Question

Dear student,

read the following nursing diagnostic statements carefully, then answer the questions :

1- Decrease cardiac output related to decreased venous return , as manifested by peripheral edema.

2- Ineffective airway clearance related to excessive mucus production secondary to retained secretion and inflammation , as manifested by abnormal breath sound ( crackles).

3- Activity intolerance related to impaired respiratory function as evidenced by shortness of breath (SOB).

4. Risk for fluid volume deficit related to fever and rapid respiratory rate ( RR = 34 breath/ mint).

5- Impaired skin integrity related to vascular insufficiency as evidenced by leg ulcer.

......... the Questions are :

1- Determine the major components for each statement.

2- determine the type of the nursing diagnosis for each statement.   

Answer 1

1. Components of nursing diagnosis include major problem , its etiology and risk factor or major reason due to which problem arised

a) Decreased cardiac output , decrease venous return and peripheral edema

b) Ineffective airway clearance , excessive mucus production secondary to retained secretion and inflammation , and abnormal breath sound ( crackles)

c) Activity intolerance , impaired respiratory function and shortness of breath

d) risk of fluid volume deficit , fever and rapid respiratory rate

e) Impaired skin integrity , vascular insufficiency and leg ulcer

Types of nursing diagnosis

a) Actual (problem ) focused

b) Actual ( problem) focused

c) Actual ( problem ) focused

d) Risk nursing diagnosis

e) Actual ( problem) focused

As other 3 types which are Health related , syndrome and possible nursing diagnosis are written in one statement unlike given question

And to differentiate risk and actual , in risk there is no evidence thus considered as risk whereas actual diagnosis are associated with evidence.

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