Health Assessment &
Praxis
Learning Outcome 2- Apply the Nursing
Process
Nursing Assessment
Learning Step 1
Nursing Assessment
• Collecting Data
• Subjective and Objective
• Comprehensive Nursing Health History
Data VS. Judgement
Methods of Data Collection
• Interview• During the Interview, you need to:
Phases of the Interview
• Orientation Phase
• Working Phase
• Open-ended Questions
• Closed-ended Questions
• Termination Phase
Nursing Health History
• Collect Data on all Health Dimensions
• Family History
• Physical Exam
• Observation of Client Behaviour
• Diagnostic and Laboratory Data
• Interpreting Assessment Data and Making Nursing Judgements
• Documentation
• Concept Mapping
The “Cs” of Concept Mapping
• Center
• Clusters
• Connections
Steps of Data Analysis
• Recognize a pattern or a trend by cues:
• Turns slowly
• Is unable to bend over
• Walks with hesitation
• Compare with normal standards:
• Has normal range of motion
• Initiates movement without hesitation
• Make a reasoned conclusion
• Has limited mobility
• Has reduced activity level
Assessment Review
• During a nursing assessment the nurse systematically collects, verifies, and analyzes
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and communicates data about a client.
The nurse must apply the principles of critical thinking.
Comprehensive approaches to data collection go from general to specific.
The nurse assesses clients by organizing patterns of behaviour and physiological
responses that pertain to a functional health category. The nurse then compares data
with the client's baseline.
The nurse must cluster clues of assessment data and begin to identify emerging
patterns and potential problems.
Nursing Diagnosis
Learning Step 1
Nursing Diagnosis
• Forming a diagnostic conclusion that will determine the nursing
care a client receives.
• Problems treated primarily by nurses are nursing diagnosis
• Focuses on actual or potential response to a health problem
Diagnosis
Medical VS. Nursing
• Diagnose- “to know”
• Medical Diagnosis- identifying a disease or condition based on specific
evaluation of physical signs, symptoms, medical history, and diagnostic tests.
• Physicians are licensed to treat these
• Nursing Diagnosis- determines health problems within the domain of
nursing. Comes from analyzing data and making a clinical judgement with
response to actual or potential health problems.
• Figure 12-6- Page 165 P&P
Collaborative Problem
• Actual or potential physiological complication that nurses monitor to detect
the onset of changes to a client’s status. Nurses collaborate with other health
care professionals.
• We use both physician-prescribed and nursing-prescribed interventions to treat and
minimize complications
• Example:
Nursing Diagnosis
• Conclusions drawn using common nomenclature
• A part of professional practice
• List of Nursing Diagnoses provided by NANDA-I
Nursing Diagnosis
Data
Clustering
Identifying
Client Needs
Formulating a
Diagnosis or
Problem
Nursing Diagnosis
• We create by identifying defining characteristics- the clinical
criteria or assessment findings that help confirm a nursing
diagnosis.
• Clinical criteria- objective or subjective signs and symptoms,
clusters of signs and symptoms, or risk factors that lead to a
diagnostic conclusion.
Nursing Diagnosis
Diagnosis: Impaired Gas Exchange
Diagnosis: Ineffective Breathing Pattern
Defining Characteristics:
Dyspnea
Abnormal rate, rhythm, depth of breathing
Abnormal arterial pH
Abnormal skin colour (pale, dusky)
Hypoxemia
Hypercarbia
Hypoxia
Confusion
Defining Characteristics:
Dyspnea
Bradypnea
Decreased vital capacity
Orthopnea
Altered chest excursion
Use of accessory muscles to breathe
Tachypnea
Pursed-lip Breathing
Nursing Diagnosis- Types
• Actual Nursing Diagnosis- responses to health conditions or life processes that
exist in an individual, family, or community.
• Risk Nursing Diagnosis- describes human responses to health conditions or life
processes that will possibly develop in a vulnerable individual, family, or community.
• Health Promotion Nursing Diagnosis- clinical judgement of a person’s, family’s
or community’s motivation and desire to increase well-being and actualize health
potential, as expressed in a readiness to enhance health behaviours
• Wellness Nursing Diagnosis- describes levels of wellness in an individual, family,
or community that can be enhanced.
Components of a Nursing Diagnosis
• Diagnostic Label + Related Factors
• Diagnostic Label- Name of the diagnosis, approved by NANDA-I
• Related Factors- condition identified from the client’s assessment data
• These can be _____________ through ________________ interventions!
Components of a Nursing Diagnosis
• Definition- approved by NANDA-I
• Risk factors
• Support of Diagnostic Statement
Nursing Diagnosis
• Problem (as identified in NANDA-I Listings) + “Cause” (if known)
• Expressed by using the following:
• Related to (r/t)
• Due to (d/t)
• As evidenced by
Where can errors occur in diagnosing?
• Collecting Data
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Lack of knowledge or skill
Inaccurate data
Missing data
Disorganization
• Interpreting Data
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Inaccurate interpretation of cues
Failure to consider conflicting cues
Using an insufficient number of cues
Using unreliable or invalid cues
Failure to consider cultural influences/developmental
stage
• Clustering Data
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Insufficient clustering of cues
Premature or early closure of clustering
Incorrect clustering
• Labelling
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Wrong diagnostic label selected
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Condition incorrectly overlooked as a collaborative
problem
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Failure to validate nursing diagnosis with client
Existence of evidence that another diagnosis is more
likely
Failure to seek guidance
Let’s Practice
• A person who has just had their right leg amputated
• A person who just had surgery for a broken leg
• A person with terminal cancer
Critical Thinking
• Mrs. Spezio has a pressure ulcer over the coccyx that is 5 cm in diameter and
approximately 1 cm deep. The tissue surrounding the ulcer is inflamed and
tender to touch. Mrs.Spezio is transferring from a long-term care facility
where she had resided for six months after a massive stroke. She is unable to
move independently in bed and does not sense pressure or discomfort over
her coccyx or hips. In view of this clinical situation, identify the defining
characteristics and related factors for the nursing diagnosis impaired skin
integrity.
Planning Stage
Planning
Planning = Setting Priorities +
Establishing Goals + Planning
Interventions
Priorities
• Setting priorities involves ranking nursing diagnoses or client problem, using
principles such as urgency or importance, to establish a preferred order for
nursing actions.
• High Priority
• If untreated, will it result in harm to the client?
Priorities
• Intermediate Priority
• Non-life threatening, non-emergency needs of the client
• Low-Priority
• Not always directly related to a specific illness or prognosis, but affect the
client’s future well-being
Goals
• Goals - what you hope to achieve with your client
• Goals need to be:
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Specific
Measurable
Observable
Time-limited
Achievable
Client-Centered
Involves only one behaviour or response
Goals
• What does it mean to be client-centered?
• Short-Term Goal
• Long-Term Goal
Begin each goal with:
Client will…
Expected Outcomes
• A specific measurable change in a client’s status that you expect in response
to nursing care.
• Help us determine when our goals have been met
• There are usually several desired outcomes for each nursing diagnosis and
goal
• The terms expected outcomes and goals are often used interchangeably and
are often combined into one statement
Let’s Practice
1. The client’s hydration will improve
2. The nurse will reduce the client’s anxiety
3. Improve muscle strength
4. The client will lose 6 lb. in 2 weeks
5. Turn and deep breath the client Q 2 hours
6. Ankle edema will decrease
7. The client’s Temperature will stay in normal range for the next 24 hours.
Nursing Interventions
• Independent Nursing Interventions-
• Dependent Nursing Interventions• Collaborative Nursing Interventions-
How to choose?
Think about:
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Characteristics of the Nursing Diagnosis
Expected Outcomes
Evidence Base
Feasibility
Acceptability to the Client
Capability of the Nurse
Type of Error
Incorrect Intervention
Failure to precisely or
completely indicate nursing
actions
Turn client every 2 hours
Failure to indicate frequency
Perform blood glucose
measurements
Failure to indicate quantity
Irrigate wound once a shift:
at 0800, 1600, and 2400
Failure to indicate method
Change client’s dressing once
a shift: 0800, 1600, and 2400
Correct Intervention
Nursing Interventions
• Always begin with:
• Nurse will….
• Should have minimum of 3-5 interventions for each nursing diagnosis.
• Include all that you plan to do to help with your client’s need- assessments,
monitoring, procedures, or other therapeutic interventions.
Nursing Care Plans
• Bringing it all together!
• Include:
• Any nurse should be able to pick up the care plan and
identify client’s needs and situation!
Terms to Know…
• Kardex- a filing system that allows quick reference to the needs of the client
for certain aspects of nursing care. The careplan is a part of this.
• Critical pathways- multidisciplinary treatment plans. Outline treatment that
a patient may require for the treatment of a condition
• Consultation- seeking the expertise of a specialist, such as another nurse or
another member of the health care team.