Nursing Process Exercise: John Chen 1
DESALES UNIVERSITY
Department of Nursing and Health
Nursing 205
Nursing Process Exercise
CASE PRESENTATION
John Chen is an 18-year-old college freshman of Chinese descent. He is being seen in the student health center for follow-up on his
complaints of loose, watery stools. When discussing his health history, John states that he has occasionally had some difficulty with diarrhea and
has been told in the past that this is due to lactose intolerance. This medical problem has just been confirmed by the student health center
physician.
John reports that his diarrhea has worsened over the last 6 months, since the beginning of the school year. He now reports four to six
large, loose stools per day with severe abdominal cramping. He reports that his stools are foul smelling and accompanied by a great deal of flatus.
He states that he finds this to be a very embarrassing problem, especially while living in a "communal" dormitory situation.
John says that he never drinks milk as a beverage and that when he lived at home he ate a fairly traditional Chinese diet with few milk
products. Now that he is eating his meals in the dormitory dining room he feels that he is less able to control the amount of milk products in his
diet. Analysis of his 3-day diet recall shows a significant intake of milk products, including cheese, yogurt, and milk-based foods.
On physical examination, you find the following: vital signs and urine specific gravity are within normal limits, height and weight are below
average; mucous membranes are pink and moist; skin turgor is normal; capillary refill time is less than 3 seconds; abdomen is soft, with
hyperactive bowel sounds.
Nursing Process Exercise: John Chen 2
1) List the significant assessment findings.
a) Subjective:
Client states “he has occasionally had some difficulty with diarrhea and was told in the past that this is due to lactose intolerance”
Client states “diarrhea has worsened over the last 6 months, since the beginning of the school year”
Clients states he has “four to six large, loose stools per day with severe abdominal cramping”
Client states “his stools are foul-smelling, accompanied by a great deal of flatus”
Client states he finds bowel problem “to be an embarrassing problem, especially while living in a ‘communal’ dormitory situation”
Client states that “he never drinks milk as a beverage”
Client states that “when he lived at home he ate a fairly traditional Chinese diet with few milk products”
Client states “now that he is eating his meals in the dormitory dining room he feels that he is less able to control the amount of milk
products in the diet”
ix) Analysis of client’s 3-day diet recall shows a significant intake of milk products, including cheese, yogurt, and milk-based products
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
b) Objective:
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
ix)
x)
18-year-old college freshman of Chinese descent
Moved to college 6 months ago
Vital signs within normal limits
Urine specific gravity within normal limits
Height and weight are below average
Mucous membranes are pink and moist
Skin turgor is normal
Capillary refill time is less than 3 seconds
Abdomen is soft
Hyperactive bowel sounds
2) Cluster the significant assessment findings by functional health patterns.
a) Health Perception/Health Management Pattern
i) Client states “he has occasionally had some difficulty with diarrhea and was told in the past that this is due to lactose intolerance”
ii) 18-year-old college freshman of Chinese descent
iii) Moved to college 6 months ago
Nursing Process Exercise: John Chen 3
b) Nutritional/Metabolic Pattern
Client states “he never drinks milk as a beverage”
Analysis of client’s 3-day diet recall shows a significant intake of milk products, including cheese, yogurt, and milk-based products
Client states “when he lived at home he ate a fairly traditional Chinese diet with few milk products”
Client states “now that he is eating his meals in the dormitory dining room he feels that he is less able to control the amount of milk
products in the diet”
v) Height and weight are below average
vi) Mucous membranes are pink and moist
vii) Skin turgor is normal
i)
ii)
iii)
iv)
c) Elimination Pattern
i)
ii)
iii)
iv)
v)
vi)
vii)
Client states “he has occasionally had some difficulty with diarrhea and was told in the past that this is due to lactose intolerance”
Client states “diarrhea has worsened over the last 6 months, since the beginning of the school year”
Client states he has “four to six large, loose stools per day with severe abdominal cramping”
Client states “his stools are foul smelling and accompanied by a great deal of flatus”
Abdomen is soft
Hyperactive bowel sounds
Urine specific gravity within normal limits
d) Activity/Exercise Pattern
i)
ii)
Capillary refill time less than 3 seconds
Vital signs within normal limits
e) Sleep/Rest Pattern
i)
ii)
f)
18-year-old college freshman of Chinese descent
Moved to college 6 months ago
Cognitive/Perceptual Pattern
Nursing Process Exercise: John Chen 4
g) Self-Perception/Self-Concept Pattern
i)
ii)
18-year-old college freshman of Chinese descent
Client states he finds bowel problem “to be an embarrassing problem, especially while living in a ‘communal’ dormitory situation”
h) Role/Relationship Pattern
i)
ii)
i)
Sexuality-Reproductive Pattern
i)
ii)
j)
18-year-old college freshman of Chinese descent
Moved to college 6 months ago
18-year-old college freshman of Chinese descent
Moved to college 6 months ago
Coping-Stress Tolerance Pattern
i)
ii)
18-year-old college freshman of Chinese descent
Moved to college 6 months ago
k) Value-Belief Pattern
i)
18-year-old college freshman of Chinese descent
3) Using your own words, what general problem areas do you see in this case?
a) General Problem Area #1: Diarrhea
b) General Problem Area #2: Inadequate Nutrition
Nursing Process Exercise: John Chen 5
4) Develop data clusters for each of the general problems identified in question 3.
a) General Problem Area #1: Diarrhea
Client states “he has occasionally had some difficulty with diarrhea and was told in the past that this is due to lactose intolerance”
Client states “diarrhea has worsened over the last 6 months, since the beginning of the school year”
Client states he has “four to six large, loose stools per day with severe abdominal cramping”
Client states “his stools are foul-smelling, accompanied by a great deal of flatus”
Client states “he never drinks milk as a beverage”
Client states that “when he lived at home he ate a fairly traditional Chinese diet with few milk products”
Client states “now that he is eating his meals in the dormitory dining room he feels that he is less able to control the amount of milk
products in the diet”
viii) Analysis of client’s 3-day diet recall shows a significant intake of milk products, including cheese, yogurt, and milk-based products
ix) Abdomen is soft
x) Hyperactive bowel sounds
i)
ii)
iii)
iv)
v)
vi)
vii)
b) General Problem Area #2: Inadequate Nutrition
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
Height and weight are below average
Client states “he has occasionally had some difficulty with diarrhea and was told in the past that this is due to lactose intolerance”
Client states “diarrhea has worsened over the last 6 months, since the beginning of the school year”
Client states he has “four to six large, loose stools per day with severe abdominal cramping”
Client states his stools are foul-smelling, accompanied by a great deal of flatus”
Client states “he never drinks milk as a beverage”
Client states that “when he lived at home he ate a fairly traditional Chinese diet with few milk products”
Client states “now that he is eating his meals in the dormitory dining room he feels that he is less able to control the amount of milk
products in the diet”
ix) Analysis of client’s 3-day diet recall shows a significant intake of milk products, including cheese, yogurt, and milk-based products
x) Abdomen is soft
xi) Hyperactive bowel sounds
5) From one of the data clusters in question 4, develop at least two tentative nursing diagnoses.
a) Tentative Nursing Diagnosis for Data Cluster #1: Diarrhea
b) Tentative Nursing Diagnosis for Data Cluster #2: Nutrition: Altered, Less Than Body Requirements
Nursing Process Exercise: John Chen 6
6) Evaluate each of the tentative nursing diagnoses by writing and comparing the definitions, related factors, and signs and symptoms of each
diagnosis.
a) Tentative Nursing Diagnosis #1: Diarrhea
i)
Definition:
(1) A state in which an individual experiences a change in normal bowel habits characterized by the frequent passage of loose, fluid,
unformed stools.
ii)
Related Factors:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Gastrointestinal disorders [e.g., inflammation, irritation, or malabsorption of bowel], fecal impaction
Metabolic/endocrine disorders
Nutritional disorders, change in dietary intake
Infectious process
Tube feedings
Adverse effects of medications; [radiation, toxins, contaminants[
High stress levels
iii) Signs and Symptoms:
(1) Subjective:
(a) Abdominal pain
(b) Urgency; cramping
(2) Objective:
(a) Increased frequency of stool
(b) Increased frequency of bowel sounds
(c) Loose, liquid stools
Nursing Process Exercise: John Chen 7
b) Tentative Nursing Diagnosis #2: Nutrition: Altered, Less Than Body Requirements
i)
Definition:
(1) The state in which an individual experiences an intake of nutrients insufficient to meet metabolic needs.
ii)
Related Factors:
(1) Inability of ingest or digest food or absorb nutrients because of biological, psychological, or economic factors
(2) [Increased metabolic demands, e.g. burns]
(3) [lack of information, misinformation, misconception
iii) Signs and Symptoms:
(1) Subjective:
(a) Reported inadequate food intake less than RDA (recommended daily allowance)
(b) Reported lack of food
(c) Aversion to eating; reported altered taste sensation; satiety immediately after ingesting food
(d) Abdominal pain with or without pathologic conditions; abdominal cramping
(e) Lack of interest in food; perceived inability to ingest food
(f) Lack of information, misinformation, misconception
(2) Objective:
(a) Body weight 20% or more under ideal [for height and frame]
(b) Loss of weight with adequate food intake
(c) Evidence of lack of food [available]
(d) Weakness of muscles required for swallowing or mastication
(e) Sore, inflamed buccal cavity
(f) Poor muscle tone
(g) Capillary fragility
(h) Hyperactive bowel sounds; diarrhea and/or steatorrhea
(i) Pale conjunctiva and mucous membranes
(j) Excessive loss of hair [or increased growth of hair on body (lanugo)]; cessation of menses
(k) [decreased subcutaneous fat/muscle mass]
(l) [abnormal laboratory studies (e.g., decreased albumin, total protein; iron deficiency; electrolyte imbalances)]
Nursing Process Exercise: John Chen 8
7) Identify any gaps and inconsistencies in the data cluster that you would need to assess (if there are gaps in the data cluster) or recheck (if
there are inconsistencies in the data cluster) before identifying the most accurate nursing diagnosis.
a) Tentative Nursing Diagnosis #1: Diarrhea
i)
Gaps
(1) Need to assess if urgency if present
ii)
Inconsistencies
(1) none
b) Tentative Nursing Diagnosis #2: Nutrition: Altered, Less Than Body Requirements
i)
Gaps
(1) Need to assess if inadequate food intake less than RDA
(2) Need to assess if altered taste sensation
(3) Need to assess if satiety immediately after ingesting food
(4) Need to assess if lack of interest in food
(5) Need to assess if body weight is 20% or more under ideal (for height and frame)
(6) Need to assess if sore, inflamed buccal cavity
(7) Need to assess muscle tone
(8) Need to assess capillary fragility
(9) Need to assess conjunctiva
(10) Need to assess for presence of hair loss
(11) Need to assess laboratory studies (e.g., albumin, total protein, iron deficiency, electrolytes)
ii)
Inconsistencies:
(1)
(2)
(3)
(4)
(5)
Perceived inability to ingest food (client can ingest food)
Reported lack of food (client can get food)
Aversion to eating (client is eating)
Weakness of muscles required for swallowing or mastication (client can swallow and masticate)
Mucous membranes pale (client’s mucous membranes are pink and moist)
Nursing Process Exercise: John Chen 9
8) Identify the most accurate nursing diagnosis. Explain your selection.
a) For the nursing diagnosis, diarrhea, the client exhibits almost all the signs/symptoms with few gaps and inconsistencies for the diagnosis.
Therefore diarrhea is a highly accurate nursing diagnosis for this client. The cluster of data related to his increased consumption of milk
products suggests an etiology. For the diagnosis Nutrition: Altered nutrition, Less Than Body Requirements, the client exhibits mainly one
sign/symptom, height and weight below average, and there are many gaps and inconsistencies. Therefore, a number of questions must be
answered to more fully consider this diagnosis. Until these questions are answered, the diagnosis of Nutrition: Altered, Less Than Body
Requirements cannot be confirmed and is therefore not an accurate diagnosis.
9) Write a complete basic three-part (PES) nursing diagnosis for the diagnosis you have identified.
a) Problem Statement/Diagnostic Label (P) = Diarrhea
b) Etiology/Related Factors (E) = related to inability to adhere to prescribed therapeutic diet in dormitory environment
c) Signs/Symptoms or Defining Characteristics (S) = as evidenced by four to six large, loose stools per day accompanied by abdominal
cramping
10) Write a client goal for your nursing diagnosis that you have identified that is the opposite healthy response of the problem statement
(diagnostic label) of the nursing diagnosis.
The client will reestablish previous bowel pattern
11) Write three expected outcomes that will demonstrate that the client goal has been met.
SUBJECT
#1 The client
VERB
will pass
CONDITION OR MODIFIER
one moderate, brown, formed
stool
CRITERION OF DESIRED PERFORMANCE
Daily.
#2 The
client’s bowel
sounds
#3 The client
will measure
5-25 per minute
In 48 hours.
will ingest
no milk products
Every day.
RATIONALE
Determines
characteristics of
stool
Determines how fast
chyme is moving
through the colon
Prevents diarrhea
from occurring due to
lactose intolerance
Nursing Process Exercise: John Chen
10
1) Write four nursing strategies/interventions that will help achieve the expected outcomes and, consequently, the client goal.
DATE
#1 11/17/99
VERB
Assess
CONTENT AREA
the client’s stools
#2 11/27/99
Assess
the client’s bowel sounds
#3 11/27/99
Record
#4 11/27/99
Consult food
service
the client’s intake of milk
products
to develop a lactose free
diet for the client
References:
TIME ELEMENT
with each bowel
movement.
Each shift.
SIGNATURE
S. Yeager, RN
RATIONALE
Assesses the characteristics of stool
S. Yeager, RN
at each meal.
S. Yeager, RN
by 11/28/99.
S. Yeager, RN
Assesses how fast chyme is moving
through the colon
Determines if adhering to lactose free
diet to prevent diarrhea
Provides lactose free diet to prevent
diarrhea