Formulating Nursing Diagnosis

Instruction: Read the following case study. In answering the following questions, use a nursing
diagnosis handbook to look up the NANDA defining characteristics.

Case Study Scenario:

Sally Perez, a 45-year-old woman, was admitted to your surgical unit directly from the
operating room. She was in a motorcycle accident this evening. In the emergency Room, her
blood pressure was falling, and she was bleeding profusely from many sites. She was sent
directly to the operating room for splenectomy, internal fixation of a compound fracture of
bilateral femurs, and traumatic amputation of the right hand. During surgery she lost 2000 ml of
blood and received 3 units of packed RBC (volume = 500 ml) along with 1000 ml of fluid
administered intravenously.
You received report on the client at 7:00 pm. Sally is receiving IV fluid through several
peripheral lines and through a central line (a catheter inserted into a major vein leading to the
heart). She has a foley catheter, which is draining 30 ml of concentrated urine each hour. Sally’s
vital signs are as follows: temperature – 39.30C via rectal; heart rate – 120 beats/min; respiration
– 28 breaths/min and blood pressure – 160/86 mmHg. Her skin is flushed, dry, and warm to
touch. On assessment, you find the following: return of skin turgor > 3 seconds, dry mucous
membranes, and bloodstained dressing on right upper extremity.
She is complaining of thirst, weakness, and pain at a level of 10 on a scale of 1 to 10 (10
highest). Sally is receiving a continuous infusion of morphine. She refuses to cough, deep-
breathe, or attempt to turn. She lies very still and rigid. Sally drifts in and out of sleep but
remains asleep for less than 30 minutes each time. She is irritable and restless. She
communicates with one-word answers only. Frequently, she displays facial grimaces and
becomes increasingly stiff. Her eyes appear dull. She complains of severe pain with any passive
or active movements.
 1. Identify 2 nursing problem

2. Prioritize problem listed

Data (cues) Inference Nx Diagnosis Prioritization Rationale

Subjective: Elevated Hyperthermia related HIGH (4) Temperature of up to

Patient complains temperature to infection as 38º C (100.4º F) 48
weakness, thirst and (tachycardia and evidence hours post-op is
severe pain. hyperthermia) by temperature usually related to
Objective: 39.30C (rectal), skin surgical stress after
 T: 39.30C (rectal) is flushed, weakness, 48 hours, temperature
 HR: 120 bpm and dehydration. of greater than 37.7º

 RR: 28 cpm (99.8º F) may

 BP: 160/80mmHg indicate infection;

very high
temperature
accompanied by
sweating and chills
may indicate
septicemia.

Subjective:
 Patient complaining Uncoordinated Acute pain in r/t HIGH (5) Evaluate pain
 of thirst, weakness, body movement regularly (every 2 hrs
and pain at a level of noting
10. characteristics,
 Discomfort on any location, and
passive or active intensity (0–10
movements. scale). Emphasize
Objective: patient’s
 Facial grimaces responsibility for
reporting pain/ relief
of pain completely.