What data from the history of present problem is relevant

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Reference no: EM133503484

Assignment:

I. History of Patient

History of Present Problem: John James is an 80-year-old man who had a coronary artery bypass graft (CABG) x4 vessels three days. He experienced significant blood loss post-operatively due to a bleeding graft site. This resulted in Mr. James almost dying. He is currently off all critical drips and his arterial line has been removed. Mr. James is clinically stable and is scheduled to transfer to a step-down unit later today.

Personal/Social History: Mr. James is a widower. His wife died six months ago. Mr. James lives alone in an apartment building. He has one son who checks in at least once a week. Mr. James is a Vietnam War veteran. He has not been active in his church for over forty years.

1. What data from the history of present problem is relevant? What is the clinical significance of that data?

2. What data from the personal/social history is relevant? What is the clinical significance of that data?

II. Current Concern

Mr. James rings his call light and as you enter the room. He states that he feels short of breath and is visibly anxious. Upon assessment, you note that his breath sounds are clear bilaterally in all lobes and his oxygen saturation is 98%. Mr. James does wear oxygen at 2L via nasal cannula. His respiratory rate is 22 breaths per minute, and his heart rate is 80bpm with a regular rhythm. Mr. James does state that he is anxious and thinks he may be having a panic attack. He states that he has never felt like this before. You ask Mr. James what he may be anxious about and he replies the following: "I use to go to church as a child, but I have not since I returned from war. I saw so many of my friends die in Vietnam. I could not save them. How can I believe in God when I have seen such horrible things? I use to be such a good kid, but I killed so many people in Vietnam. How could I be forgiven for everything I have done?"

3. What data from the current concern is relevant? What is the clinical significance of this data?

III. Working through the Dilemma

1. Using the relevant data, what is the essence of this current dilemma?

2. What additional information should the nurse obtain that could help clarify the current dilemma?

3. What other members of the healthcare team could be used in the situation and why?

4. What is an appropriate nursing diagnosis for Mr. James? Must be complete nursing diagnosis.

5. What nursing interventions would be appropriate in this situation?

6. How would the nurse evaluate the effectiveness of the nursing interventions?

7. What response by the patient would indicate that a change in the plan of care and nursing interventions is necessary?

8. How could the nurse show Mr. James that he matters as a person?

Reference no: EM133503484

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