Page 16 - Advanced Communication in Nursing

The pattern to apply the terms to state the diagnosis
PROBLEM-FOCUSED DIAGNOSIS
Problem-Focused Diagnoses related to (r/t) __________________ (related factors) as evidenced by
________________ (defining characteristics).
Example:
• Ineffective airway clearance r/t asthma as manifested by difficulty of breathing.
• Acute pain r/t inflammation of gastric mucosa as evidenced by recurrent abdominal pain.

RISK DIAGNOSIS
The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced
by __________________________ (Risk Factors).

Example:
• Risk for aspiration r/t ineffective cough as evidenced by pain while coughing, mucus built up in
throat.
• Risk for fall r/t impaired balance as evidenced by unsteady walk, partially paralyzed body.

Write the nursing diagnosis using the provided vocabularies.

Problem-focused Related / risk factors Problem-focused

diagnosis • facial paralysis • Coughing and food oozing
• Swallowing • nausea, vomiting and from the lips

• Fluid volume diarrhea • Decreased urine output,
• Nutrition less than body • inability to ingest, digest skin/tongue turgor, dry
requirements • increased mucosal mucus membrane
• Airway clearance edema and secretion • Weight loss, fatigue, poor
• Trauma occurring with muscle tone, nausea and
• Allergy response respiratory infection vomiting

• Family history of neglect • Expiratory wheezing, RR:
or physical, emotional or 60-80/min, nasal flaring.
sexual abuse • Bruises, scars, unusual

• Insect sting interaction of the client.

Example:
Impaired: Impaired swallowing related to facial paralysis as evidenced by coughing and food oozing from
the lips.
1. Deficient : ________________________________________________________________
2. Imbalanced : ________________________________________________________________
3. Ineffective : ________________________________________________________________
4. Risk for : ________________________________________________________________
5. Risk for : ________________________________________________________________

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