Quote from juli44
"in this nursing diagnosis, 'hyperthermia related to exposure to hot environment as evidenced by temp 101 fahrenheit, skin flushed and warm to touch,' which part represents the problem?"
a) exposure to hot environment
c) skin flushed and warm to touch
d) temp 101 fahrenheit
the book says b is the correct choice and i don't know why
hyperthermia is an officially recognized nursing diagnosis in the nanda taxonomy. hyperthermia related to exposure to hot environment as evidenced by temp 101 fahrenheit, skin flushed and warm to touch
is a 3-part nursing diagnostic statement
. it might look a little more familiar to you if written this way:
hyperthermia r/t exposure to hot environment aeb temp of 101 f, skin flushed and warm to touch.
a three part nursing diagnostic statement consists of the following parts:
p (the problem) which is expressed as a nursing diagnosis. the nursing diagnosis in this case is hyperthermia
e (the etiology) which is the cause of the problem. nanda calls these related factors. in the three part statement they are referred to as "related to". the etiology of this problem is exposure to hot environment.
s (the symptoms) which are the symptoms that the nurse found in the patient during the assessment of the patient. nanda calls these defining characteristics. in the three part statement they are referred to as "as evidenced by". the symptoms of this patient are temp 101 fahrenheit, skin flushed and warm to touch.
and it is put together this way:
p - e - s
problem - etiology - symptom
nursing diagnosis - related factor - defining characteristic
hyperthermia related to exposure to hot environment as evidenced by temp 101 fahrenheit, skin flushed and warm to touch
what this diagnostic statement is telling us is that the patient was exposed to a very hot setting for a long period of time which caused his entire body to become overheated as a result. he developed a fever and his skin became flushed and very warm to the touch. the name that we nurses can attach to this problem is hyperthermia (elevated body temperature). the doctor may want to call this heat stroke, but we nurses can't do that.
this was a straight forward question of knowledge about what a nursing diagnostic statement is. if you have a care plan book you need to read the very beginning of the book on how a care plan is written. this information on the construction of a nursing diagnostic statement that i've given above is in the very first pages of nursing diagnosis handbook: a guide to planning care
, 7th edition, by betty j. ackley and gail b. ladwig (it's actually on page 3). if you know someone who has a copy of this book, ask them if they will xerox pages 2 - 14 for you.