### Nursing Diagnosis Worksheet
#### Part 1: Case Study
**Patient:** Mrs. Johnson
**Age:** 72 years
**Diagnosis:** Congestive Heart Failure (CHF)
**Presenting Symptoms:** Shortness of breath, peripheral edema, fatigue, and orthopnea
**Past Medical History:** Hypertension, diabetes mellitus type 2, previous myocardial infarction
**Assessment Findings:** Crackles heard in bilateral lower lung fields, jugular venous distention, pitting edema in lower extremities, and elevated BNP levels
#### Part 2: Nursing Diagnosis Identification
1. **Nursing Diagnosis 1: Excess Fluid Volume**
**Rationale:** Mrs. Johnson’s assessment reveals signs of fluid overload, including peripheral edema, crackles in the lungs, and elevated BNP levels. These symptoms are indicative of excess fluid volume, which is a common complication of congestive heart failure.
2. **Nursing Diagnosis 2: Impaired Gas Exchange**
**Rationale:** The presence of crackles in the lungs, shortness of breath, and orthopnea suggest that Mrs. Johnson is experiencing impaired gas exchange. This can result from the accumulation of fluid in the alveoli, impairing oxygen and carbon dioxide exchange.
3. **Nursing Diagnosis 3: Activity Intolerance**
**Rationale:** Mrs. Johnson’s fatigue and shortness of breath with minimal exertion indicate that she is experiencing activity intolerance. This can be attributed to her compromised cardiac function and reduced oxygenation, limiting her ability to perform daily activities.
#### Part 3: Prioritization and Justification
1. **Priority Nursing Diagnosis: Impaired Gas Exchange**
**Justification:** Impaired gas exchange is prioritized first because it directly affects Mrs. Johnson’s oxygenation status, which is critical for sustaining life. Immediate interventions are needed to improve her breathing and prevent further respiratory complications.
2. **Second Nursing Diagnosis: Excess Fluid Volume**
**Justification:** Excess fluid volume is the next priority as it contributes to Mrs. Johnson’s impaired gas exchange and overall cardiac workload. Addressing fluid overload through diuretics and fluid restriction is essential to improve her respiratory function and reduce edema.
3. **Third Nursing Diagnosis: Activity Intolerance**
**Justification:** Activity intolerance, while important, is prioritized last because it is a consequence of the underlying issues of impaired gas exchange and fluid overload. Once these primary concerns are managed, Mrs. Johnson’s tolerance for activity is likely to improve.
### References
– Jarvis, C. (2019). Physical Examination & Health Assessment (8th ed.). Elsevier.
– Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2019). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.
– Wilkinson, J. M., Treas, L. S., Barnett, K. L., & Smith, M. H. (2020). Fundamentals of Nursing: Theory, Concepts, and Applications (3rd ed.). F.A. Davis Company.
– American Nurses Association. (2015). Nursing: Scope and Standards of Practice (3rd ed.). American Nurses Association.
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### Rubric for Nursing Diagnosis Worksheet
| Criteria | Ratings | Points |
|—————————————|——————————————|——–|
| **Identification of Nursing Diagnoses** | Excellent: Identifies three appropriate nursing diagnoses with clear rationales based on patient data. | 5 |
| **Rationale for Nursing Diagnoses** | Excellent: Provides strong, evidence-based rationales for each diagnosis. | 5 |
| **Prioritization and Justification** | Excellent: Prioritizes diagnoses accurately with clear justification. | 5 |
| **Clarity and Organization** | Excellent: Information is well-organized, clear, and free of grammatical errors. | 5 |
| **APA Format** | Excellent: Follows APA format accurately with all references cited properly. | 5 |
| **Total** | | 25 |
### Comments
**Identification of Nursing Diagnoses:** Excellent work in identifying relevant nursing diagnoses based on the case study.
**Rationale for Nursing Diagnoses:** Clear and concise rationales that reflect a strong understanding of the patient’s condition.
**Prioritization and Justification:** Thoughtful prioritization with logical justifications for each diagnosis.
**Clarity and Organization:** The assignment is well-organized, easy to follow, and free of errors.
**APA Format:** Proper use of APA format and appropriate referencing.
Great job on this assignment! You have demonstrated strong critical thinking and application of nursing fundamentals. Keep up the good work!
Due No Due Date Points 100 Submitting a file upload
Start Assignment
Nursing Diagnosis Worksheet
Objective:
The objective of this assignment is to familiarize nursing students with the process of identifying and formulating nursing diagnoses. Through this assignment, students will practice applying critical thinking skills to assess patient data and prioritize nursing interventions.
Instructions
Part 1: Case Study
1. Review a case study of a patient admitted to a healthcare facility with specific health concerns or conditions.
2. Familiarize yourself with the patient’s history, presenting symptoms, and relevant assessment findings.
Part 2: Nursing Diagnosis Identification
3. Based on the information provided in the case study, identify three potential nursing diagnoses that reflect the patient’s health needs and concerns.
4. For each nursing diagnosis, provide a brief rationale explaining why you selected it based on the patient’s data and presenting problems.
Part 3: Prioritization and Justification
5. Prioritize the three nursing diagnoses identified in Part 2 based on the patient’s immediate needs and potential risks.
6. Justify your prioritization by explaining the rationale behind each prioritized nursing diagnosis and its relevance to the patient’s condition.
Your assignment must be in APA 7 Format and your references should be no older than 5 years.
Example Case Study:
Mr. Smith is a 65-year-old male admitted to the hospital with a diagnosis of pneumonia. He presents with a productive cough, fever, dyspnea, and decreased oxygen saturation levels. His past medical history includes chronic obstructive pulmonary disease (COPD) and hypertension. Upon assessment, crackles are auscultated in his lower lung fields, and he appears fatigued and anxious.
Nursing Diagnosis Worksheet Example:
1. Nursing Diagnosis 1: Ineffective Airway Clearance
Rationale: Mr. Smith’s productive cough, dyspnea, and crackles indicate potential airway obstruction due to increased mucus production and impaired gas exchange, placing him at risk for respiratory distress.
2. Nursing Diagnosis 2: Impaired Gas Exchange
Rationale: Mr. Smith’s decreased oxygen saturation levels, dyspnea, and history of COPD suggest compromised gas exchange, impacting his respiratory function and oxygenation status.
3. Nursing Diagnosis 3: Anxiety
Rationale: Mr. Smith’s presentation of fatigue, anxiety, and hospitalization for pneumonia can contribute to heightened anxiety levels, which may further impair his respiratory status and overall well-being.
Your assignment must have the following:
Identification of Nursing Diagnoses Rationale for Nursing Diagnoses Prioritization and Justification Clarity and Organization
Refer to example (https://agmu.instructure.com/courses/29834/files/7312726?wrap=1) (https://agmu.instructure.com/courses/29834/files/7312726/download?download_frd=1) .
Institutional Rubrics for Writing Assignments
This assignment aims to provide nursing students with hands-on practice in identifying and prioritizing nursing diagnoses based on patient data and clinical judgment. Ensure that your responses are clear, concise, and well-justified, reflecting critical thinking and application of nursing fundamentals principles. Adjust the case study and rubric criteria as needed to align with specific learning objectives and instructor preferences.
Criteria Ratings Pts
5 pts
5 pts
Professional
Application of concepts
5 pts Excellent
Student complies 100% with the content required by the assignment showing facts, theories, definitions, and others applicable to the situation recognizing all basic and complex factors. Based on the information presented, the writing assignment complies with the information requested.
3 pts Good
Student complies between 85% to 99% with the content required by the assignment showing facts, theories, definitions, and others applicable to the situation recognizing all basic and complex factors. Based on the information presented, the writing assignment complies with the information requested.
2 pts Acceptable
Student complies between 70% to 84% with the content required by the assignment showing facts, theories, definitions, and others applicable to the situation recognizing all basic and complex factors. Based on the information presented, the writing assignment complies with the information requested.
1 pts Non Compliant
Student presents information containing below 70% of the expected content required by the assignment showing facts, theories, definitions, and others applicable to the situation recognizing all basic and complex factors. Based on the information presented, the writing assignment complies with the information requested.
0 pts Not Submitted Not submitted
Communication
Writing Mechanics
5 pts Excellent Writing is entirely free of grammatical, punctuation or formatting errors.
3 pts Good Writing is mostly free of grammatical, punctuation or formatting errors. The few it has do not interfere with the expressed ideas.
2 pts Acceptable Several errors are evident in grammatical, punctuation or formatting errors, but do not interfere with expressed ideas.
1 pts Non Compliant Several errors are evident in grammatical, punctuation or formatting errors. Errors interfere with expressed ideas.
0 pts Not Submitted
Not submitted
Criteria Ratings Pts
5 pts
5 pts
Communication Format
Especific Format
5 pts Excellent
The written piece complies 100% with the elements of the required format, as described in the assignment requirements. The information presented is complete in all these elements.
3 pts Good
The written piece complies 85% to 99% with the elements of the required format, as described in the assignment requirements. The information presented is complete in all these elements.
2 pts Acceptable
The written piece complies 70% to 84% with the elements of the required format, as described in the assignment requirements. The information presented may miss a few details, but without distorting the required format.
1 pts Non Compliant
The written piece complies with 69% or below with the elements of the required format, as described in the assignment requirements. The information presented may miss a few details and distorts the required format.
0 pts Not Submitted Not submitted
Critical Thinking and Logical Reasoning
Process of thought analysis
5 pts Excellent All basic and complex details are considered, and identification of the situation, problem or diagnosis is made accurately and introduced properly in the document. The analysis and thought process as presented in the written assignments is
3 pts Good Most (85% to 95%) basic and complex details are considered and identification of the situation problem or diagnosis is made accurately and introduced properly in the document. The analysis and thought process as presented in the written assignments is
2 pts Acceptable Most (70% to 84%) basic and complex details are considered and identification of the situation problem or diagnosis is made. Some of the parameters may not have been introduced properly in the document. The analysis and thought process as presented in the written
1 pts Non Compliant Only about 69% and below of the basic and complex details are considered and identification of the situation problem or diagnosis is made. Some of the parameters may not have been introduced properly in the document. The analysis and thought process, as presented in the document, are not clear as
0 pts Not Submitted
Not submitted
Total Points: 25
Criteria Ratings Pts
5 pts
flawless and clear.
flawless and clear.
assignments is clear.
conclusions and are not based on information presented or discussed previously.
Information Literacy
Use of information
5 pts Excellent
Supporting information is pertinent to the discussion topic and all sources are recognized or cited properly.
3 pts Good
Supporting information is pertinent to the discussion topic, but one of the sources is not recognized or cited properly.
2 pts Acceptable
Supporting information is pertinent to the discussion topic, but more than one of the sources is not recognized or cited properly.
1 pts Non Compliant
Does not use any supporting information, or information is not pertinent to the discussion. May not recognize or cite sources properly
0 pts Not Submitted Not submitted
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