Reference no: EM133895167

Question

Jane is a 69-year-old African American female presenting to her primary physician office. Jane complains of a "racing heart" and shortness of breath. Jane has a history of anxiety attacks, hypertension and hypercholesterolemia, gout and 4 ½ years ago had a two-vessel coronary bypass after suffering an anterior wall MI. She had a double mastectomy 2 years ago for breast cancer, stage 2 and completed radiation 1½ years ago. She states she has been having problems sleeping through the night for the past month and has been sleeping with 3 pillows; she has also been experiencing fatigue and weakness throughout the day and believes she may be gaining weight since her shoes and pants are getting tight. She says she will not go to the hospital since she is still paying from her last surgery.

The nurse notes her Temp is 98.6 F, Pulse is 94 (irregular), Resp 20, Denies pain. BP 125/80. Weight is 215 lbs (up 9 pounds since her last visit one month ago). She appears to be anxious and slightly diaphoretic. She is alert and oriented, answering the phone throughout her assessment, asking her family and friends to pray for her as she is sure she is dying. Current medications: Allopurinol, Atorvastatin, Baby ASA, and clopidogrel. She states she stopped smoking when she had her "heart attack," although when she gets anxious, she may "sneak 1 or 2 cigarettes" but "no more than a pack a week."

1. What focused assessments would you perform on Jane? What cues are you looking for and why?

2. What problems would you deduce? What do you believe is happening to Jane? How severe is the problem? 

3. Utilizing NANDA diagnostic labels, identify 3 nursing diagnoses.

4. Based on the data, develop 3 goals. (Goals must be SMART.)

5. What recommendations do you have? What are some probable interventions you would recommend based upon the assessment data and goals? Define the assessment data and evidence-based prior knowledge upon which you are basing your recommendations.