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 defining standard diagnosis. The

NANDA system has identified three different types of diagnosis and they are: actual diagnosis,

risk diagnosis, and wellness diagnosis. In the following modules, you will listen to actual dialogue,

practice note taking, as well as, fill out different forms according to information given to you.

Content goals

In this module the student will:

1. Review and use phrases and idioms people used when making an actual diagnosis 2. Identify and demonstrate proper note-taking techniques; take notes of an actual diagnosis3. Identify and use some common medical abbreviations used in recording actual diagnosis4. Conduct an interview with a patient making an actual diagnosis5. Identify actual diagnosis two-part statements6. Review the present perfect continuous tense 7. Practice making two-statement actual nursing diagnosis8. Identify ways to improve communication between health care workers and clients.

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Unit 5 ACTUAL DIAGNOSIS H5:1 Terminology/Vocabulary Development

Idiom/ phrase/word Meaning Example

really scared very frightened, very afraid When Janet learned she needed surgery she was really scared

bringing up blood coughing / vomiting blood Bringing up blood can be a frightening sight.

on top of it all to make things worse I’ve had a bad day, on top of it all, I lost my wallet.

worn out exhausted, very tired, fatigued The new mother always felt worn out.

lost all my appetite was not hungry After hearing the bad news, I lost all my appetite.

can’t catch my breath difficulty in breathing After coughing non-stop for ten minutes, I couldn’t catch my breath.

had the runs di diarrhea Rosa complained of having the runs.

go to the bathroom Use the toilet to urinate or defecate

Before leaving the house, Alice had gone to the bathroom.

acute pain sharp pain, extreme pain The patient complained of acute pain in her abdomen.

take a look at examine, check The dentist took a look at Janet’s broken tooth.

pick (you) up to collect someone in your car Lisa’s mother picked her up from the mall.

A. Read the following words / phrases, their definitions and example of usage.

B. Read the sentences and choose the best word from the box to complete each sentence.

take a look at worn out acute pain pick ( ) up scared

1. One of the symptoms of appendicitis is ____________________ in the abdominal area.

2. I’d like the doctor to __________________my foot. It looks swollen.

3. Melinda told her gynecologist how _________________she felt about giving birth.

4. The children waited for their parents to ___________________from school.

5. After being sick for three days and not being able to eat well, the patient felt ________________.

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Unit 5 ACTUAL DIAGNOSIS H5:2 Listening & Writing

A. Listen to and complete the following sentences with the words and expressions from your vocabulary list.

1. Mr. Johnson complained of ______________________and feeling __________________________.

2. Another complaint that Mr. Johnson had was the fact that he could not ______________________

very well.

3. Nurse Adams asked Mr. Johnson why he felt __________________________ .

4. One of the side effects of the medication that Mr. Johnson was taking was that it made him

_____________________________.

5. ____________________ is another way that some people use to describe the term diarrhea.

6. Luckily, Mr. Johnson did not suffer from any ________________________.

7. The nurse felt that a doctor should ________________________ at the patient and had an

ambulance sent out to __________________________.

B. Listen to the following phone conversation between a nurse on the nurse advice line and a patient. You will hear the conversation twice. The first time just listen, the second time fill in the blanks with the phrases, letters or numbers you hear. Finally, listen again and recheck your answers.

Nurse: Good afternoon. I’m Joy Adams, and I’ll be your nurse this afternoon. May I please have your name and the last _______________________________________________________?

Patient: Mark Johnson (in a weak voice).

Nurse: That’s Johnson, ___ ___ ___ ___ ___ ___ ___?

Patient: Yes. I don’t feel well right now and I’m______________________.

Nurse: I understand Mr. Johnson but could you please tell me the last four digits of your social security number?

Patient: Oh…Ummm…. ___ ___ ___ ___ No, no, it’s ___ ___ ___ ___.

Nurse: Thank you. Mr. Johnson, __________________________________?

Patient: I’ve been coughing and ______________________________ all day and _______________________ I feel _______________________.

Nurse: How long have you been coughing up blood?

Patient: Since yesterday.

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Unit 5 ACTUAL DIAGNOSIS H5:2 (Cont.)

Nurse: Mr. Johnson, how many times have you coughed up blood today?

Patient: I don’t know………………..lets see……………..ummm…………________________________________ at least.

Nurse: How long have you been feeling tired and worn out?

Patient: I started feeling tired around six weeks ago- around the time I started taking my medicine.

Nurse: I see. Mr. Johnson, can you give me the name of the medication you are taking and tell me why you are taking it?

Patient: I have AIDS and so the doctor gave me something by the name of…….I don’t know, it starts with a ‘z’. Hold on just a minute (pause)….here it is. Let me spell it for you…. ___ ___ ___ ___ ___ ___ ___ ___ ___ ___and ___ ___ ___ ___ ___ ___ ___ ___ ___. But the medicine is just making me feel worse. I can’t eat and have ______________________________.

Nurse: Thank you Mr. Johnson. Tell me, are you having any ______________________________?

Patient: Well, I can’t really ___________________________ very well and have _______________________ for the past couple of days.

Nurse: Are you having difficulty breathing now?

Patient: Just a little.

Nurse: How many times have you ____________________________ today?

Patient: So many times I’ve lost count.

Nurse: Mr. Johnson, other than coughing up blood, having diarrhea, feeling tired, and having difficulty breathing, are you in any ________________________?

Patient: No.

Nurse: Mr. Johnson, I feel a doctor should _________________________ you. An ambulance will be there soon to _________________________.

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Unit 5 ACTUAL DIAGNOSIS H5:3 Note Taking

Note Taking:

A. Tips for taking notes while making a nursing diagnosis:When making a nursing diagnosis the two most common formats used are the two-part statement and the three-part statement. The two-part statement is NANDA approved and used by most nurses because of its brief and precise format. For nurses who wish to add more information to the diagnostic statement, the three-part statement is used. The following is a list of two-part statements that could be used in making an actual nursing diagnosis in this module:

Acute pain Anxiety

Aspiration risk

Blood pressure alteration

Body nutrition deficit

Body nutrition deficit risk

Bowel elimination alteration

Bowel incontinence

Breathing pattern impairment

Caregiver role strain

Chronic low self-esteem disturbance Comfort alteration Decisional conflict

Diarrhea Fatigue Fear Fluid volume alteration Fluid volume deficit Fluid volume deficit risk Gastrointestinal alteration Hopelessness Immunologic alteration Individual coping impairment Infection risk Infection unspecified Knowledge deficit of disease Medication risk Memory impairment Nausea Nutrition alteration Self concept alteration Sleep deprivation

B. Using as many as the above two-part statements as possible make an actual diagnosis about Mr. Johnson’s case.

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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__________________________________________________________________________________

__________________________________________________________________________________

Unit 5 H5:4 ACTUAL DIAGNOSIS

Listening & WritingListening:

B. Listen carefully and fill in the blanks with the appropriate two-part statement.

1. Among people over the age of 65, women more frequently experience _____________________________.

2. In infants and children (especially under age 3), __________________ is more concerning because they can

become dehydrated fairly quickly.

3. _____________________ is a feeling of apprehension and fear characterized by physical symptoms such as

palpitations, sweating, and feelings of stress.

4. Diminished or inability to recall past events is called _____________________________.

5. ___________________ is the despair you feel when you have abandoned hope of comfort or success.

6. ________________ may be a symptom of a variety of disorders, some minor and some more serious.

7. Women who face difficult health decisions are likely to experience _________________________ .

8. The effects of ________________________ lead to impaired hearing, sight, brain function, mental

alertness, as well as physical ability, meaning slow reflexes and clumsiness.

9. Any change or modification of the stomach or intestines is known as _____________________________.

10. It has been observed that ____________________________ follow acute stroke, particularly a reduction in

the day-night difference and a transient elevation in blood pressure after stroke.

C. Critical Thinking: In what way is a two-part statement different from a three-part statement?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

D. Use the following two-part statements in sentences of your own.

1. fatigue:_________________________________________________________________________________

2. body nutrition deficit:______________________________________________________________________

__________________________________________________________________________________________

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3. infection unspecified: _____________________________________________________________________

__________________________________________________________________________________________

Unit 5 ACTUAL DIAGNOSIS H5:5 Grammar Tips

Grammar Note: Present Perfect Continuous Tense

In this module, the present perfect continuous tense has been used throughout the telephone conversation.

E.g. I have been coughing all day.

E.g. How long have you been coughing up blood?

The 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:

subject + have/has + verb + ing

I have been working all day. He has been working all day.

You have been working all day. She has been working all day.

We have been working all day. It has been working all day.

They have been working all day.

A. Put the verbs into the correct form (present perfect continuous).

1. Dr. Welch _______________________(check) in on his patient all night.

2. Mrs. Martinez _______________________(have) contractions since this morning.

3. The nurse on duty ________________________(administer) non-narcotic cough suppressants to

the patient as ordered by the physician.

4. How long has the patient been having difficulty breathing?

He __________________________(have) difficulty breathing for at least five hours.

5. How long ____________________________(work / you) at the hospital as a nurse?

7

Unit 5 ACTUAL DIAGNOSIS H5:6 Case Studies

A. Study the following case and be prepared to ask Mary questions enabling you to make a correct actual nursing diagnosis.

Case # 1

Mary Rogers came into the clinic for her six-week post-partum visit. You noticed the following behaviors:

Mary, age 28, handled her baby with confidence when holding and feeding the baby. However, she looked

distracted and fatigued. When the baby started crying, Mary seemed to get irritated and upset.

Case # 2

Jack Van, age 77, came into the clinic for his bi-annual check-up. The nurse on duty noticed that Mr. Van had

lost a lot of weight since his last visit. He also complained of insomnia, energy loss, inability to think, and

expressed the fact that he felt he was no longer living a meaningful life.

B. Write down some possible questions that you might ask Mrs. Rogers to make an actual nursing diagnosis. Try to ask questions using the present perfect continuous form.Case 11. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

5. ____________________________________________________________________________

Write down some possible questions that you might ask Mr. Van to make an actual nursing diagnosis. Try to ask questions using the present perfect continuous form.Case 26. ____________________________________________________________________________

7. ____________________________________________________________________________

8. ____________________________________________________________________________

9. ____________________________________________________________________________

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10. ____________________________________________________________________________

Unit 5 ACTUAL DIAGNOSIS H5:7 Case Studies

B. Write down an actual nursing diagnosis for each case. Use as many two-part statements as possible.

Case # 1

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Case # 2

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

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Unit 5 ACTUAL DIAGNOSIS H5:7 Summary

Reading Comprehension and Note Taking

A. Read the following passage paying attention to the underlined words.

A nursing diagnosis is a clinical diagnosis made by a registered nurse, in contrast to a MD's

diagnosis, the nursing diagnosis does not cover the patient's medical condition, but the patient's

response to the medical condition. Most patients usually have multiple nursing diagnosis covering

everything from their physical well-being through their psychosocial well-being to the well-being

of their family and caregivers. These diagnoses must cover problems that the nurse can treat

independently of the physician. A complete nursing diagnosis is written in the format problem

related to cause of problem as evidenced by symptoms of problem .

The NANDA system has identified three different types of diagnosis and they are: actual

diagnosis, risk diagnosis, and wellness diagnosis. The actual diagnosis is a statement made by a

licensed nurse identifying a health problem that the client has and the benefit from nursing care.

An example of an actual nursing diagnosis might be the following: Ineffective airway clearance

related to decreased energy as manifested by an ineffective cough. There are a couple of rules to

remember when writing a two or three-part statement:

Do not write a diagnostic statement in such a way that it may be legally incriminating.

Do not write a diagnostic statement based on value judgment.

Do not rename a medical problem to make it sound like a nursing diagnosis.

Do not make a nursing diagnosis out of a physicians orders.

Do not state or write two problems at the same time.

In summary, a nursing statement implies that the patient needs nursing care.

Applying Nursing Process, Rosalinda Alfaro-LeFevre

Unit 5 ACTUAL DIAGNOSIS H5:8 Summary

Reading Comprehension and Note Taking

B. Listen to the following passage once then listen again filling in the blanks.

A ___________________ is a _________________diagnosis made by a _____________

nurse, in contrast to a MD's diagnosis, the nursing diagnosis does not cover the

______________ medical _______________, but the patient's response to the

_______________condition. Most patients usually have _______________ nursing diagnosis

covering everything from their ______________________ through their ________________

well-being to the well-being of their family and __________________. These diagnoses must

cover problems that the nurse can treat ________________of the physician. A

______________nursing diagnosis is written in the ______________________to

______________________as evidenced by ________________________.

The ______________system has identified ___________ different types of diagnosis and

they are: __________diagnosis, ___________ diagnosis, and ___________ diagnosis. The

actual diagnosis is a __________________ made by a ________________ nurse identifying a

health problem that the ______________ has and the benefit from nursing care. An

_____________of an actual nursing diagnosis might be the following:

________________________related to decreased energy as _____________by

an____________________. There are a couple of rules to remember when writing a two or

three-part statement:

Do not write a diagnostic statement in such a way that it may be ___________________

Do not write a diagnostic statement based on ________________________.

Do not rename a ______________________to make it sound like a nursing diagnosis.

Do not make a nursing diagnosis out of a ________________________.

Do not ______________________two problems at the same time.

In summary, a ____________________implies that the patient needs __________________.

Unit 5 Answer Key / Actual Diagnosis H5:1 Terminology/Vocabulary Development

Idiom/ phrase/word Meaning Example

really scared very frightened, very afraid When Janet learned she needed surgery she was really scared

bringing up blood coughing / vomiting blood Bringing up blood can be a frightening site.

on top of it all to make things worse I’ve had a bad day, on top of it all, I lost my wallet.

worn out exhausted, very tired, fatigued The new mother always felt worn out.

lost all my appetite was not hungry After hearing the bad news, I lost all my appetite.

can’t catch my breath difficulty in breathing After coughing non-stop for ten minutes, I couldn’t catch my breath.

had the runs di diarrhea Rosa complained of having the runs.

go to the bathroom Use the toilet to urinate or defecate

Before leaving the house, Alice had gone to the bathroom.

acute pain sharp pain, extreme pain The patient complained of acute pain in her abdomen.

take a look at examine, check The dentist took a look at Janet’s broken tooth.

pick (you) up to collect someone in your car Lisa’s mother picked her up from the mall.

A. Read the following words / phrases, their definitions and example of usage.

B. Read the sentences and choose the best word from the box to complete each sentence.

take a look at worn out acute pain pick ( ) up scared

1. One of the symptoms of appendicitis is acute pain in the abdominal area.

2. I’d like the doctor to take a look at my foot. It looks swollen.

3. Melinda told her gynecologist how scared she felt about giving birth.

4. The children waited for their parents to pick them up from school.

5. After being sick for three days and not being able to eat well, the patient felt worn out.

Unit 5 Answer Key / Actual Diagnosis H5:2

C. Read the following passage twice. The first time read at a normal speed, and on the second time read at a slower speed.

Nurse: Good afternoon. I’m Joy Adams, and I’ll be your nurse this afternoon. May I please have your name and the last four digits of your social security number?

Patient: Mark Johnson (in a weak voice).

Nurse: That’s Johnson, J o h n s o n?

Patient: Yes. I don’t feel well right now and I’m really scared.

Nurse: I understand Mr. Johnson but could you please tell me the last four digits of your social security number?

Patient: Oh…Ummm……6695 . No, no, it’s 7695.

Nurse: Thank you. Mr. Johnson, what is scaring you?

Patient: I’ve been coughing and bringing up blood all day and on top of it all I feel worn out.

Nurse: How long have you been coughing up blood?

Patient: Since yesterday.

Nurse: Mr. Johnson, how many times have you coughed up blood today?

Patient: I don’t know………………..lets see……………..ummm…………five or six times at least.

Nurse: How long have you been feeling tired and worn out?

Patient: I started feeling tired around six weeks ago- around the time I started taking my medicine.

Nurse: I see. Mr. Johnson, can you give me the name of the medication you are taking and tell me why you are taking it?

Patient: I have AIDS and so the doctor gave me something by the name of…….I don’t know, it starts with a ‘z’. Hold on just a minute (pause)….here it is. Let me spell it for you…. z i d o v u d i n e and i n d i n a v a r . But the medicine is just making me feel worse. I can’t eat and have lost all my appetite.

Nurse: Thank you Mr. Johnson. Tell me, are you having any difficulty breathing?

Patient: Well, I can’t really catch my breath very well and have had the runs for the past couple of days.

Nurse: Are you having difficulty breathing now?

Unit 5 Answer Key / Actual Diagnosis H5:2 (Cont.)

Patient: Just a little.

Nurse: How many times have you gone to the bathroom today?

Patient: So many times I’ve lost count.

Nurse: Mr. Johnson, other than coughing up blood, having diarrhea, feeling tired, and having difficulty breathing, are you in any acute pain?

Patient: No.

Nurse: Mr. Johnson, I feel a doctor should take a look at you. An ambulance will be there soon to pick you up.

D. Read the following sentences twice. The first time read at a normal pace, and on the second time read at a slower pace.

1. Mr. Johnson complained of bringing up blood and feeling worn out.

2. Another complaint that Mr. Johnson had was the fact that he could not catch his breath

very well.

3. Nurse Adams asked Mr. Johnson why he felt really scared .

4. One of the side effects of the medication that Mr. Johnson was taking was that it made him

lose his appetite.

5. The runs is another way that some people use to describe the term diarrhea.

6. Luckily, Mr. Johnson did not suffer from any acute pain.

7. The nurse felt that a doctor should take a look at the patient and had an ambulance sent

out to pick him up.

Unit 5 Answer Key / Actual Diagnosis H5:4 Listening & Writing

Listening:B. Read the following sentences twice. The first time read at a normal speed, and on the second time read at a slower speed so that students may write in the appropriate two-part statement.

1. Among people over the age of 65, women more frequently experience bowel incontinence.

2. In infants and children (especially under age 3), diarrhea is more concerning because they can

become dehydrated fairly quickly.

3. Anxiety is a feeling of apprehension and fear characterized by physical symptoms such as

palpitations, sweating, and feelings of stress.

4. Diminished or inability to recall past events is called memory impairment.

5. Hopelessness is the despair you feel when you have abandoned hope of comfort or success.

6. Nausea may be a symptom of a variety of disorders, some minor and some more serious.

7. Women who face difficult health decisions are likely to experience decisional conflict .

8. The effects of sleep derprivation lead to impaired hearing, sight, brain function, mental alertness, as well

as physical ability, meaning slow reflexes and clumsiness.

9. Any change or modification of the stomach or intestines is known as gastrointestinal alteration.

10. It has been observed that blood pressure alterations follow acute stroke, particularly a reduction in the

day-night difference and a transient elevation in blood pressure after stroke.

C. Critical Thinking: In what way is a two-part statement different from a three-part statement?The two-part statement is a problem statement that describes the patient’s response to a potential

health problem and the etiology (related cause or contributor to problem). The three-part statement

contains the first two components in the two-part statement ;in addition, to a defining characteristics

component.

D. Use the following two-part statements in sentences of your own. Answers will vary.

1. fatigue:______________________________________________________________________________

2. body nutrition deficit:___________________________________________________________________

3. infection unspecified: ____________________________________________________________________

Unit 5 Answer Key / Actual Diagnosis H5:5 Grammar Tips

Grammar Note: Present Perfect Continuous Tense

In this module, the present perfect continuous tense has been used throughout the telephone conversation.

E.g. I have been coughing all day.

E.g. How long have you been coughing up blood?

The 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:

subject + have/has + verb + ing

I have been working all day.

He has been working all day.

You have been working all day.

She has been working all day.

We have been working all day.

It has been working all day.

They have been working all day.

A. Fill in the blanks with the correct form of the verbs.

1. Dr. Welch has been checking (check) in on his patient all night.

2. Mrs. Martinez has been having (have) contractions since this morning.

3. The nurse on duty has been administering (administer) non-narcotic cough suppressants to the patient as ordered by the physician.

4. How long has the patient been having difficulty breathing? He has been having (have) difficulty breathing for at least five hours.

5. How long have you been working (work / you) at the hospital as a nurse?

Unit 5 Key/ Actual Diagnosis H5:6 Case Studies

A. Study the following case and be prepared to ask Mary questions enabling you to make a correct actual nursing diagnosis.

Case # 1

Mary Rogers came into the clinic for her six-week post-partum visit. You noticed the following behaviors:

Mary, age 28, handled her baby with confidence when holding and feeding the baby. However, she looked

distracted and fatigued. When the baby started crying, Mary seemed to get irritated and upset.

Case # 2

Jack Van, age 77, came into the clinic for his bi-annual check-up. The nurse on duty noticed that Mr. Van had

lost a lot of weight since his last visit. He also complained of insomnia, energy loss, inability to think, and

expressed the fact that he felt he was no longer living a meaningful life.

B. Write down some possible questions that you might ask Mrs. Rogers to make an actual nursing diagnosis. Try to ask questions using the present perfect continuous form. Answers will vary.Case 1

1. Have you been getting enough rest at night?2. Has the baby been letting you get enough rest during the day?3. Have you been having difficulty concentrating?4. Have you ever been depressed before?

5. Have you been taking any medication?

Case 2

Write down some possible questions that you might ask Mr. Van to make an actual nursing diagnosis. Try to ask questions using the present perfect continuous form.

1. Have you been eating properly?2. Has something been worrying you that keeps you awake at night?3. Have you been exercising regularly?4. Have you been staying at home all day by yourself or have you been going out?

5. Do you belong to a church, synagogue, mosque or any other religious affiliate?

Unit 5 Key/ Actual Diagnosis H5:7 Case Studies

C. Write down an actual nursing diagnosis for each case. Use as many two-part statements as possible.

Case # 1

Answers will vary

Case # 2

Answers will vary

Unit 5 Key/ Actual Diagnosis H5:7 Summary

Reading Comprehension and Note Taking

Directions: Read the following passage once at normal speed. On the second time, read at a slower pace.

A nursing diagnosis is a clinical diagnosis made by a registered nurse, in contrast to a MD's

diagnosis, the nursing diagnosis does not cover the patient's medical condition, but the

patient's response to the medical condition. Most patients usually have multiple nursing

diagnoses covering everything from their physical well-being through their psychosocial well-

being to the well-being of their family and caregivers. These diagnoses must cover problems

that the nurse can treat independently of the physician. A complete nursing diagnosis is

written in the format problem related to cause of problem as evidenced by symptoms of

problem .

The NANDA system has identified three different types of diagnosis and they are: actual

diagnosis, risk diagnosis, and wellness diagnosis. The actual diagnosis is a statement made by

a licensed nurse identifying a health problem that the client has and the benefit from nursing

care. An example of an actual nursing diagnosis might be the following: Ineffective airway

clearance related to decreased energy as manifested by an ineffective cough. There are a

couple of rules to remember when writing a two or three-part statement:

Do not write a diagnostic statement in such a way that it may be legally

incriminating.

Do not write a diagnostic statement based on value judgment.

Do not rename a medical problem to make it sound like a nursing diagnosis.

Do not make a nursing diagnosis out of a physicians orders.

Do not state or write two problems at the same time.

In summary, a nursing statement implies that the patient needs nursing care.

Applying Nursing Process, Rosalinda Alfaro-LeFevre