Assessment, Clinical Judgmentand Nursing Diagnoses

Chapter Two

Assessment, Clinical Judgmentand Nursing Diagnoses

ContributorMargaret Lunney

Nursing Process• Conceptual Description of What Nurses Do • Broadly Accepted Worldwide• Five Phases, Cyclical:

• Assessment• Diagnosis• Planning• Implementation• Evaluation

Nursing Assessment

Nursing Diagnosis

PlanningImplementation

Evaluation

Continuous Clinical JudgmentDefinition

“Interpretation or Conclusion About a Patient’s Needs, Concerns, or Health Problems, and/or the Decision to Take Action (or Not), Use or Modify Standard Approaches, or Improvise New Ones as Deemed Appropriate by the Patient’s Response” (Tanner, 2006, p.204)

Assessment Data are Interpreted• What Happens?

• Nurses Convert Data to Interpretations

• Why?• Nurses, as Other People, Have Limited Space in

Short-Term Memory, Cannot Remember All Data But Remember Interpretation

• How?• Connect Patient Data with Knowledge in Memory

1973: First Conference to Identify the Names for Data Interpretations• 80 Nursing Diagnoses First Identified

• Evolved to NANDA International (I)

• Purpose of NANDA-I: Approve Nurse-Developed Research-Based Names for Data Interpretations, Labels and Descriptions

Nurses are Diagnosticians• Nurses Use a Diagnostic Process in

Partnership with Patients

• Why? • Focus is Health• People Make Themselves Healthy

Diagnostic Competencies

• Intellectual

• Interpersonal

• Technical

• Personal Strengths:• Tolerance of Ambiguity• Use of Reflective Practice

Intellectual Competencies• Knowledge• Mental Processes

Mental Processes: Cognitive Skills and Habits of the Mind

• Examples of Cognitive Skills:• Analyzing• Logical Reasoning• Applying Standards

• Studies Show That:• Adults Vary in Cognitive Abilities• Thinking Processes can be Improved

To Develop Thinking Abilities• Use Thinking

• Think About Nursing Concepts, e.g.:• Health Management• Sleep

• Seek Support

• Develop Confidence

Interpersonal Competencies• Trust Enables Patients to Share Valid and

Reliable Data with Nurses

• Communication Skills Enhance Trust

• Work in Partnership with Patients

• Listen

Technical Competencies• Nursing Assessment:

• Health History• Physical Examination

• Use a Framework That Yields Nursing Concepts,

e.g. Functional Health Patterns

Personal Strength: Tolerance of AmbiguityWhy?• Numerous Factors Influence Clinical

Situations

• Human Beings are Complex and

Unique

• Enables Consideration of Many Factors

Reflective Practice• Re-examine Feelings and Behaviors• Reflection Needed for Self-Evaluation

Assessment and Nursing Diagnosis• Units of Analysis: Individual, Family or

Community

• Books That Appropriately Link Assessment to Nursing Diagnosis

Principles of Diagnostic Reasoning and Assessment• Work in Partnership with Individual, Family or

Community

• Think About Diagnostic Hypotheses; Collect Data to Support or Reject Hypotheses

• Complete Data Collection Before Deciding on Diagnoses

• Validate Diagnoses with Patients

Recognize Cues• Cues: Units of Data That Have Meaning in Relation

to Diagnoses, e.g. Rate of Breathing and Ineffective Breathing Pattern

• Recognition of a Cue and Its Meaning Depends on Knowledge in Memory

• For Meaning: Compare Cues to Knowledge and the Individual Patient

Mentally Generate Possible Diagnoses• Consider Context of Situation

• Compare Cues with Knowledge in Memory

• Consider Multiple Possible Explanations

• Avoid Deciding Too Soon (Premature Closure)

• Be Flexible in Thinking

Conduct Focused Data Collection• Collect Additional Data to Support Diagnostic

Hypotheses

• Collect Data to Rule Out Competing Hypotheses

• Summarize Data with a Possible Explanation or Diagnosis

Validate Diagnoses with Patients and Others• Collaborate with Patient and Family

• If Patient is Unable to Validate, Collaborate with Other Nurses or Providers

Name Diagnoses Using NANDA-I

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