Question

You are a nurse admitting a patient to the hospital from the emergency department with shortness of breath and recent weight loss. After receiving a report from the emergency department nurse,you ready the patients room according to unit specifications and collect the necessary equipment and forms. When the patient arrives she is using oxygen via a nasal cannula and seems to be comfortable. As you begin your admission activities and paperwork,you note that her shortness of breath increases slightly as she answers your questions. Accompanying the patient is her daughter who comments "This is the fourth time she's been admitted to this hospital in the past year ".The patient and her daughter demonstrate a close loving relationship. The daughter not only encourages her mother,but also sets boundaries regarding her mother's anxiety.
a. What data in this scenario are pertinent?
b. Which conditions within the case study could be addressed by a nursing diagnosis?
c. Which conditions within the case study would be addressed by a medical diagnosis?
d. How are medical diagnoses,collaborative diagnoses and nursing diagnoses different?
e. Compare how a medical diagnosis is written versus a nursing diagnosis?

Answer 1

A. Pertinent data :In the given case study the patient is using oxygen via nasal canula and seem to be comfortable. The shortness of breath is increasing and it is said by her daughter that it's the 4th time. As daughter is very close to her mother the information is reliable.

B. The main components of nursing diagnosis include data analysis, problem identification and formulation. And there are four types of nursing diagnosis actual nursing diagnosis, wellness nursing diagnosis, risk nursing diagnosis and syndrome diagnosis.

Considering the actual nursing diagnosis it include problem related to etiology and manifested by signs and symptoms

In the above case study the actual nursing diagnosis approach is asking the what makes them breathless, what makes them breath easier, current and past medical history,medications.

C. The conditions that are addressed for medical diagnosis are signs and symptoms of present illness, eliciting relfelxes, history of past illness family history . The medical diagnosis is the identification of disease condition based on specific physical signs, symptoms and patient's medical history.

D. Medical diagnosis, collaborative diagnosis and nursing diagnosis are different in way of approach and assessment.

Medical diagnosis identifies a disorder, nursing diagnosis identifies unique ways in which individual respond to health nursing diagnosis intigreted patient involvement when possible throughout the process. Collaborative diagnosis is the patient centred, so that the patient can take best decision for their own health.