UNIT 5 Nursing Diagnosis

Introduction
Nursing Diagnosis
Simply put, a nursing diagnosis is a standardized statement about the health
of a client for the purpose of providing nursing care. NANDA-International
(North American Nursing Diagnosis Association is an organization that has
helped in setting and de!ning standard diagnosis. "he NANDA system has
identi!ed three di#erent types of diagnosis and they are$ actual diagnosis, ris%
diagnosis, and &ellness diagnosis. In the follo&ing modules, you &ill listen to
actual dialogue, practice note ta%ing, as &ell as, !ll out di#erent forms
according to information given to you.
Content goals
In this module the student &ill$
'. (evie& and use phrases and idioms people used &hen ma%ing an actual
diagnosis
). Identify and demonstrate proper note-ta%ing techni*ues+ ta%e notes of
an actual diagnosis
,. Identify and use some common medical abbreviations used in recording
actual diagnosis
-. .onduct an intervie& &ith a patient ma%ing an actual diagnosis
/. Identify actual diagnosis t&o-part statements
0. (evie& the present perfect continuous tense
'
1. 2ractice ma%ing t&o-statement actual nursing diagnosis
3. Identify &ays to improve communication bet&een health care &or%ers
and clients.
Unit 5 ACTUAL DIAGNOSIS
H5:1 Terminology/Voa!ulary De"elo#ment

A. (ead the follo&ing &ords 4 phrases, their de!nitions and e5ample of usage.
6. (ead the sentences and choose the best &ord from the bo5 to complete each
sentence.
ta%e a loo% at &orn out acute pain pic% (
up scared
)
Idiom/ phrase/word Meaning Example
really scared very frightened, very afraid 7hen 8anet learned she needed surgery
she &as really scared
bringing up
blood
coughing 4 vomiting blood 6ringing up blood can be a frightening
sight.
on top of it all to ma%e things &orse I9ve had a bad day, on top of it all, I lost
my &allet.
&orn out e5hausted, very tired,
fatigued
"he ne& mother al&ays felt worn out.
lost all my
appetite
&as not hungry After hearing the bad ne&s, I lost all my
appetite.
can9t catch my
breath
di:culty in breathing After coughing non-stop for ten minutes,
I couldnt catch my breath.
had the runs diarrheaddd di diarrhea (osa complained of having the runs.
go to the
bathroom
;se the toilet to urinate or
defecate
6efore leaving the house, Alice had
gone to the bathroom.
acute pain sharp pain, e5treme
pain
"he patient complained of acute pain in
her abdomen.
ta%e a loo% at e5amine, chec% "he dentist took a look at 8anet9s bro%en
tooth.
pic% (you up to collect someone in your
car
<isa9s mother picked her up from the
mall.
'. One of the symptoms of appendicitis is ____________________ in the abdominal area.
). I9d li%e the doctor to ==================my foot. It loo%s s&ollen.
,. >elinda told her gynecologist ho& =================she felt about giving birth.
-. "he children &aited for their parents to ===================from school.
/. After being sic% for three days and not being able to eat &ell, the patient felt
================.
Unit 5 ACTUAL DIAGNOSIS
H5:$ Listening % &riting

A' Listen to an( om#lete t)e *ollo+ing sentenes +it) t)e +or(s an(
e,#ressions *rom your "oa!ulary list'
'. >r. 8ohnson complained of ======================and feeling
==========================.
). Another complaint that >r. 8ohnson had &as the fact that he could not
====================== very &ell.
,. Nurse Adams as%ed >r. 8ohnson &hy he felt ========================== .
-. ?ne of the side e#ects of the medication that >r. 8ohnson &as ta%ing &as that
it made him =============================.
/. ==================== is another &ay that some people use to describe the term
diarrhea.
0. <uc%ily, >r. 8ohnson did not su#er from any ========================.
1. "he nurse felt that a doctor should ======================== at the patient and
had an ambulance sent out to ==========================.
-' Listen to t)e *ollo+ing #)one on"ersation !et+een a nurse on t)e
nurse a("ie line an( a #atient' .ou +ill )ear t)e on"ersation t+ie'
T)e /rst time 0ust listen1 t)e seon( time /ll in t)e !lan2s +it) t)e
#)rases1 letters or num!ers you )ear' 3inally1 listen again an( re)e2
your ans+ers'
Nurse$ @ood afternoon. I9m 8oy Adams, and I9ll be your nurse this afternoon. >ay I
please have your name and the last
=======================================================A
4atient$ >ar% 8ohnson (in a &ea% voice.
Nurse$ "hat9s 8ohnson, === === === === === === ===A
,
4atient$ Bes. I don9t feel &ell right no& and I9m======================.
Nurse$ I understand >r. 8ohnson but could you please tell me the last four digits of your
social security numberA
4atient$ ?hC;mmmC. === === === === No, no, it9s === === === ===.
Nurse$ "han% you. >r. 8ohnson, ==================================A
4atient$ I9ve been coughing and ============================== all day and
======================= I feel =======================.
Nurse$ Do& long have you been coughing up bloodA
4atient$ Since yesterday.
Unit 5 ACTUAL DIAGNOSIS
H5:$ 5Cont'6
Nurse$ >r. 8ohnson, ho& many times have you coughed up blood todayA
4atient$ I don9t %no&CCCCCC..lets seeCCCCC..ummmCCCC
================================ at least.
Nurse: Do& long have you been feeling tired and &orn outA
4atient: I started feeling tired around si5 &ee%s ago- around the time I started ta%ing
my medicine.
Nurse: I see. >r. 8ohnson, can you give me the name of the medication you are ta%ing
and tell me &hy you are ta%ing itA
4atient: I have AIDS and so the doctor gave me something by the name ofCC.I don9t
%no&, it starts &ith a Ez9. Dold on Fust a minute (pauseC.here it is. <et me spell it for
youC. === === === === === === === === === ===and === === === === === === === ===
===. 6ut the medicine is Fust ma%ing me feel &orse. I can9t eat and have
==============================.
Nurse$ "han% you >r. 8ohnson. "ell me, are you having any
==============================A
4atient$ 7ell, I can9t really =========================== very &ell and have
======================= for the past couple of days.
Nurse$ Are you having di:culty breathing no&A
4atient: 8ust a little.
Nurse$ Do& many times have you ============================ todayA
4atient: So many times I9ve lost count.
-
Nurse$ >r. 8ohnson, other than coughing up blood, having diarrhea, feeling tired, and
having di:culty breathing, are you in any ========================A
4atient$ No.
Nurse$ >r. 8ohnson, I feel a doctor should ========================= you. An ambulance
&ill be there soon to =========================.

Unit 5 ACTUAL DIAGNOSIS
H5:7 Note Ta2ing

Note Ta2ing:
A' Ti#s *or ta2ing notes +)ile ma2ing a nursing (iagnosis:
7hen ma%ing a nursing diagnosis the t&o most common formats used are the
t&o-part statement and the three-part statement. "he t&o-part statement is
NANDA approved and used by most nurses because of its brief and precise
format. Gor nurses &ho &ish to add more information to the diagnostic statement,
the three-part statement is used. "he follo&ing is a list of t&o-part statements
that could be used in ma%ing an actual nursing diagnosis in this module$
Acute pain
An5iety
Aspiration ris%
6lood pressure alteration
6ody nutrition de!cit
6ody nutrition de!cit ris%
6o&el elimination alteration
6o&el incontinence
6reathing pattern
impairment
.aregiver role strain
.hronic lo& self-esteem
disturbance
.omfort alteration
Decisional conHict
Diarrhea
Gatigue
Gear
Gluid volume alteration
Gluid volume de!cit
Gluid volume de!cit ris%
@astrointestinal alteration
Dopelessness
Immunologic alteration
Individual coping
impairment
Infection ris%
Infection unspeci!ed
/
Ino&ledge de!cit of
disease
>edication ris%
>emory impairment
Nausea
Nutrition alteration
Self concept alteration
Sleep deprivation
-' Using as many as t)e a!o"e t+o8#art statements as #ossi!le ma2e
an atual (iagnosis a!out 9r' :o)nson;s ase'
==================================================================================
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Unit 5
H5:< ACTUAL DIAGNOSIS
Listening % &riting
Listening:
-' Listen are*ully an( /ll in t)e !lan2s +it) t)e a##ro#riate t+o8#art
statement'
'. Among people over the age of 0/, &omen more fre*uently e5perience
=============================.
). In infants and children (especially under age ,, ================== is more concerning
because they can become dehydrated fairly *uic%ly.
,. ===================== is a feeling of apprehension and fear characterized by physical
symptoms such as palpitations, s&eating, and feelings of stress.
-. Diminished or inability to recall past events is called =============================.
/. =================== is the despair you feel &hen you have abandoned hope of comfort
or success.
0. ================ may be a symptom of a variety of disorders, some minor and some
more serious.
0
1. 7omen &ho face di:cult health decisions are li%ely to e5perience
========================= '
3. "he e#ects of ======================== lead to impaired hearing, sight, brain function,
mental alertness, as &ell as physical ability, meaning slo& reHe5es and clumsiness.
J. Any change or modi!cation of the stomach or intestines is %no&n as
=============================.
'K. It has been observed that ============================ follo& acute stro%e,
particularly

a reduction in the day-night di#erence and a transient elevation

in blood
pressure after stro%e.
C' Critial T)in2ing: In +)at +ay is a t+o8#art statement (i=erent *rom a t)ree8#art
statement>
=========================================================================================
=========================================================================================
=========================================================================================
===
D' Use t)e *ollo+ing t+o8#art statements in sentenes o* your o+n'
'.
fatigue$=================================================================================
). body nutrition
de!cit$======================================================================
==========================================================================================
,. infection unspeci!ed$
=====================================================================
==========================================================================================
Unit 5 ACTUAL DIAGNOSIS
H5:5
Grammar Ti#s
Grammar Note: 4resent 4er*et Continuous Tense
In this module, the present perfect continuous tense has been used throughout
the telephone conversation.
L.g. I have been coughing all day.
L.g. Do& long have you been coughing up bloodA
1
"he present perfect continuous tense is used to describe an action that started
sometime in the past and has continued up until the present.

When we want to describe an action that started in the past and has continued up to the present we
use the following formula:
su!0et ? )a"e/)as ? "er! ? ing
I have been &or%ing all day. De has been &or%ing all
day.
Bou have been &or%ing all day. She has been &or%ing all
day.
7e have been &or%ing all day. It has been &or%ing all day.
"hey have been &or%ing all day.
A' 4ut t)e "er!s into t)e orret *orm 5#resent #er*et ontinuous6'
'. Dr. 7elch =======================(chec% in on his patient all night.
). >rs. >artinez =======================(have contractions since this morning.
,. "he nurse on duty ========================(administer non-narcotic cough
suppressants to
the patient as ordered by the physician.
-. Do& long has the patient been having di:culty breathingA
De ==========================(have di:culty breathing for at least !ve
hours.
/. Do& long ============================(&or% 4 you at the hospital as a nurseA
Unit 5 ACTUAL DIAGNOSIS
H5:@
Case Stu(ies
A' Stu(y t)e *ollo+ing ase an( !e #re#are( to as2 9ary Auestions
ena!ling you to ma2e a orret atual nursing (iagnosis'
Case B 1
3
>ary (ogers came into the clinic for her si5-&ee% post-partum visit. Bou noticed the
follo&ing behaviors$ >ary, age )3, handled her baby &ith con!dence &hen holding and
feeding the baby. Do&ever, she loo%ed distracted and fatigued. 7hen the baby started
crying, >ary seemed to get irritated and upset.
Case B $
8ac% Man, age 11, came into the clinic for his bi-annual chec%-up. "he nurse on duty
noticed that >r. Man had lost a lot of &eight since his last visit. De also complained of
insomnia, energy loss, inability to thin%, and e5pressed the fact that he felt he &as no
longer living a meaningful life.
-' &rite (o+n some #ossi!le Auestions t)at you mig)t as2 9rs' Cogers to
ma2e an atual nursing (iagnosis' Try to as2 Auestions using t)e #resent
#er*et ontinuous *orm'
Case 1
'. ============================================================================
). ============================================================================
,. ============================================================================
-. ============================================================================
/. ============================================================================
&rite (o+n some #ossi!le Auestions t)at you mig)t as2 9r' Van to ma2e an
atual nursing (iagnosis' Try to as2 Auestions using t)e #resent #er*et
ontinuous *orm'
Case $
0. ============================================================================
1. ============================================================================
3. ============================================================================
J. ============================================================================
'K. ============================================================================
Unit 5 ACTUAL DIAGNOSIS
H5:D
Case Stu(ies
-' &rite (o+n an atual nursing (iagnosis *or ea) ase' Use as many t+o8#art
statements as #ossi!le'

J
Case B 1
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=======================================================================================

Case B $
=======================================================================================
=======================================================================================
=======================================================================================
=======================================================================================
'K
Unit 5 ACTUAL DIAGNOSIS
H5:D
Summary
Cea(ing Com#re)ension an( Note Ta2ing
A' Cea( t)e *ollo+ing #assage #aying attention to t)e un(erline(
+or(s'
A nursing diagnosis is a clinical diagnosis made by a registered nurse, in
contrast to a >DNs diagnosis, the nursing diagnosis does not cover the patientNs
medical condition, but the patientNs response to the medical condition. >ost
patients usually have multiple nursing diagnosis covering everything from their
physical &ell-being through their psychosocial &ell-being to the &ell-being of
their family and caregivers. "hese diagnoses must cover problems that the
nurse can treat independently of the physician. A complete nursing diagnosis is
&ritten in the format problem related to cause of problem as evidenced by
symptoms of problem .
"he NANDA system has identi!ed three di#erent types of diagnosis and they
are$ actual diagnosis, ris% diagnosis, and &ellness diagnosis. "he actual
diagnosis is a statement made by a licensed nurse identifying a health problem
that the client has and the bene!t from nursing care. An e5ample of an actual
nursing diagnosis might be the follo&ing$ Inefective airway clearance related
to decreased energy as manifested by an inefective cough. "here are a couple
of rules to remember &hen &riting a t&o or three-part statement$
Do not &rite a diagnostic statement in such a &ay that it may be legally
incriminating.
Do not &rite a diagnostic statement based on value Fudgment.
Do not rename a medical problem to ma%e it sound li%e a nursing
diagnosis.
Do not ma%e a nursing diagnosis out of a physicians orders.
Do not state or &rite t&o problems at the same time.
In summary, a nursing statement implies that the patient needs nursing care.
Applying Nursing Process, Rosalinda Alfaro-Lee!re
Unit 5 ACTUAL DIAGNOSIS
H5:E
Summary
Cea(ing Com#re)ension an( Note Ta2ing
-' Listen to t)e *ollo+ing #assage one t)en listen again /lling in
t)e !lan2s'
A =================== is a =================diagnosis made by a
============= nurse, in contrast to a >DNs diagnosis, the nursing diagnosis
does not cover the ============== medical ===============, but the patientNs
response to the ===============condition. >ost patients usually have
=============== nursing diagnosis covering everything from their
====================== through their ================ &ell-being to the &ell-
being of their family and ==================. "hese diagnoses must cover
problems that the nurse can treat ================of the physician. A
==============nursing diagnosis is &ritten in the ======================to
======================as evidenced by ========================.
"he ==============system has identi!ed =========== di#erent types of
diagnosis and they are$ ==========diagnosis, =========== diagnosis, and
=========== diagnosis. "he actual diagnosis is a ================== made by
a ================ nurse identifying a health problem that the ==============
has and the bene!t from nursing care. An =============of an actual nursing
diagnosis might be the follo&ing$ ========================related to
decreased energy as _____________by an====================. "here are a
couple of rules to remember &hen &riting a t&o or three-part statement$
Do not &rite a diagnostic statement in such a &ay that it may be
===================
Do not &rite a diagnostic statement based on ========================.
Do not rename a ======================to ma%e it sound li%e a nursing
diagnosis.
Do not ma%e a nursing diagnosis out of a ========================.
Do not ======================t&o problems at the same time.
In summary, a ====================implies that the patient needs
==================.
Unit 5 Ans+er Fey / Atual Diagnosis
H5:1
Terminology/Voa!ulary De"elo#ment

A. (ead the follo&ing &ords 4 phrases, their de!nitions and e5ample of usage.
Idiom/ phrase/word Meaning Example
really scared very frightened, very afraid 7hen 8anet learned she needed surgery
she &as really scared
bringing up
blood
coughing 4 vomiting blood 6ringing up blood can be a frightening
site.
on top of it all to ma%e things &orse I9ve had a bad day, on top of it all, I lost
my &allet.
&orn out e5hausted, very tired,
fatigued
"he ne& mother al&ays felt worn out.
lost all my
appetite
&as not hungry After hearing the bad ne&s, I lost all my
appetite.
can9t catch my
breath
di:culty in breathing After coughing non-stop for ten minutes,
I couldnt catch my breath.
had the runs diarrheaddd di diarrhea (osa complained of having the runs.
go to the
bathroom
;se the toilet to urinate or
defecate
6efore leaving the house, Alice had
gone to the bathroom.
acute pain sharp pain, e5treme
pain
"he patient complained of acute pain in
her abdomen.
ta%e a loo% at e5amine, chec% "he dentist took a look at 8anet9s bro%en
tooth.
pic% (you up to collect someone in your
car
<isa9s mother picked her up from the
mall.
6. (ead the sentences and choose the best &ord from the bo5 to complete each
sentence.
ta%e a loo% at &orn out acute pain pic% (
up scared
'. One of the symptoms of appendicitis is acute pain in the abdominal area.
). I9d li%e the doctor to ta2e a loo2 at my foot. It loo%s s&ollen.
,. >elinda told her gynecologist ho& sare( she felt about giving birth.
-. "he children &aited for their parents to #i2 t)em u# from school.
/. After being sic% for three days and not being able to eat &ell, the patient felt +orn
out.
Unit 5 Ans+er Fey / Atual Diagnosis
H5:$


C' Cea( t)e *ollo+ing #assage t+ie' T)e /rst time rea( at a
normal s#ee(1 an( on t)e seon( time rea( at a slo+er s#ee('
Nurse$ @ood afternoon. I9m 8oy Adams, and I9ll be your nurse this afternoon. >ay
I please have your name and the last *our (igits o* your soial seurity
num!erA
4atient$ >ar% 8ohnson (in a &ea% voice.
Nurse$ "hat9s 8ohnson, : o ) n s o nA
4atient$ Bes. I don9t feel &ell right no& and I9m really sare(.
Nurse$ I understand >r. 8ohnson but could you please tell me the last four digits of
your social security numberA
4atient$ ?hC;mmmCC@@G5 . No, no, it9s D@G5.
Nurse$ "han% you. >r. 8ohnson, +)at is saring youA
4atient$ I9ve been coughing and !ringing u# !loo( all day and on to# o* it all I
feel +orn out.
Nurse$ Do& long have you been coughing up bloodA
4atient$ Since yesterday.
Nurse$ >r. 8ohnson, ho& many times have you coughed up blood todayA
4atient$ I don9t %no&CCCCCC..lets seeCCCCC..ummmCCCC/"e or si,
times at least.
Nurse: Do& long have you been feeling tired and &orn outA
4atient: I started feeling tired around si5 &ee%s ago- around the time I started
ta%ing my medicine.
Nurse: I see. >r. 8ohnson, can you give me the name of the medication you are
ta%ing and tell me &hy you are ta%ing itA
4atient: I have AIDS and so the doctor gave me something by the name ofCC.I
don9t %no&, it starts &ith a Ez9. Dold on Fust a minute (pauseC.here it is. <et me
spell it for youC. H i ( o " u ( i n e and i n ( i n a " a r . 6ut the medicine is
Fust ma%ing me feel &orse. I can9t eat and have lost all my appetite.
Nurse$ "han% you >r. 8ohnson. "ell me, are you having any (iIulty !reat)ingA
4atient$ 7ell, I can9t really at) my !reat) very &ell and have )a( t)e runs
for the past couple of days.
Nurse$ Are you having di:culty breathing no&A
Unit 5 Ans+er Fey / Atual Diagnosis
H5:$ 5Cont'6

4atient: 8ust a little.
Nurse$ Do& many times have you gone to t)e !at)room todayA
4atient: So many times I9ve lost count.
Nurse$ >r. 8ohnson, other than coughing up blood, having diarrhea, feeling tired,
and having di:culty breathing, are you in any aute #ainA
4atient$ No.
Nurse$ >r. 8ohnson, I feel a doctor should ta2e a loo2 at you. An ambulance &ill
be there soon to #i2 you u#'

D' Cea( t)e *ollo+ing sentenes t+ie' T)e /rst time rea( at a
normal #ae1 an( on t)e seon( time rea( at a slo+er #ae'
'. >r. 8ohnson complained of !ringing u# !loo( and feeling +orn out.
). Another complaint that >r. 8ohnson had &as the fact that he could not
at) )is !reat) very &ell.
,. Nurse Adams as%ed >r. 8ohnson &hy he felt really sare( .
-. ?ne of the side e#ects of the medication that >r. 8ohnson &as ta%ing &as
that it made him lose )is a##etite.
/. T)e runs is another &ay that some people use to describe the term
diarrhea.
0. <uc%ily, >r. 8ohnson did not su#er from any aute #ain.
1. "he nurse felt that a doctor should ta2e a loo2 at the patient and had
an ambulance sent out to #i2 )im u#.


Unit 5 Ans+er Fey / Atual Diagnosis
H5:< Listening % &riting
Listening:
-' Cea( t)e *ollo+ing sentenes t+ie' T)e /rst time rea( at a
normal s#ee(1 an( on t)e seon( time rea( at a slo+er s#ee( so
t)at stu(ents may +rite in t)e a##ro#riate t+o8#art statement'
'. Among people over the age of 0/, &omen more fre*uently e5perience !o+el
inontinene.
). In infants and children (especially under age ,, (iarr)ea is more concerning
because they can become dehydrated fairly *uic%ly.
,. An,iety is a feeling of apprehension and fear characterized by physical
symptoms such as palpitations, s&eating, and feelings of stress.
-. Diminished or inability to recall past events is called memory im#airment.
/. Ho#elessness is the despair you feel &hen you have abandoned hope of comfort or
success.
0. Nausea may be a symptom of a variety of disorders, some minor and some more
serious.
1. 7omen &ho face di:cult health decisions are li%ely to e5perience (eisional
onJit '
3. "he e#ects of slee# (er#ri"ation lead to impaired hearing, sight, brain function,
mental alertness, as &ell as physical ability, meaning slo& reHe5es and clumsiness.
J. Any change or modi!cation of the stomach or intestines is %no&n as
gastrointestinal alteration'
'K. It has been observed that !loo( #ressure alterations follo& acute stro%e,
particularly

a reduction in the day-night di#erence and a transient elevation

in blood
pressure after stro%e.
C' Critial T)in2ing: In +)at +ay is a t+o8#art statement (i=erent *rom a
t)ree8#art statement>
T)e t+o8#art statement is a #ro!lem statement t)at (esri!es t)e #atient;s
res#onse to a #otential )ealt) #ro!lem an( t)e etiology 5relate( ause or
ontri!utor to #ro!lem6' T)e t)ree8#art statement ontains t)e /rst t+o
om#onents in t)e t+o8#art statement Kin a((ition1 to a (e/ning
)arateristis om#onent'
D' Use t)e *ollo+ing t+o8#art statements in sentenes o* your o+n'
Ans+ers +ill "ary'
'.
fatigue$==============================================================================
). body nutrition
de!cit$===================================================================
,. infection unspeci!ed$
====================================================================
Unit 5 Ans+er Fey / Atual Diagnosis
H5:5
Grammar Ti#s
Grammar Note: 4resent 4er*et Continuous Tense
In this module, the present perfect continuous tense has been used
throughout the telephone conversation.
L.g. I have been coughing all day.
L.g. Do& long have you been coughing up bloodA
"he present perfect continuous tense is used to describe an action that started
sometime in the past and has continued up until the present.

When we want to describe an action that started in the past and has continued up to the present
we use the following formula:
su!0et ? )a"e/)as ? "er! ? ing
I have been &or%ing all day.
De has been &or%ing all day.
Bou have been &or%ing all day.
She has been &or%ing all day.
7e have been &or%ing all day.
It has been &or%ing all day.
"hey have been &or%ing all day.
A' 3ill in t)e !lan2s +it) t)e orret *orm o* t)e "er!s'
'. Dr. 7elch )as !een )e2ing (chec% in on his patient all night.
). >rs. >artinez )as !een )a"ing (have contractions since this morning.
,. "he nurse on duty )as !een a(ministering (administer non-narcotic
cough suppressants to the patient as ordered by the physician.
-. Do& long has the patient been having di:culty breathingA
De )as !een )a"ing (have di:culty breathing for at least !ve hours.
/. Do& long )a"e you !een +or2ing (&or% 4 you at the hospital as a nurseA
Unit 5 Fey/ Atual Diagnosis
H5:@
Case Stu(ies
A' Stu(y t)e *ollo+ing ase an( !e #re#are( to as2 9ary Auestions
ena!ling you to ma2e a orret atual nursing (iagnosis'
Case B 1
>ary (ogers came into the clinic for her si5-&ee% post-partum visit. Bou noticed the
follo&ing behaviors$ >ary, age )3, handled her baby &ith con!dence &hen holding and
feeding the baby. Do&ever, she loo%ed distracted and fatigued. 7hen the baby started
crying, >ary seemed to get irritated and upset.
Case B $
8ac% Man, age 11, came into the clinic for his bi-annual chec%-up. "he nurse on duty
noticed that >r. Man had lost a lot of &eight since his last visit. De also complained of
insomnia, energy loss, inability to thin%, and e5pressed the fact that he felt he &as no
longer living a meaningful life.
-' &rite (o+n some #ossi!le Auestions t)at you mig)t as2 9rs' Cogers to
ma2e an atual nursing (iagnosis' Try to as2 Auestions using t)e #resent
#er*et ontinuous *orm' Ans+ers +ill "ary'
Case 1
'. Ha"e you !een getting enoug) rest at nig)t>
). Has t)e !a!y !een letting you get enoug) rest (uring t)e (ay>
,. Ha"e you !een )a"ing (iIulty onentrating>
-. Ha"e you e"er !een (e#resse( !e*ore>
/. Ha"e you !een ta2ing any me(iation>
Case $
&rite (o+n some #ossi!le Auestions t)at you mig)t as2 9r' Van to ma2e an
atual nursing (iagnosis' Try to as2 Auestions using t)e #resent #er*et
ontinuous *orm'
'. Ha"e you !een eating #ro#erly>
). Has somet)ing !een +orrying you t)at 2ee#s you a+a2e at nig)t>
,. Ha"e you !een e,erising regularly>
-. Ha"e you !een staying at )ome all (ay !y yoursel* or )a"e you !een going out>
/. Do you !elong to a )ur)1 synagogue1 mosAue or any ot)er religious aIliate>
Unit 5 Fey/ Atual Diagnosis
H5:D
Case Stu(ies
C'&rite (o+n an atual nursing (iagnosis *or ea) ase' Use as many t+o8
#art statements as #ossi!le'

Case B 1
Ans+ers +ill "ary

Case B $
Ans+ers +ill "ary
Unit 5 Fey/ Atual Diagnosis
H5:D
Summary
Cea(ing Com#re)ension an( Note Ta2ing
Diretions: Cea( t)e *ollo+ing #assage one at normal s#ee(' On
t)e seon( time1 rea( at a slo+er #ae'
A nursing (iagnosis is a linial diagnosis made by a registere(
nurse, in contrast to a >DNs diagnosis, the nursing diagnosis does not cover
the #atientLs medical on(ition, but the patientNs response to the me(ial
condition. >ost patients usually have multi#le nursing diagnoses covering
everything from their #)ysial +ell8!eing through their #sy)osoial
&ell-being to the &ell-being of their family and aregi"ers. "hese
diagnoses must cover problems that the nurse can treat in(e#en(ently of
the physician. A om#lete nursing diagnosis is &ritten in the *ormat
problem relate( to cause of problem as evidenced by symptoms of
problem '
"he NANDA system has identi!ed t)ree di#erent types of diagnosis and
they are$ atual diagnosis, ris2 diagnosis, and +ellness diagnosis. "he
actual diagnosis is a statement made by a liense( nurse identifying a
health problem that the lient has and the bene!t from nursing care. An
e,am#le of an actual nursing diagnosis might be the follo&ing$ Inefective
airway clearance related to decreased energy as manifested by an
inefective cough. "here are a couple of rules to remember &hen &riting a
t&o or three-part statement$
Do not &rite a diagnostic statement in such a &ay that it may be
legally inriminating'
Do not &rite a diagnostic statement based on "alue 0u(gment.
Do not rename a me(ial #ro!lem to ma%e it sound li%e a nursing
diagnosis.
Do not ma%e a nursing diagnosis out of a #)ysiians or(ers.
Do not state or +rite t&o problems at the same time.
In summary, a nursing statement implies that the patient needs nursing
are.
Applying Nursing Process, Rosalinda Alfaro-Lee!re