Question

Read the scenario and complete the following: 1. any subjective and objective assessment data 2. Cluster the data 3. Formulate two (2) actual nursing diagnoses for this client A male client 68 years of age and was admitted to the aged care facility four days ago. He speaks little English. He refuses to take his medications and is spending a lot of time lying on his bed. When approached by a staff member he speaks rapidly and loudly. He has a reddened area at the base of his spine and his right elbow. He is overweight, has mild right-sided weakness from a stroke (Cerebral Vascular Accident - CVA), mobilizes independently with a cane and has a history of severe -sided shoulder pain. He has had no bowel movement since entering the facility

Answer 1

Below are the data of the client grouped under objective and subjective data

OBJECTIVE DATA

- Age- 68years

- SEX- Male

- Overweight

- Refuses to take his medications

- Speaks little English

- Mobilizes independently with a cane

- Aggressive

- Sedentary lifestyle.

SUBJECTIVE DATA

- Have history of CVA (cerebrovascular accident)

- Right sided weakness

- History of severe sided shoulder pain

- Reduced bowel movement (Constipation)

- Reddened area at the base of the right shoulder.

NURSING DIAGNOSIS

1, Constipation related to lack of activity/sedentary lifestyle.

2, Anxiety related to disease condition evidenced by client speaking rapidly and loudly.(aggressive)