PES Template (Three-Part Nursing Problem Statement)
Cluster the data (assessment findings / cues) to identify specific patient problems. (Analyzing Cues). List the
highlighted (abnormal) subjective and objective data from the physical assessment and medical record here:
Neurosensory
Oxygenation & Cardiac
Endocrine
Nutrition
WNL,
LOCx3
-Irregular, weak pulses
-Cap. Refill delayed >2 sec
-Right
shoulder
injury w/
pain level
5/10
-SpO2 98% w/NC, but below
95% w/o NC placement
-Wheezing lung sounds on
LUL when inhaling
-Continuous coughing w/
moderate yellow thick sputum.
-High CO2 (36.0), BNP (160)
-Low RBC (3.27), WNL
Hgb (11.1), Hct
(Regular)
(32.3), WBC (2.8)
-Low K
- High MCV
(3.1), T.
(98.7)
protein (5.4),
albumin
-Low ALT (6)
(3.3),
Elimin
Skin Integ.
Activity
& Rest
Psychosocial
-Distended
abdomen w/
protrusion
on left side
-Redness/Rash
on upperpubic
-Bruises/dry
scalp on left
leg by fall
Unbalanced
/weak gait
Medication
(donepezil)
to treat
delirium/
dementia
-Elimination
WNL
Moderate
fall risk 35
(had a fall 2
days ago)
Create your problem statements from the clusters in this manner:
Patient problem R/T Etiology AEB Supporting Data
=> Impaired gas exchange R/T irregular pulmonary opacities in the LUL, AEB wheezing sounds on the upper
left lung when inhaling, coughing with yellow moderate sputum, and SpO2 under 94% without NC
placement.
Patient problem (These are real or potential problems) related to: Risk for bleeding
Etiology (this is the physiologic or psychologic underlying cause of the problem (not a medical diagnosis), as
evidenced by:
Signs and symptoms (This is the cluster or list of associated data taken directly from the assessment information):
Problem List (Generate Hypothesis) Nursing Diagnosis Problem Statement
Nursing Problem Statement
R/T:
AEB:
System-based problem
Actual or Potential problem
Etiology
Underlying cause
Related Factor
Risk Factors
Patient Cues
Signs and Symptoms
Defining Characteristics
Associated Data
Impaired gas exchange
Irregular pulmonary opacities
Wheezing sounds on the upper left
lung when inhaling, cough with
yellow moderate sputum, and SpO2
under 94% without NC placement.
Two-part statements are used for potential or risk for problems.
One-part statements are used for health promotion and syndrome diagnoses.
Guidelines for using template:
1.
Look up disorder/medical diagnosis in course textbook
2.
Review nursing management to identify potential problems
3.
Utilize sample lists: “Problems Grouped by System”
See Appendix B in Lewis textbook for a general list of nursing diagnoses