Clinical Analysis and Diagnosis

Overview

Review the case study and respond to the following clinical judgment questions. Submit your answers on a Word document to Brightspace.

Tasks

Case Study:

Andrea has come to the emergency department (ED) with complaints of not being able to sleep or eat for the past five days. She does not have anyone accompanying her because “I’m so embarrassed that this is happening.” In the past, Andrea has had bouts of feeling sad, but she states that she has always been able to sleep and eat. Andrea is taken to a room where Susan, RN, completes the admission. Susan notes that Andrea
is slow in answering questions and appears unsure of her responses. Susan also notes that Andrea appears unkempt, has body odor, has no facial expression, is gaunt
looking, and has dark circles under eyes. Vital signs were as follows: temperature 98°F, pulse 88, respirations 18, blood pressure 90/60 mm Hg, O2 saturation 97% room air.
Andrea states that all she has done the last five days is sit on the couch and look out the window.

Questions:

1. Recognize Cues (Assessment)
   ● What assessment data indicated the client may be displaying depression?
   ● What assessment information is relevant to the client’s condition?
2. Analysis Clues (Analysis)
   ● What cues regarding the client’s physical appearance are significant? Provide a rationale.
   ● What assessment findings are of immediate concern?

Susan determines that Andrea needs further assistance and develops a plan of action based on building a therapeutic relationship with Andrea. Susan begins to develop the therapeutic relationship by getting to know Andrea better through building trust and rapport.

3. Prioritize Hypotheses (Analysis)

● What are the top three priority problems for the client? Provide a rationale for your decision.

Both Susan and Andrea discuss the problems that Andrea has been experiencing.
Within the working phase of the therapeutic relationship, Susan and Andrea have determined Andrea needs further assistance and have collaboratively developed goals and a plan of action.

4. Generate Solutions (Planning)

● Identify a measurable client outcome for each of the three priority problems.

5. Take Actions (Implementation)

● Identify the nursing actions that should be taken based on the prioritized client problems.

Andrea is preparing for discharge from the emergency department. During the final phase of the therapeutic relationship, Susan understands that the evaluation of the goals set earlier in the therapeutic relationship have either been met or not met.

6. Evaluate Outcomes (Evaluation)

● What response by the client indicated that the client’s goals were met?
● How would you modify the place of care if the client outcomes were not met?