When writing a diagnostic statement using the Problem-etiology-symptom PES method, we are conveying a lot of information to our colleagues. We start with the diagnosis itself, followed by the etiologic factors related factors in an actual diagnosis.
He was in his usual state of health until today when, while sitting in a chair, he developed the abrupt onset of a diffuse left anterior chest pain without radiation, associated with shortness of breath.
It was unaffected by position. There was no fever, cough, sputum, chest pressure, nausea, vomiting, bloating, or hematemesis. He has no prior history of trauma to the chest, prior coronary artery disease or anxiety. Other causes of chest pain to consider in this case are pneumonia fever, cough, sputumcoronary artery disease radiating chest pressure, nauseapeptic ulcer disease nausea, vomiting, hematemesisanxiety or musculoskelatal disease.
Only negative statements belong in the pertinent negatives section. If you discover that your patient has not been taking his coumadin, you would tell the story chronologically.
He has not been taking his coumadin over the last three weeks. He was in his usual state of health until today when Because these symptoms did not improve and were similar to prior PE's that he experienced, he went to his local physician who hospitalized him at St. Evaluation there revealed a swollen left lower extremity, a sub-therapeutic prothrombin time and a moderate probability VQ scan.
He was given the diagnosis of PE and transferred to our hospital for further evaluation. Alternatively, this data may be incorporated into the chronology for the patients HPI if it is relevant to the story and helps build the hypothesis being constructed in the first paragraph.
Past Medical History Include all medical problems active or remote. We suggest that you order the problems outline the problems from the most pertinent to the least pertinent to the issues of the current illness.
Noncompliance with coumadin, see HPI 3. MVA with left leg fracture 4.
Cellulitis, group A streptococcal bactermia, no recurrences 5. Womack was admitted for lower abdominal pain with a differential including small bowel obstruction, then the appendectomy would take higher priority in the PMH listing and be mentioned in the HPI.
Your residents can assist you. Other items to include in the Past Medical History, as taught in physical diagnosis:New federal exercise recommendations include the first-ever federal activity parameters for 3-year-olds, as well as a few surprising omissions.
Developing a three-part nursing diagnosis consists of data analysis, problem identification and the formulation of the nursing diagnosis. There are four different types of nursing diagnosis; actual nursing diagnosis, wellness (or health promotion) nursing diagnosis, risk nursing diagnosis and syndrome diagnosis.
2) Status and Function: The second prerequisite for a wellness diagnosis is the presence of status or function required to perform tasks related to the diagnosis.
3) Assessment: Assessing a patient's readiness to respond to a wellness diagnosis involves patient interviews and interaction. While most nursing diagnoses require at least two parts, the diagnosis and the “related to” factors, wellness diagnoses are written a little different.
They are started with the word “readiness” followed by the action or health-seeking behavior that will be enhanced. Wellness and family nursing diagnosis are different tha standard nursing diagnosis.
A list of wellness and family diagnosis, from J.R. Weber’s Nurses Handbook of health assessment (5th ed), can be found at the following link.
Wellness Diagnoses describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement. Examples of wellness diagnosis would be Readiness for Enhanced spiritual Well Being or Readiness for Enhanced Family Coping.