Janet Long is a 75-year-old woman who

Janet Long is a 75-year-old woman who was admitted to the skilled nursing facility today for physical therapy after having a right total knee replacement at the hospital. Janet has a history of hypertension which is well controlled with the use of antihypertensive medications. After completing a Comprehensive Assessment on Janet, you find the following assessment data cues: Functional: Using the Hester Davis Scale for Fall Risk, Janet is assessed to be a high-risk fall. Physical: Using the OPQRSTU Pain Assessment Tool: O: the patient’s right knee pain started one hour ago P: movement makes the pain worse Q: it is described as a throbbing pain R: it radiates to her right thigh and lower leg S: on the pain scale the pain is rated at an 8/10 T: the ordered medication oxycodone brings the pain level down to a 2/10, the patient gets a “little dizzy” after taking the medication U: the pain and the dizziness makes it difficult to ambulate. Cognitive: Janet is alert and oriented to person, place, time, and situation. Psychological: Janet has no history of mental health problems. She reports being in a good mood and her affect is normal. Social: Janet has a supportive husband and son who visit frequently and will be able to assist with her care once discharged. Spiritual: Janet is a member of the local Catholic church and attends worship weekly. 1) From your assessment data, what data cues did you recognize? List the cues. 3) Categorize the assessment data cues as subjective or objective and write them in the table below. 4) What were the most significant findings? Circle these. 5) What information is less important or distracting? Underline these. Subjective Assessment Data Cues Objective Assessment Data Cues 6) What findings did you expect based on the patient’s diagnosis/concern? List the expected findings. 7) Are there any findings that seem contradictory? Discuss the contradictory findings. 8) What other information can you gather to help determine the significance of the cues? Discuss this other information. 9) Cluster your assessment data cues into at least two sets of data cues: Data Cues- Set 1 Data Cues- Set 2 Data Cues- Set 3 10) What data cues set is most concerning? Circle the most concerning on the table above. 11) Are there any potential complications for which the patient is at risk based on the data cues sets? Discuss the potential complications. 12) Given the data cues sets, what is most likely occurring? Discuss this. 13) What are your hypotheses or interpretations of the problem? What hypotheses or problems is the patient at risk for? Discuss your hypotheses or interpretations of the problem. 14) Using your data cues sets, write a Problem Statement for each data cues set. First use the below table to organize your thoughts: Hypothesis (Interpretation of the Problem) Related to (primary data cue) Supported by additional data cues (assessment data) Ex: Constipation Patient taking opioid pain medication. “I have not had a bowel movement in three days.” Abdominal distention upon inspection. Abdominal tenderness upon palpation. Sample Problem Statement: Constipation related to opioid pain medication supported by patient stating they have not had a bowel movement in three days, abdominal distention, and abdominal tenderness. 15) What will happen if these hypotheses-problems are not treated? Discuss this. 16) What is the risk of ignoring these hypotheses-problems? Discuss this 17) What else might explain what is going on? Discuss this. 18) Which hypothesis-problem is the most important and the nurse should manage first? Circle the most important on the table above. 19) Write at least one short term goal and one long term goal for each hypothesis-problem. 20) Write measurable outcomes (data) for each goal which will demonstrate the goal has been achieved or met. Hypothesis-Problem: Short Term Goal(s) Measurable Outcomes (data): Long Term Goal(s) Measurable Outcomes (data): Hypothesis-Problem: Short Term Goal(s) Measurable Outcomes (data): Long Term Goal(s) Measurable Outcomes (data): Hypothesis-Problem: Short Term Goal(s) Measurable Outcomes (data): Long Term Goal(s) Measurable Outcomes (data): 21) What interventions are indicated for each hypotheses-problem? Research possible interventions for each problem and cite references. 22) What interventions should be avoided? Discuss and cite references. 23) Write at least four actions or interventions for each problem statement (hypothesis). See table at end of document. 24) Which interventions take priority and should be taken immediately? Circle these on the below table. 25) What interventions can you delegate? Who would you delegate these to? 26) What information will you teach the patient? 27) What findings or measurable outcome data would show an intervention is working? Write these on the table. 28) What findings or measurable outcome data would show an intervention is not effective? Write these on the table. 29) Are there any critical values you will need to monitor? Circle the critical values on the table. Problem Statement: Interventions: 1. 2. 3. 4. Evaluating Outcomes: Data to show short term goal met or not met: Met: Not met: Data to show long term goal met or not met: Met: Not met: Problem Statement: Interventions: 1. 2. 3. 4. Evaluating Outcomes: Data to show short term goal met or not met: Met: Not met: Data to show long term goal met or not met: Met: Not met: Problem Statement: Interventions: 1. 2. 3. 4. Evaluating Outcomes: Data to show short term goal met or not met: Met: Not met: Data to show long term goal met or not met: Met: Not met:

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