Nursing Diagnosis Case Study

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Diagnosis Actual or potential health problem that can be prevented or resolved by independent nursing intervention are termed nursing diagnosis. (Taylor, 2015, p. 254) Diagnosis is the second step of the nursing process. It is very critical part for nurses to analysis and interpret the patients’ data according to their strength and health problem. After assessment of patient’s sign and symptoms, nurse has to prioritize list of nursing diagnosis, which determine actual and potential risk factors. Medical diagnosis deal with disease or patient pathology, which can be detected by physician and directs primary treatment of disease, whereas nursing diagnosis focuses on human response which gives holistic care to the patient’s actual and potential…show more content…
It formulate by problem, etiology and defining characteristics. According to the case study, Mr. Robert has been diagnose with actual problem, such as
1) Impaired ability to performed or complete self-bathing activities related to weakness evidence by the patient wife states, ‘He has just gotten too weak and I have to bathe him.’ (Venes, 2017, p. 2704)
2) Inability to remember related to decrease in cardiac output evidence by the patient wife sates, ‘He can be so forgetful.’ (Venes, 2017, 2686)
3) Inability to perform or complete self-feeding activities related to weakness evidence by the patient wife state, ‘He has just gotten to weak, I’ve had to feed him myself or he won’t eat.’ (Venes, 2017, p. 2704)
Potential diagnosis: - It is called risk factor, which is clinically judgmental. Patient, his/her family, or community are more susceptible in same condition. According to Mr. Robert McClelland’s complete assessment, medical diagnosis, and get admission to nursing care, he is more susceptible for risk factors, which are
1) Risk for impaired gas exchange is possibly evidenced by risk for alveolar-capillary membrane changes (fluid collection or shift into interstitial space or alveoli). (Venes, 2017, p.
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According to nursing diagnosis of the patient’s health status, nurses allow to set the priorities depends on patient’s health condition and determine the nursing intervention. Nurse plan individualized care for each patient to get maximum achievements and involve or communicate the care plan to the patient and his/her family. There is specific reason to call the planning as ‘road map’ because, outcome of the patient’s care should be specific, measurable, applicable, relevant and timely oriented called ‘SMART’ goal. Nurse has to think critically, which is called self-directed learning process according to patient’s situation. Planning or outcome of the nursing process divided mainly into three type. First one is initial or comprehensive planning, which is based on complete assessment include complete history and physical assessment. Priorities of the patient’s care plan goal is listed according to Maslow’s hierarchy and ABC (airway, breathing or circulation), which make nurses to give better idea how to plan for nursing process. This is standardized care plan, which provide basic and initial plan for the patient. Second type is ongoing planning, which is carried out by the nurse who interact with patient in special health care settings such as long-term, hospices, community care or hospital. Nurse collect continuous data during the treatment of the patient and analysis. If there is not effective outcome,

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