Name : Yufita Fitrianti

NPM : 1814201110081

Nursing English II

Task and Answer

Task 3. 3
Fill Data Analysis Table according case study. Then, write nursing diagnosis suitable to the table
with formula Problem + related to +Etiology

Case study
A 65 year old male comes into the ER complaining of blurred vision and a “very painful”
headache. He states that his wife took his blood pressure from his home blood pressure machine
at home and it read 210/110 mmHg. He states that it scared him so that is why he came to the
hospital. The patient has the following history: TIA (2005), Diabetes Type 2, Hyperlipidemia,
Hypertension, and Heart Failure (2009).

The patient takes the following medications: Metformin 150 mg PO Daily, Liptor 20 mg PO at

night, Plavix 75 mg PO Daily, Coumadin 2 mg PO once a day, and Clonidine 2 mg PO Daily. Pt
admits to not taking Clonidine for the past week because it makes him dizzy and weak feeling.
Current VS: HR 85, BP 220/115, O2 Sat 96% on RA, Temp 36.8 ‘C, and RR 16. Pt blood sugar
is 150.

Data analysis
DATA ETIOLOGY PLOBLEMS
Subjective data: Biological injury agent Pain Acute
- A 65 years old male comes (NANDA, domain 12, Class
into ER complaining of 1, Diagnosis Code 00132.
blurred vision and a “very Page 445)
painfull” headache.
- He states that his wife took
 his blood pressure from his
home blood pressure
machine at home and it
read 210/110 mmHg.

Objective data:
Current VS : HR 85, BP
220/115, 02 sat 96% on RA,
Temp 36,80C, and RR 16.
Subjective data: Risk Factor: Risk for ineffective
- The patient admits to not Hypertension peripheral tissue perfusion
taking Clonidine for the (NANDA, domain 4, class 4,
past week because it makes diagnosis code 00228, page
him dizzy and weak 237)
feeling.
- The patient takes the
following medications:
metformin 150 mg PO
daily, Liptor 20 mg PO at
night, Plavix 75 mg PO
Daily, Coumadin 2 mg PO
once a day, and Clonidine
2 mg PO Daily.

Objective data:
- Current VS : HR 85, BP
220/115, 02 sat 96% on
RA, Temp 36,80C, and RR
16, blood sugar is 150
Subjective data: Stressor (NANDA, Domain 9, Class
- He states that his wife took 2, Diagnosis Code 00148.
his blood pressure from his Page 324)
 home blood pressure
machine at home and it
read 210/110 mmHg. He
states that it scared him so
that is why he came to the
hospital

Objective data:
Current VS: HR 85, BP
220/115, O2 Sat 96% on RA,
Temp 36.8 ‘C, and RR 16. Pt
blood sugar is 150.

Nursing Diagnosis:
1. Acute pain related to biological injury agent (NANDA, domain 12, Class 1, Diagnosis
Code 00132. Page 445)
2. Risk for ineffective peripheral tissue perfusion (NANDA, domain 4, class 4, diagnosis
code 00228, page 237)
3. Anxiety related to stressors (NANDA, Domain 9, Class 2, Diagnosis Code 00148. Page
324)