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What data from the histories is important and RELEVANT; therefore, it has clinical significance to the nurse? RELEVANT Data from Present Problem: • Blood loss of 100 mL after coronary artery byp... ass graft surgery and almost died as a result • Currently off all vasoactive drips, his arterial line has been discontinued, and he is considered clinically stable. He is also scheduled to transfer to the cardiac step-down unit later today. Clinical Significance: • The volume of blood loss (100 ml) is clinically significant. Also, because he almost died as a result of the blood loss volume, he will likely experience psychosocial implications. Thus, it is important as the nurse to assess and monitor these potential implications. • The following data suggests that he is clinically stable with no physiologic concerns present in relation to his physical status at this time, even though he experienced a critical event. RELEVANT Data from Social History: • Death of John’s wife six months ago after fifty years of marriage and now currently lives alone • Son who lives in the area and checks in at least once a week to see how he is doing • Vietnam War veteran who has not been active within his church since he returned from the war forty years ago Clinical Significance: • The loss of a spouse or loved one can cause a person to experience significant psychosocial stressors. John’s loss of his wife is very recent. This loss has now caused him to live alone after fifty years of marriage. Thus, this is another significant piece of psychosocial data that the nurse should assess and note. • It’s important to keep in mind that although he is living at home alone currently, he has family involvement within his care. His son lives in the area and is able to check in on him at least one day a week. • It is very common for an active combat war veteran to experience psychosocial distress or PTSD. While the chart information does not suggest the reason for why he is not active in his church, it is important as a nurse to note that John is most likely experiencing psychosocial distress or PTSD due to his active combat within the Vietnam War forty years ago. II. The Dilemma Begins... Current Concern: John puts on his call light and as you enter the room he states that he feels short of breath and is visibly anxious. His breath sounds are clear and his O2 saturation is 98% on 2 liters n/c. His respiratory rate is 20/minute and his heart rate is 78/minute-sinus rhythm. He acknowledges that he is anxious and feels like he is having [Show More]

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