The nurse is using the PED model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Select all that apply.
Ineffective Breathing Pattern as evidenced by cyanotic lips.
Risk for infection related to recent surgery.
Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds.
Ineffective coping related to depression as evidenced by a suicide attempt.
Noncompliance (DASH diet) related to denial of having the disease.
Correct Answer : A,C,D
The PED model is a framework for writing nursing diagnoses that stands for Problem, Etiology, and Defining Characteristics. A nursing diagnosis written using the PED model includes a statement of the client's problem (P), the cause or contributing factors of the problem (E), and the observable signs and symptoms that indicate the presence of the problem (D). In this case, options a), c), and d) are examples of nursing diagnoses that demonstrate appropriate use of the PED model. Each of these diagnoses includes a statement of the client's problem, the cause or contributing factors, and the defining characteristics that indicate the presence of the problem.
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Correct Answer is D
Explanation
A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity. This diagnosis reflects the fact that the client's skin has been damaged and is no longer intact. Risk for Injury, Altered Tissue Perfusion, and Impaired Tissue Integrity are also NANDA nursing diagnoses, but they are not as specific or relevant to the client's condition as Impaired Skin Integrity.
Correct Answer is A
Explanation
A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.
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