Need help with a Nursing Diagnosis!

Daytonite, BSN, RN · Nov 4, 2009

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

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let's dissect your diagnosis:

impaired verbal communication r/t physiological conditions m/b increased confusion to place, difficulty hearing in left ear, and dyspnea upon exertion.

problem:

impaired verbal communication.

definition

: decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols

etiology (cause):

physiological conditions
- what physiological condition is causing this? just saying
physiological conditions
is rather vague and i know that this is what the nanda taxonomy lists, but that is meant to be a guideline. you also mentioned in your post that his sob, no doubt a result of his copd, has something to do with this. that is the
physiological condition
but you need to word it in acceptable nursing language.
etiology: shortness of breath secondary to copd

symptoms:

when you see these together a light bulb should go off and you should be able to say, "oh, yeah, they have a verbal communication problem." look at the symptoms you listed. do they represent a verbal communication problem?

increased confusion to place
- i thought of dementia or low o2 levels when i saw this
difficulty hearing in left ear
dyspnea upon exertion
- i thought of breathing problems when i saw this
only replies to yes and no questions by shaking or nodding his head
- this is clear evidence of a verbal communication problem and should be included with your m/b items

without the information that he only replies to yes and no questions by shaking or nodding his head and that he has difficulty hearing in his left ear the confusion and dyspnea make absolutely no sense as symptoms of this nursing problem.

symptoms: only replies to yes and no questions by shaking or nodding his head and has difficulty hearing in the left ear

better diagnosis:

impaired verbal communication r/t shortness of breath secondary to copd m/b only replies to yes and no questions by shaking or nodding his head and has difficulty hearing in the left ear.

when somebody reads that diagnostic statement they get a better visual picture in their mind of what is going on with this patient without having to go to the bedside and see the patient.

your next step is to develop nursing interventions. they are aimed at the m/b items which would be:

only replies to yes and no questions by shaking or nodding his head
has difficulty hearing in the left ear

obviously, he keeps his answers short because of his sob, so keep talking to a minimum. work on using some kind of sign language instead with him. if you couldn't hear out of your left ear what would be helpful for you? try plugging one of your ears and see what it feels like and what works so you can hear better.

is this the only diagnosis you have for this patient? sob with activity is activity intolerance, another nursing problem that you might want to look into. did you listen to his lungs? are they clear? any cough? it would be unusual for a copder not to have any respiratory nursing diagnoses.