This discussion review the developmental, age, socioeconomic, and cross-cultural considerations that should be considered during the gathering of subjective and objective data and the provision of health care. In addition, relate expected (normal) findings to the findings described, discuss any additional information that may be needed before a judgment or diagnosis can be made. Identify at least one relevant nursing diagnosis for any actual or potential problem identified. Provide one short-term and one long-term goal (that is measurable and realistic) and identify interventions to support those goals.
A 40 year-old woman is recovering from a cholecystectomy. The nurse giving report indicates that she was not receiving good pain relief with the medications prescribed. During the AM assessment the nurse notes crackles in both lower lobes.