Nursing Diagnosis made simple

Here are a few examples of Nursing Diagnosis for you to practice with
Stay focused only on the information provided:

Scenario one
Mr. Ford has arrived on your ward from the Emergency Department. He has been diagnosis
as having a CVA and has suddenly become incontinent with frequent episodes overnight. He
is now very drowsy, difficult to rouse and dysphagic since the CVA
Scenario two
Mr. Warren has been admitted with pain following falling over and fracturing his right arm. He
is obviously in pain, holding his arm and rates his pain 6/10. He is unable to use his arm to
feed himself.
Scenario three
Mrs. Scott is 93 years of age and has been admitted after being found collapsed at home.
Until then she was reported to be well. She presents with poor skin turgor, a dry tongue,
having not taken fluid for an estimated four days.
Since the fall she is confused. The medical staff believe that, as a Diabetic, she had a
hypoglycaemic episode. As a result of lying in the one spot for so long, she has a stage one
pressure area sore on her hip.
Scenario four
Mr Woods is admitted with COAD. He is short of breath, anxious, cyanosed, confused and
has a respiratory rate of 40. All of these symptoms began yesterday when he suddenly found
it difficult to breath.
From each scenario:
1. Select a significant problem (Nursing Diagnosis) that the patient is evidently experiencing
2. State what the cause of the above problem is (related to factor)
3. State the signs and symptoms (manifestations) of the significant problem you have
selected – i.e. what are the signs and symptoms (manifestations) of the problem the patient is
experiencing (not the signs and symptoms of the cause).
When specifying the signs and symptoms, state only what you observe or see in
relation to the problem. For example, the signs and symptoms of constipation are a dry
hard stool or no bowel action for 5 days.
When you have done this for each scenario you have completed the first part of Nursing
Diagnosis. Now, choose another problem and go through the same process. Some of your
causes and your signs and symptoms for each problem may overlap and you may find
yourself repeating yourself. But remember, when doing the causes and the signs and
symptoms, refer only to the problem.
All the possible Nursing Diagnosis you can use are listed in Potter and Perrycauses (related
to) are on the reverse of this page.
You will need to chose the signs and symptoms (manifestations) from only the information
provided in the scenario
All the possible signs and symptoms (manifestations) are on the reverse
Once you have done a Nursing Diagnosis including R/T & M/B, you then need to write three
interventions for each problem you identify. When deciding on your interventions include
interventions that focus solely on the problem and the signs and the symptoms
(manifestations) of the problem (Nursing Diagnosis).
Then, for each intervention you need to state why (rationale) you did this. Do not concern
yourself with evaluation at this stage.
When learning Nursing Diagnosis it is important to stay away from using medical language
and to separate all the different problems out from each other. When you register as a Nurse
and are working on the ward, it may be that you throw all the problems together and just
come up with one Nursing Diagnosis that covers all your patient’s problems. You may find that
many problems cross over. At this stage you need to tediously identify them all.
When you have finished, these interventions form the foundation for a Nursing care plan that
goes at the foot of the bed as a guide to Nursing Care.
The only time you will be expected to do this on clinical placement is under the supervision of
your clinical teacher, in your log book, for practice only
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Here are some already completed examples
1. Mr. Sampson is 83. He is admitted following a fall at home. His weight is low at 46kg.
He has no teeth or dentures
Nursing Diagnosis
Altered Nutrition less than body requirements
Related to (cause)
No dentures
Manifested by (signs and symptoms)
Weight of 48 kg
Interventions
• Encourage a well balanced diet…..
• Explain to the patient the importance of diet.
• Assist with meals
• Ensure food are soft and of preference
Rationale
To achieve substantial weight gain.
....................................................................................................................................................
..............
2. Mr. Johns has been admitted with a stage 1 pressure sore. He is incontinent and
cannot use a urinal because of contractures of his lower limbs.
Nursing Diagnosis
Incontinence
Related to (cause)
Contractures
Manifested by (signs and symptoms)
Frequent wet beds especially at night
Interventions
• Offer urinal 2/24
• Continence plan
• Buzzer close at hand
• Use of kylie at night
Rationale
To resolve incontinence
To prevent pressure area sores that result from constant exposure of
skin to urine