Here are a few examples of Nursing Diagnosis for you to practice with
Stay
focused only on the information provided:
Mr.
Ford has arrived on your ward from the Emergency Department. He has been
diagnosis as having a CVA and has suddenly become incontinent with frequent
episodes overnight. He is now very drowsy, difficult to rouse and dysphagic
since the CVA
Scenario
two
Mr. Warren has been admitted
with pain following falling over and fracturing his right arm. He is obviously
in pain, holding his arm and rates his pain 6/10. He is unable to use his arm to
feed himself.
Scenario
three
Mrs. Scott is 93 years of age
and has been admitted after being found collapsed at home. Until then she was
reported to be well. She presents with poor skin turgor, a dry tongue, having
not taken fluid for an estimated four days.
Since
the fall she is confused. The medical staff believe that, as a Diabetic, she had
a hypoglycaemic episode. As a result of lying in the one spot for so long, she
has a stage one pressure area sore on her hip.
Scenario
four
Mr Woods is admitted with
COAD. He is short of breath, anxious, cyanosed, confused and has a respiratory
rate of 40. All of these symptoms began yesterday when he suddenly found it
difficult to breath.
From
each scenario:
1.
Select a significant problem (Nursing Diagnosis) that the patient is
evidently experiencing
2.
State what the cause of the above problem is (related to factor)
3.
State the signs and symptoms (manifestations) of the significant
problem you have selected – i.e. what are the signs and symptoms
(manifestations) of the problem the patient is experiencing (not the signs and
symptoms of the cause).
When
specifying the signs and symptoms, state only what you observe or see in
relation to the problem. For example, the signs and symptoms of constipation are
a dry hard stool or no bowel action for 5 days.
When you have done this for
each scenario you have completed the first part of Nursing Diagnosis. Now,
choose another problem and go through the same process. Some of your causes and
your signs and symptoms for each problem may overlap and you may find yourself
repeating yourself. But remember, when doing the causes and the signs and
symptoms, refer only to the problem.
All the possible Nursing
Diagnosis you can use are listed in Potter and Perrycauses (related to) are on
the reverse of this page.
You will need to chose the
signs and symptoms (manifestations) from only the information provided in the
scenario
All the possible signs and
symptoms (manifestations) are on
the reverse
Once you have done a Nursing
Diagnosis including R/T & M/B, you then need to write three interventions
for each problem you identify. When deciding on your interventions include
interventions that focus solely on the problem and the signs and the symptoms
(manifestations) of the problem (Nursing Diagnosis).
Then, for each intervention
you need to state why (rationale) you did this. Do not concern yourself with
evaluation at this stage.
When learning Nursing
Diagnosis it is important to stay away from using medical language and to
separate all the different problems out from each other. When you register as a
Nurse and are working on the ward, it may be that you throw all the problems
together and just come up with one Nursing Diagnosis that covers all your
patient’s problems. You may find that many problems cross over. At this stage
you need to tediously identify them all.
When you have finished, these
interventions form the foundation for a Nursing care plan that goes at the foot
of the bed as a guide to Nursing Care.
The only time you will be
expected to do this on clinical placement is under the supervision of your
clinical teacher, in your log book, for practice only
...................................................................................................................................................................
Here
are some already completed examples
1.
Mr. Sampson is 83. He is admitted following a fall at home.
His weight is low at 46kg. He has no teeth or dentures
Nursing
Diagnosis
Altered
Nutrition less than body requirements
Related to (cause)
No
dentures
Manifested by (signs and symptoms)
Weight
of 48 kg
Interventions
Encourage
a well balanced diet…..
Explain
to the patient the importance of diet.
Assist
with meals
Ensure
food are soft and of preference
Rationale
To achieve substantial weight gain.
..................................................................................................................................................................
2.
Mr. Johns has been admitted with a stage 1 pressure sore. He is incontinent and
cannot use a urinal because of contractures of his lower limbs.
Nursing
Diagnosis
Incontinence
Related
to (cause)
Contractures
Manifested
by (signs and symptoms)
Frequent
wet beds especially at night
Interventions
Offer
urinal 2/24
Continence
plan
Buzzer
close at hand
Use
of kylie at night
Rationale
To
resolve incontinence
To prevent pressure area sores that result from constant exposure of skin to urine