Term
| Data Analysis: Step 2 of Nursing Process |
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Definition
*Difficult step because nurse must use diagnostic reasoning skills to interpret data correctly (form of critical thinking
*Development of Nursing Diagnosis |
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Term
| Essential Elements of Critical Thinking |
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Definition
*Keep an open mind
*Use rationale to support opinions or decisions
*Reflect on thoughts before reaching a conclusion
*Use past clinical experiences to build knowledge
*Acquire an adequate knowledge base that continues to build
*Be aware of the interactions of others
*Be aware of the environment |
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Term
| Steps to the Diagnostic Reasoning Process |
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Definition
1. Identify abnormal data and strengths
2. Cluster data
3. Draw inferences
4. Propose possible nursing diagnosis
5. Checking for defining characteristics
6. Confirm or rule out diagnosis
7. Document conclusions |
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Term
| The Diagnostic Reasoning Process Step 1: Identify Abnormal Data and Strengths |
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Definition
| Subjective and Objective Data |
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Term
| The Diagnostic Reasoning Process Step 2: Cluster Data |
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Definition
*Identify abnormal findings/strengths that are related
*Consider, again, if additional data is needed |
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Term
| The Diagnostic Reasoning Process Step 3: Draw Inferences |
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Definition
*Write down "hunches"
*Consider nursing diagnosis
*If cues suggest both medical and nursing interventions to resolve problem, then need to develop collaborative plan |
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Term
| The Diagnostic Reasoning Process Step 4: Propose Possible Nursing Diagnosis |
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Definition
*If resolution of a problem requires nursing intervention then need to develop nursing diagnosis
*Different types of Diagnosis
-Wellness Diagnosis: Indicates client has motivation to increase wellbeing
-Risk Diagnosis: Client does not currently have a problem but is "high" risk for developing one
-Actual Nursing Diagnosis: Client has stated problem |
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Term
| The Diagnostic Reasoning Process Step 5: Checking for Defining Characteristics |
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Definition
*Use reference text such as NANDA
-Helps rule out invalid diagnosis
*Compare findings to NANDA |
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Term
| The Diagnostic Reasoning Process Step 6: Confirm/ Rule Out Diagnosis |
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Definition
| Validate diagnosis with client and other health care providers who are caring for the client |
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Term
| The Diagnostic Reasoning Process Step 7: Document Conclusions |
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Definition
*Health Promotion Diagnosis
*Risk Diagnosis
*Collaborative problems/referrals |
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Term
| Actual Nursing Diagnosis (Example) |
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Definition
*Most useful format for actual nursing diagnoses
*NANDA label (for problem) + related to (r/t) + etiology + as manifested by (AMB) + defining characteristics
*Fatigue r/t an increase in job demands and personal stress AMB client’s statements of feeling exhausted all of the time and inability to perform usual work and home responsibilities |
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Term
| Wellness or Health Promotion Nursing Diagnoses |
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Definition
*Client does NOT have a problem but is at a point he or she can attain a higher level of health
*Worded: Readiness for enhanced…
Example:
-Readiness for enhanced/effective + NANDA problem-oriented diagnostic label minus the modifiers + r/t + etiology + AMB + symptoms (defining characteristics)
-Readiness for enhanced immunization status r/t mother’s expressed desire to resume recommended immunization schedule for 3 year old child AMB mother’s description of recommended immunization schedule and importance of following it to prevent infections. |
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Term
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Definition
*Describes a situation in which an actual diagnosis will most likely occur if the nurse does not intervene
*Does not have any symptoms or defining characteristics
*Shorter diagnosis
*Risk for + diagnostic label + r/t + etiology
*Example:
-Risk for infection r/t presence of dirty knife wound and lack of client knowledge on how to provide adequate care of the wound |
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Term
| Collaborative Problems and Referrals |
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Definition
*Documented as Risk for complications (RC): _______________ (what problem is)
*Document nursing goals: parameters nurse should monitor and how often
*Indicate when MD or NP should be notified
*Identify nursing interventions to help prevent complications |
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Term
| Assessment phase pitfalls |
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Definition
*Too many or too few data
*Unreliable or invalid data
*Insufficient number of cues available to support the diagnosis |
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Term
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Definition
*Clustering cues that are unrelated to each other
*Quickly diagnosing without hypothesizing several diagnoses
*Incorrectly wording the diagnostic statement |
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Term
| Key Steps to Analyze Assessment Data |
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Definition
1. Identify abnormal data and strengths
2. Cluster Data
3. Draw Inferences
4. Propose possible nursing diagnosis
5. Check for presence of defining characteristics
6. Confirms or rule out nursing diagnoses
7. Document conclusions |
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