70 UNIT III THE NURSING PROCESS
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:b.Possible problem:c. Actual or potential nursing diagnosis:d.Clinical problem other than nursing
diagnosis:4.Give three examples of how standards may be
used to identify significant cues.
a.
b.
c.
5.List five questions a nurse should consider
when using critical thinking in diagnostic
reasoning.
a.
b.
c.
d.
e.
6.In her book on the nursing process, Alfaro-
LeFevre (2006) describes the shift from
Diagnose and Treat (DT) to Predict, Prevent,
Manage, and Promote (PPMP). The latter
approach focuses on early evidence-based
intervention to prevent and manage problems
and their potential complications. Describe
the three activities nurses need to perform to
follow this approach in daily nursing care.
a.b.c.7.Read the three mini-cases that follow. In each
one, underline the cues that form a data clus-
ter indicating a nursing diagnosis, and write
the appropriate nursing diagnosis as a three-
part statement.
a.Mr. Klinetob, age 86, has been seriously
depressed since the death 6 months ago of
his wife of 52 years. Although he suffersfrom degenerative joint disease and has
talked for years about having “just a touch
of arthritis,” this never kept him from
being up and about. Recently, however, he
spends all day sitting in a chair and seems
to have no desire to engage in self-care
activities. He tells the visiting nurse that he
doesn’t get washed up anymore because
he’s “too stiff” in the morning to bathe and
“I just don’t seem to have the energy.” The
visiting nurse notices that his hair is matted
and uncombed, his face has traces of previ-
ous meals, and he has a strong body odor.
His children have complained that their
normally fastidious father seems not to care
about personal hygiene any longer.
Nursing Diagnosis:b.Miss Adams sustained a right-sided cerebral
infarct that resulted in left hemiparesis
(paralysis on the left side of the body) and
left “neglect.” She ignores the left side of
her body and actually denies its existence.
When asked about her left leg, she stated
that it belonged to the woman in the next
bed—this while she was in a private room.
This patient was previously quite active:
she walked for 45 to 60 minutes four or five
times a week and was an avid swimmer. At
present, she cannot move either her left
arm or leg.
Nursing Diagnosis:c.After trying to conceive a child for
11 years, Ted and Rosemary Hines sought
the assistance of a fertility specialist who
was highly recommended by a friend. It
was determined that Ted’s sperm was inad-
equate, and Rosemary was inseminated
with sperm from an anonymous donor. The
couple was told that the donor was healthy
and that he was selected because he resem-
bled Ted. Rosemary became pregnant after
the second in-vitro fertilization attempt and
delivered a healthy baby girl named Sarah.
Sarah is now 7 years old, and Ted and
Rosemary have learned from blood tests
that their fertility specialist is the biologicLWBK696-C13_p66-71.qxd 9/2/10 9:25 AM Page 70 Aptara Inc