Essentials Health Info Management Principles/Practices
4th Edition
ISBN:9780357191651
Author:Bowie
Publisher:Bowie
Chapter6: Patient Record Documentation Guidelines: Inpatient, Outpatient, And Physician Office
Section6.3: Hospital Inpatient Record— Clinical Data
Problem 13E
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NURSING DIAGNOSIS EXERCISES: WRITING DIAGNOSIS STATEMENTS
Instruction: Formulate a three-part diagnostic statement that clearly describes the nursing diagnosis. In other words, you also must include the “relate to” and “as evidenced by” statements that corresponds to the given situation.
- Silverman has recently completed chemotherapy and radiation therapy for breast cancer. She arrived at the clinic this morning with the following signs and symptoms: no appetite, weight loss of 4 pounds since her last visit 2 weeks ago, and nausea without vomiting. She states that most of the time she feels exhausted. “The inside of my mouth hurts,” she says. Assessment reveals oral ulcerations that are erythematous (reddened). Her vital signs are within normal range.
2. Kim returned from Baguio 1 week ago. He experienced nausea, vomiting, and diarrhea for 4 days and exhibits the following additional symptoms: inelastic skin turgor, dry oral mucous membranes, weakness, and an elevated temperature.
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