CENTRO ESCOLAR UNIVERSITY

Department of Nursing

FUNDAMENTALS OF NURSING

NURSING DIAGNOSIS: CASE SCENARIO

Module 5 – Post-Task

Actual Nursing Diagnosis:

Assessment Data Nursing Diagnosis Scientific Explanation

Subjective Data: Fatigue-related to sleep The patient is fatigable as the

●​ “I feel so weak and deprivation manifested by body patient shows signs and
wobbly that I can’t get weakness, headaches, and fever. symptoms of difficulty in
up from bed to work.” performing her tasks which was
●​ The client experienced directly verbalized by the patient
lingering headaches 2 during the assessment period.
days prior to admission. According to the patient, she
●​ The client felt body feels weak and wobbly, and she
weakness and headache can’t get up from bed to work.
4 hours prior to As stated by Enoka and
admission. Duchateau (2016), fatigue is
●​ It is mentioned that she defined as a disabling symptom
just feels so weak and in which physical and cognitive
tired. And according to function is limited by interactions
her, she gets tired easily. between performance fatigability
and perceived fatigability.
Perceived fatigability is derived
Objective Data: from the sensations that regulate
●​ Vital Signs: the integrity of the performer
Temperature: 37.8°C based on the maintenance of
Respiratory Rate: 20 homeostasis and the
bpm psychological state of the
Cardiac Rate: 85 bpm individual. With this statement
Blood Pressure: 120/80 from Enoka and Duchateau,
●​ The client looks weak along with the data from the
and tired and has no assessment, we can conclude that
obvious physical the patient experienced these
deformity. symptoms due to the disruption
of homeostasis brought by a lack
of rest and sufficient nutrition due

FUNDAMENTALS OF NURSING BSN1AS1

to her activity and lifestyle in
which both categories affect her
integrity to accomplish tasks.

References:
●​ ENOKA, R. M., &
DUCHATEAU, J. (2016).
Translating Fatigue to
Human Performance.
Medicine & Science in
Sports & Exercise, 48(11),
2228–2238.

Risk Diagnosis:
Assessment Data Diagnosis Scientific Explanation

Subjective Data: Risk for Fall related to injury as Defined by Doenges, Moorhouse,
●​ “I feel so weak and evidenced by the weakness and & Murr (2019), Risk for Falls is
wobbly that I can’t get headache experienced by the susceptible to increased [risk for]
up from bed to work.” client. falling, which may cause physical
●​ The client experienced harm and compromise health.
lingering headaches 2 Risk for falls can be a cause of
days prior admission. acute, even short term situations
●​ The client felt body that can affect any client such as
weakness and headache sudden dizziness, headaches,
4 hours prior to sleeplessness, insufficient
admission. automobile restraints, recent use
●​ It is mentioned that she of alcohol and other drugs, new
just feels so weak and medication, and so on. The signs
tired. And according to and symptoms as evidence in the
her, she gets tired easily. patient, shows she has a high risk
for falling. According to her, she
Objective Data: feels so weak and wobbly that she
●​ Vital Signs: can’t get up from bed to work.
Temperature: 37.8°C Two days prior to her admission,
Respiratory Rate: 20 the client experienced lingering
bpm headaches, these symptoms can
Cardiac Rate: 85 bpm already increase her risk for
Blood Pressure: 120/80 falling. Based on Dinges et al.,
●​ Her conjunctiva is pale. (2005), sleep loss, while neither
●​ The client looks weak a formal syndrome nor a disorder,
and tired and has no has a serious consequence for

FUNDAMENTALS OF NURSING BSN1AS1

obvious physical health, performance, and safety.
deformity. Based on the assessment data that
●​ She approximately gets a was gathered and the definition of
minimum sleep of 4 risk for fall, the patient's poor
hours a day. sleep pattern, body weakness,
wobbly feeling, pale conjunctiva
and fever is a risk factor for fall
that can lead to injuries to an
individual in which this factor is
evident by the client.

References:
●​ Doenges, Moorhouse, and
Murr. (2019). Risk for
falls. Nurse’s Pocket
Guide 15th Edition.
●​ Institute of Medicine (US)
Committee on Sleep
Medicine and Research;
Colten, Altevogt. (2005).
Sleep Disorders and Sleep
Deprivation: An Unmet
Public Health Problem.

Health Promotion / Wellness Diagnosis:

Assessment Data Nursing Diagnosis Scientific Explanation

Subjective Data: Readiness for Enhanced Sleep According to Jensen and Herr
●​ It is mentioned that she 1993, sleep is an essential
just feels so weak and component of health, affecting
tired. And according to the well-being and quality of life
her, she gets tired easily. of individuals. This means that
●​ She has an unhealthy lack of sleep can cause tiredness
sleeping pattern since and wobbly which Ms. Y has
she is a call center agent been experiencing. Lack of sleep
worker. can lead to sleep deprivation that
can be acute or chronic and
Objective Data: results from insufficient or
●​ ND disrupted sleep.

The excess fatigue resulting from

exhausting or stressful work

FUNDAMENTALS OF NURSING BSN1AS1

makes falling asleep difficult.
This is often seen in adolescents
who keep long, stressful
schedules because of work. Sleep
deprivation can cause illness,
emotional stress, medications,
environmental disturbances, and
variability in the timing of sleep
as a result of shift work. It is
shown in the patient's assessment
that has an unhealthy sleeping
pattern since she is a call center
agent worker.

References:
●​ Potter, Perry, Stockert, &
Hall. (2020).
fundamentals of nursing
(10th ed., pp. 3393-3401).
●​ Fox, M. (2013). The
importance of sleep.
Nursing Standard,
13(24), 44.

FUNDAMENTALS OF NURSING BSN1AS1