Potter & Perry: Chapter 13 (159-176): Nursing Assessment and Diagnosis (dirk)
The nursing process is a problem-solving approach to identifying, diagnosing, and treating the health
issues of clients.
Figure 13-1: Five step nursing process; circular process, after 5 repeat to 1
1. Assess: Gather information about client’s condition (Ms Devine, 52 year old woman fell 2 months ago
and ruptured a lumbar disc, she is scheduled for a laminectomy this afternoon; has limited mobility and
acute back pain)
2. Diagnose: identify the client’s problem (acute pain related to pressure on spinal nerves)
3. Plan: set goals of care desired outcomes and identify appropriate nursing actions (to relieve
discomfort nurse will order analgesic, repositions and if that offers no solace discuss how Ms Devine can
practice relaxation exercises)
4. Implement: Perform the nursing actions identified in planning (administer drugs)
5. Evaluate: determine if goals met and outcomes achieved (check 40 min later to see if analgesic
relieving pain, and offer to try relaxation exercises)
The nursing process is a variation of scientific reasoning because you organize, systematize and draw
inferences.
Critical Thinking Approach to Assessment
Assessment: gather info about client’s condition (two steps)
1. Collection and verification of data from primary source (client) and secondary sources (family, health
professionals, patient record)
2. The analysis of data as a basis for developing nursing diagnoses, identifying collaborative problems,
and developing a plan of individualized care
Purpose of assessment: to create a database for what is believed the client needs, their health
problems, and responses to these problems.
What you do during an assessment:
-See client’s that present an initial health problem to you
-you observe client’s behaviour
-ask questions about the nature of the problem
-listen to cues the client provides, conduct a physical examination
-interview family members who are familiar with the client’s health problem
-review existing medical data
Figure 13-2 Critical thinking and the assessment process
During the Assessment of the nursing process, a nurse synthesizes data from 4 areas:
1. Knowledge:
-underlying disease process
-normal growth and development
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-normal physiology and psychology
-normal assessment findings
-health promotion
-assessment skills
-communication skills
2. Standards:
-CNA
-Specialty standards of practice
-Intellectual Standards of measurement
3. Qualities:
-Perseverance
-Fairness
-Integrity
-Confidence
-Creativity
4. Experience
-Previous client care experience
-Validation of assessment findings
-Observation of assessment techniques
Experience is the most important because of similarities between past and future clients (back pain
normally disabling and limits motion for all); also allows you to see other professionals at work, also
allows you to realize what counts as normal standards of practice
Data Collection
Box 13-1: Guidelines for Documenting a Comprehensive Nursing History (note: don’t get bogged down
on the examples, focus on the headings)
When a client comes in, acquire as full a health history as possible along such criteria as:
A. Identifying Data:
Name, age, sex, date, and place of birth
B. Reason for health History interview:
Explain why you are interviewing the client at the present time (e.g., the client has just been admitted to
an inpatient unit or clinic
C. Current State of Health:
General state of health and health goals (i.e. if illness present collect data about illness through a system
analysis)
D. Developmental Variables:
-Marital Status: single married, separated, widowed, divorced
-Number of Children
-Development stage
-Current job
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-Significant life experiences (education, previous jobs, financial situation, retirement, coping or stress
tolerance, and measures normally used to reduce stress)
-Safety hazards (biological, chem., ergonomic, physical, psychosocial, reproductive)
-Housing, environmental hazards (type of housing, location, living arrangements; specific hazards in
home or community
-Safety measures (seatbelts, fire extinguishers, and such in work, community or home)
E. Psychological Variables:
Mental processes, relationships, support systems, statements regarding client’s feelings about self
F. Spiritual Variables:
Rituals, religious practices, life beliefs
G. Sociocultural Variables:
-Culture: beliefs and practices related to health
-Primary language and languages spoken
-Recreation
-Family: composition, interaction, support?
H. Physiological Variables (Body Structure and Function)
-History of past illnesses and Injuries, including dates
-Current medications: legal, non legal, prescribed, effects, side effects, adverse rxns, attempts to quit
-Review of systems (body systems), continuation of H:
-General manifestations of symptoms: fevers chills, malaise, pain, sleep patterns, fatigue, weight
-Integumentary: itching, colour or texture changes, lesions, dryness, hair texture and changes; any
lotions or creams used
-Ocular: visual acuity, blurring, eye pain, change in vision, discharge, excessive tearing, dryness, date of
last exam
-Auditory: hearing loss, pain, discharge, dizziness, ringing, wax
-Upper respiratory: nosebleeds, nasal discharge, nasal allergies, sinus problems, colds, sore throat,
hoarseness, voice changes
-Lower respiratory: tobacco use, exposure to airborne pollutants, tuberculosis, last chest x-ray
-Breast and axillae: rashes, lumps, discharge, pain, breast self exam practices
-Lymphatic: pain, swelling
-Cardiovascular: chest pain or distress; possible causes, duration; exercise tolerance, hypertension,
dyspnea, edema, circulatory problems
-Gastrointestinal: appetite, digestion, food intolerance, abdominal pain, vomiting, stool, dietary patterns
(restrictions, special diets, alcohol consumption)
-Urinary: painful, blood, stones, puss, past infections to kidneyor bladder, stream style (dribbling,
stopping, constant), night visits
-Genital and reproductive:
Male: puberty onset, erections, testicular pain, libido, infertility, discharge, STDs, self exam,
sexual preference
Female: menses (onset, duration, regularity, flow, discomfort, last time), menopause, pap test,
pregnancies (number, complications), BC, sexual preference
-Muscuoloskeletal: pain, joint (stiffness, swelling, limited mobility), muscle wasting, weakness, general
mobility
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-Neurological: injury, headaches, dizziness, fainting, abnormalities of sensation or coordination, tremors,
seizures
-Endocrine: excessive sweating, thirst, hunger, urination, heat/cold intolerance, changes in distribution
of facial hair, thyroid enlargement, change in weight, change in glove or shoe size
-Hemotological: anemia, bruise or bleed easily, transfusions
-Psychiatric: depression, mood changes, difficulty concentrating, nervousness, anxiety, suicidal thoughts,
irritability
-Immunological: communicable diseases (onset, age), immunizations (year), allergies
Definitions:
Cue: information obtained through senses
Inference: judgement or interpretations of cues
When collecting data you group cues then, inferences and patterns arise then you can anticipate
potential problems and solutions.
Figure 13-3 Example of branching logic for selecting assessment questions:
This figure shows how to ask better, more relevant questions based on client’s verbal and nonverbal
cues and previous answers. (note: not that important, but I said to include such things)
Types of Data
1. Subjective Data: From client’s verbal descriptions about themselves (feelings, perceptions, symptoms)
2. Objective Data: observations or measurements about client’s health status (wound size, BP,
behavioural characteristics: fear, anxiety)
Sources of Data
From variety of sources; provides info on: level of wellness, strengths, anticipated prognosis, risk factors,
health practices, goals, patterns of health and illness
Client
Best source of info when client is conscious and alert because they will generally answer questions
correctly. If the client is experiencing acute symptoms in emergency generally do not give as much
information, so be interested to coax more information out of them.
Family and Significant Others
1. Family and significant others are primary sources of information if the client is an infant, child,
critically ill adult, mentally handicapped, disoriented or unconscious.
2. Family and significant others are secondary sources for adult patients in healthy mindsets; secondary
sources provide such info on medications taking practices, and sleeping and eating irregularities
Health Care Team
-Pass and obtain information to other members of the health care team about client because each has
different view points and backgrounds (other nurses from next shift, physicians, physical therapists,
social workers, other pertinent staff consultants)
Medical Records
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Medical history, lab and diagnostic tests, current physical findings, medical treatment plan (confidential)
Info obtained:
Baseline and ongoing information about client’s response to illness and progress (Tool for
checking the consistency and similarity of personal observations)
Literature
Assessments based on (medical, pharmacological, etc lit)
Nurses Experience
Refines your assessing abilities in subsequent interactions with differing patients with similar symptoms
Methods of Data Collection
Interview
Orientation phase:
-Introduce yourself to the client, explain your role, confidentiality, and explain the role of other health
care professionals during care
-Establish a caring therapeutic relationship with the client
Working phase:
-gather info about health status using nursing health history
-explore client’s current illness, health history, and expectations of care and worries
-objective: identify patterns of health and illness, risk factors for behavioural health problems, changes
from normal function, available resources for adaptation
-1st interview is most extensive because you are updating their info
Termination phase:
-give a cue that the interview is ending, “so I’m gonna ask you 2 more questions”
-this gives the client the opportunity to ask questions
-be sure to summarize important points and emphasize important ones
Cultural considerations in Assessment
Be wary of client’s culture and value system, and their ways of communicating (Spanish and French use
strong eye contact; Asians, Middle Easterners and North Americans let their eyes wander); but don’t for
opinions on client based on culture alone
Use open ended questions when you need them to elaborate on a matter (long drawn out answers)
Use close ended questions when you don’t need additional info (yes/no answers)
Box 13-2: Examples of Open and Close Ended Questions
Open ended: How are you feeling?
Close ended: Are you having pain now?
Nursing Health History
See above, Box 13-1: Guidelines for Documenting a Comprehensive Nursing History
You don’t have to go through all questions, as you are more experienced you’ll focus on the
pertinent stuff according to what the patient shows you
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The health history is just meant to have as much data as possible to draw patterns and
inferences from. The more someone knows the more prepared they will be...
Family History
Purpose is to obtain data about immediate and blood relatives to see an illness is genetic or familial in
nature, and find ways of preventing it in client and other potential family members.
Also provides history on family interaction and function (is the family supportive or stress causing)
Documentation of History Findings
Make sure the info you obtain is clear, concise, uses appropriate terminology so subsequent lookers can
get a clear picture of the client’s status. This information will be the baseline against which you evaluate
any future changes.
Physical Examination
Investigation of the body to determine state of health (using techniques: inspection, palpation,
percussion, auscultation, smell; measurements: height, weight, vital signs, body system)
Observation of Client Behaviour
Observing verbal and nonverbal behaviour allows you to verify data: see if they match (e.g. adult male
client says injury doesn’t hurt but is bawling like child). Also allows you to gather additional data like
level of function (physical, developmental, psychological and social)
Diagnostic and Laboratory Data
Diagnostic or lab tests verify, clarify questions you have form the nursing health history and physical
exam. (client comes in bc he is coughs up brown sputum and has a cough; examination shows elevated
temp and respiration; blood test shows elevated WBC count; X ray shows lower lobe infiltrate = add all
together and you get pneumonia)
Interpreting Assessment Data and Making Nursing Judgments
Again... collect data, analyze and interpret it be noting patterns (critical thinking aspect), then make a
decision on how to proceed with client’s are.
Data Validation
Comparison of data with another source to determine accuracy, so validate findings from the
physical examination and observation of client behaviour by comparing data in the medical
record and by consulting with other nurses or health care team members and family members.
This is to make sure that the client’s data base of info is correct when you analyze it
Analysis and Interpretation
After collecting data about the client interpret it by recognizing patterns and trends in clustered
data, comparing them with standards and formulate a reasonable conclusion
Box 13-3 Steps to data analysis
1. Recognize a pattern or trend by cues: Turns slowly, unable to bend over, walks with hesitation
2. Compare with normal standards: has normal range of motion, initiates movement w/o
hesitation
3. Make a reasoned conclusion: has limited mobility, has reduced activity level
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Data Documentation
Last part of complete assessment, record everything seen, heard, smelled. When entering data don’t
generalize or form judgments through written communication.
Concept mapping:
A visual way of showing connection between health problems
Figure 13-4: sample of concept map: (pretty much a regular mind map)
Client with medical assessment in middle, symptoms with possible connections to the medical
assessment radiating from middle (positioned by similarity)
Middle: medical diagnosis: herniated disc, scheduled for lumbar laminectomy,
Surrounding connections: back pain reported at 10, grimacing; moves awkwardly, client scared
of surgery; unfamiliar with surgery
Nursing diagnosis
Next step diagnostic conclusion. Diagnostic conclusions include problems treated primarily by and
problems necessitating treatment by several disciplines
Medical diagnosis – identification of a disease on the basis of a specific evaluation of physical signs,
symptoms, the client’s medical history and the results of diagnostic tests and procedures (ie. Diabetes
Mellitus)
Nursing diagnosis – clinical judgment about individual, family, or community responses to actual and
potential health problems or life processes that is within the domain of nursing (no example given)
Collaborative problem – potential physiological complication that nurses monitor to detect the onset of
changes in a client’s status. Nurses intervene in collaboration with other disciplines such as physician
and nursing diagnosis (i.e surgical wound infection on client; Dr prescribes antibiotics; nurses monitor
fever and and apply wound care)
Figure 13-5: Critical thinking and the nursing process
Nursing process: 1. Assessment; 2. Diagnosis; 3. Planning; 4. Implementation; 5. Evaluation; back to 1
During Diagnosis you just incorporate Experience, Knowledge, Standards and Qualities
(similar to figure 13-2)
Nursing diagnoses provides the basis for selection of nursing interventions to achieve outcomes for
which, a nurse, is accountable.
Nursing diagnosis serves several purposes:
1. Provide a precise definition that give all members of the health care team a common
language for understanding a client’s needs
2. They allow nurses to communicate their actions amount themselves, to other health care
professionals
3. They distinguish the nurse’s role from that of the physician or other health care
professionals
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4. They foster the development of nursing knowledge
Figure 13-6 Differentiating nursing diagnosis from collaborative programs:
Nurses do not give primary interventions, doctors do; they provide interventions for prevention,
treatment or promotion
Nurses are part of the collaborative process: prescribe and implement interventions that are in the
domain of nursing; monitor and evaluate conditions, implement prescriptive orders of medicine or
dentistry
Critical Thinking and the Nursing Diagnostic Process
Using assessment data to logically explain a clinical judgment, a nursing diagnosis. (steps: data
clustering, identifying client needs to formulating the diagnosis)
Clusters and patterns of data that help confirm an actual nursing diagnosis.
Clinical criteria – objective or subjective signs and symptoms, clusters of signs and cues (symptoms), or
risk factors that lead to a diagnostic conclusion
Box 13-4: Examples of NANDA nursing diagnoses (not a full list, these are generally easy diagnoses, not
like in “House”):
Activity tolerance, latex allergy, risk for falls, diarrhea, acute confusion, contamination, disturbed body
image, risk of aspiration, deficient in knowledge (condition or surgery)
-------------How to: first you cluster similar data, see if they are defining characteristics then based on similar data
you draw on conclusion = diagnosis
Example: defining characteristics (dyspnea, abnormal respiratory rate, abnormal depth of breathing) =
diagnosis (impaired gas exchange or ineffective breathing)
From your assessment, the symptoms (cues) that equate to defining characteristics will lead you
towards your diagnosis
But if client uses accessory muscles to breath and demonstrates pursed lip breathing, the correct
diagnosis is not impaired gas exchange but ineffective breather pattern (from Table 13-1)
--------------Check other patterns, and see if they are within healthy norms, and make not of them if they are not
Formulation of Nursing Diagnosis (created by NANDA International, another governing body)
1. Actual Nursing Diagnosis: responses to health conditions or life processes that exist for individual,
family or community; defining characteristics (manifestations, signs, and symptoms) that cluster in
patterns of related cues or inferences support this diagnostic judgment (client says back pain is at an 8 =
acute pain)
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2. Risk nursing diagnosis: human responses to health conditions that will probably develop in a
vulnerable individual, family or community (i.e. a patient shows a vulnerability due to poor nutrition, is
going to have a surgery and will be staying in the hospital = risk for infection)
3. health-promotion nursing diagnosis: clinical judgement of a person’s, family’s, or community’s
motivation and desire to increase well-being and actualize human health potential, as expressed in their
readiness to enhance specific health behaviours, such as nutrition and exercise (can be used in any
health state)
4. Wellness nursing diagnosis: describes levels of wellness in an individual, family, or community that
can be enhanced; when a client wants to achieve an optimum level of health (diagnosis: readiness for
enhanced coping related to successful cancer treatment – nurse and family work together to adapt to
the stressors associated with with cancer while incorporating clients strengths and resources.
Components of a Nursing Diagnosis
Nursing diagnoses are in a two part format: diagnostic label followed by a statement of related factors.
Diagnostic Label: nursing diagnosis approved by NANDA (see above figure 13-4); diagnostic label
descriptors to give additional meaning. For example impaired physical mobility, impaired is the
descriptor (other descriptors (compromised, promised, decreased, deficient, delayed, effective,
imbalanced, impaired and increased).
Related Factors: a condition or origin identified from the client’s assessment data. (diagnosis = deficient
in knowledge regarding post operative routines; cause = lack of exposure to instruction, client has not
had surgery before)
Figure 13-7: Diagnostic process of a client
Assessment of client’s status: client is concerned about an upcoming back surgery; is worried about
paralysis; showing signs of restlessness; uncertain about expectations
Validate data: nursing staff says client has poor eye contact
Do we need more data? No
Interpret and analyze data:
Grouped signs: restless + poor eye contact
Grouped behaviours: concerned + uncertain of expectations
Look for defining characteristics: reveals problem with coping
Nursing diagnosis: anxiety related to surgery
Table 13-3
Nursing diagnosis: Anxiety related to surgery
Intervention: provide detailed instructions about surgical procedure, recovery process and post op care
Figure 13-8: the relationship between etiology (origin) and problem isn’t one of cause and effect, they
are just associated/related to each other. For example the problem, decreased physical functioning is
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related to etiology, limited physical activity, strength, coordination, and nutrition. Etiology does not
necessarily cause problem, but is related to it.
Table 13-4 Defining characteristics and etiologies to confirm nursing diagnosis:
Assessment activities: ask client to rate pain 0-10; observe positioning in bed
Defining Characteristics: pain at 8; client bends knees while on back
Nursing diagnosis: Acute pain
Etiologies (“related to”): physical pressure on spinal nerves
Definition: approved definition for a diagnosis that follows clinical use and testing
Risk factors: environmental, physiological, psychological, genetic or chemical elements that increase the
vulnerability of an individual, family or community to an unhealthy event (client shows signs of invasive
procedure, trauma, malnutrition, immunosuppression and lack of knowledge to avoid pathogens =
diagnosis: risk of infection)
Support of the diagnostic statement: nursing assessment must support diagnostic label – make sure
your diagnosis falls from the data you collected and clustered
Concept mapping for Nursing Diagnosis
Figure 13-9: this figure is just stating that when you do a concept map for a patient when you assess
them and then analyze the data by clustering similar traits together, the cluster will be interconnected
still.
Concept mapping is just a way of seeing the big picture and possibly predicting problems.
Sources of Diagnostic Errors (elaborated from box 13-5)
Errors in Data collection
Check for inaccuracy by:
-reviewing your level of comfort and competency before conducting interview, physical exam and data
collection
-go through section by section (interview, phys exam, body systems, head to toe exam)
-review clinical assessment in a clinical or class setting for constructive criticism for revision
-have a more experienced worker validate your findings
-be organized with appropriate forms and equipment, and the environment is comfortable for client
Errors in Interpretation and Analysis of Data
Review data collected, organize assessments; consider conflicting cues, also consider cultural
background, developmental stage when determining meaning of cues (pain is expressed differently in
differing cultures; misinterpreting data will lead to inaccurate diagnosis)
Errors in Data Clustering
-insufficient clustering of cues
-premature or early closure of clustering
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-incorrect clustering
Errors in the Diagnostic Statement
-use approved language
Labelling
-wrong diagnostic label selected
-existence of evidence that another diagnosis is more likely
-condition incorrectly overlooked as a collaborative problem
-failure to validate nursing diagnosis with client
-failure to seek guidance
Documentation
-once identifying a client’s nursing diagnosis, list it on plan of care, chronologically
Nursing Diagnoses: Application to Care Planning
The nursing diagnosis shows us what care is necessary for the clients and provides direction for the
planning process and selection of interventions.
The care plan is a map for nursing care and demonstrates your accountability for client care; subsequent
care plans will assist in communicating to other professionals the client’s health care problems and
ensure that you select relevant and appropriate nursing interventions.
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