her husband, therefore she does not want the police to be notified. Information regarding shelters for women are given to her but Jody wants to go back home because, "My husband left the house to cool off after I left and said he would go to a friend's house for the night." Despite the primary care provider communicating that her life is possibly in danger if she returns home, Jody states that she has no place to go. She relates that she does not want to go to a woman's shelter with her baby because everything is going to be OK and this time, he is really sorry. What data from the current concern is important and RELEVANT; therefore it has clinical significance to the nurse? (Reduction of Risk Potential) RELEVANT Data from Current Concern: Clinical Significance: Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved. Resolving the Dilemma

1. Interpreting RELEVANT clinical data, what is the essence of this clinical dilemma? (Management of Care)

2. What additional information is needed by the nurse to clarify the dilemma? (Management of Care)

3. What additional members of the healthcare team could be used in this situation? Why? (Management of Care)

4. What is the nursing PRIORITY? (Management of Care)

5. What are the PRIORITY nursing interventions? (Management of Care) PRIORITY Nursing Interventions: Rationale: Expected Outcome:

6. What is the expected response of the patient that indicates nursing interventions were effective? (Management of Care)

7. What response by the patient would indicate that a change in the plan of care and nursing interventions are needed? (Management of Care)

8. What principles of therapeutic communication can be utilized to develop trust and encourage dialogue between the nurse, patient, and/or family? (Psychosocial Integrity)

9. What is the patient and/or family likely experiencing/feeling right now in this situation? (Psychosocial Integrity/Basic Care and Comfort)

10. What can I do to engage myself with this patient's experience, and show that he/she matters to me as a person? (Psychosocial Integrity/Basic Care and Comfort)

11. What was learned from this case study that you will incorporate into your practice? (Management of Care.