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Documentation of Nursing Diagnosis

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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Formulating and Validating Nursing Diagnosis II

Nursing diagnoses represent a problem validated by major defining characteristics. There are four categories of nursing diagnoses: problem-focused, risk, health promotion or wellness, and syndrome. The anatomy of a nursing diagnosis includes three components: problem statement or diagnostic label, defining characteristics, and related factors.
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Nursing Diagnosis

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The nursing diagnosis focuses on evidence-based...

Formulating and Validating Nursing Diagnosis I

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A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
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Peptic Ulcer Disease III: Clinical Manifestations and Diagnostic Studies

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Diagnostic and Statistical Manual of Mental Disorders (DSM)

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The Diagnostic and Statistical Manual of Mental Disorders (DSM) serves as the primary classification system for mental health disorders, providing standardized diagnostic criteria for clinicians and researchers. First published by the American Psychiatric Association (APA) in 1952, the DSM has undergone several revisions to reflect evolving psychiatric understanding. The fifth edition, DSM-5, released in 2013, introduced key updates that expanded diagnostic categories and modified diagnostic...

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Updated: Jun 11, 2026

Lateral Molar Approach-Driven Transoral Endoscopic Procedure for Benign Infratemporal Fossa Tumor Resection

Lateral Molar Approach-Driven Transoral Endoscopic Procedure for Benign Infratemporal Fossa Tumor Resection

Published on: August 15, 2025

Unroofing the diagnosis.

Giuseppe Cannavale¹, Charles B Higgins, Karen G Ordovas

¹Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy. giuseppe_cannavale@hotmail.it

The International Journal of Cardiovascular Imaging

|July 9, 2010

Summary

This summary is machine-generated.

Unroofed coronary sinus is a rare congenital heart defect. MRI successfully diagnosed this anomaly in a patient, enabling assessment of shunt severity.

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Area of Science:

Cardiology
Congenital Heart Disease
Medical Imaging

Background:

Unroofed coronary sinus (UCS) is a rare congenital cardiac anomaly.
It involves a communication between the coronary sinus and the left atrium due to absent roof of the coronary sinus.
Diagnosis is crucial to prevent complications like pulmonary hypertension and cerebral emboli.

Observation:

A symptomatic 35-year-old male presented with symptoms suggestive of a cardiac anomaly.
Transesophageal echocardiography did not visualize any atrial septal defects.
Magnetic Resonance Imaging (MRI) was employed for further investigation.

Findings:

MRI enabled the definitive diagnosis of unroofed coronary sinus.
The imaging modality also allowed for the assessment of shunt severity.
This highlights MRI's utility in diagnosing rare cardiac anomalies.

Implications:

Accurate diagnosis of unroofed coronary sinus is vital for patient management.
MRI offers a valuable tool for diagnosing UCS when other methods are inconclusive.
Early detection and assessment can guide interventions and prevent serious complications.