Page 17 - Advanced Communication in Nursing

Writing

Writing assessment and nursing diagnosis in the nursing care plan

a. Complete assessment and nursing diagnosis below based on the provided case scenario.

Ners Joe : What do we have?
Ners Dawn : Ok, we have a 25-year-old patient admitted with extreme nausea and vomiting. The
patient had chemotherapy treatment 24 hours ago. She is receiving chemo for stage 4
cervical cancer. The patient was laying on her side with her arms around her stomach. She
said that says she was extremely nauseous. Her skin was cold. The blood pressure was 120
over 80. The temperature was 99.2 degrees Fahrenheit. The oxygen saturation was 98% on
room air.

Assessment Nursing Diagnosis
Subjective: 9____________ related to 10___________
“Pt says she feels chemotherapy 11_____________ by patient reporting
1_______________________” 12____________ and 13______________
Objective:
• Pt is 2____ on her side with
3_____________________________
• Skin cold and 4_________
• VS: HR 5____, BP: 6__/___, Temp:7
_____ F, Oxy: Sat 8___’

b. Write the assessment and nursing diagnosis from the provided case scenario.

A 45-year-old woman comes to the clinic

and asks for medication to help her sleep.
She states that she is worrying too much
and adds, “It takes me about an hour to get

to sleep, and it is very hard to fall asleep. I
feel like I can’t do anything because I am so
tired. My job has become very stressful
because of a new boss and too much work.”

pg. 9