1. First, identify the abnormal data and strengths in subjec
1. First, identify the abnormal data and strengths in subjective… 1. First, identify the abnormal data and strengths in subjective and objective findings, 2. Assemble cue clusters, 3. Draw inferences, 4. Make possible nursing diagnoses, 5. Identify defining characteristics, 6. Confirm or rule out the diagnoses, and 7. Document your conclusions. Use the table below to collect subjective and objective date provided to guide you. Propose nursing diagnoses that are specific to the client in the case study. Identify collaborative problems, if any, for this client. Finally identify data, if any, which point toward a medical problem requiring a referral. Case Study Evelyn Vaughn is a 47-year-old white woman, who comes to the clinic for evaluation. She is a single mother and sells cosmetics in her home. She is lethargic and walks slowly into the room. She asks if she can have some “special lotion” for her dry skin. When interviewed, Evelyn states that her skin has been dry and scaly for the past several months, unrelieved by numerous moisturizers. She expresses concern about “fly-away hair that I can’t do anything with” and about brittle, easily broken fingernails. When asked about medications, she explains that she is supposed to take Synthroid daily for “my low thyroid” but cannot afford to get the prescription filled. She has a poor appetite, and with “not enough money to go around,” she has been nibbling on crackers, lunch meat, and sodas daily. Exercise is out of thebecause she lacks energy, and she is rarely able to get through a day without one or two 30- minute naps. Evelyn takes a shower and washes her hair using ivory soap and baby shampoo. She applies moisturizer to her skin and conditioner to her hair but states that neither helps for any length of time. She keeps her nails cut short because they break so easily. She states that she has cut down on her cosmetic sales appointments because “I look like I never use my own products.” Initial assessment reveals dry flaking skin that is cool to the touch and yellow tinged. Facial and edema are present. The client’s facial expression is blank. She has multiple bruises on both forearms and anterior lower legs, which are in various stages of healing and tender when touched. Her scalp hair is dry and breaks easily. Her scalp is scaling. Sparse hair is noted in the axillae and the pubic area. Her fingernails are dry; her cuticles are dry and torn. Her toenails are thick and yellow. Health Science Science Nursing
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