Nursing Process: Assessment and Diagnosis – Structured Study Notes

Nursing Process

Definition and Overview

The nursing process is a systematic, cognitive framework used by nurses to identify, diagnose, and treat actual or potential health issues from a holistic perspective. It guides clinical judgement, decision making, and reflective nursing practice, and encourages critical thinking in all aspects of patient care.

• Definition: A cognitive [thinking] framework for identifying, diagnosing, and treating health issues (Potter et al., 2019).

• Main Purpose: To provide safe, competent, and holistic care.

• Key Feature: The process is unified and continuously linked, supporting ongoing clinical judgement.

Five Steps of the Nursing Process

The nursing process consists of five interrelated steps, often remembered by the mnemonic ADPIE:

• Assessment

• Diagnosis

• Planning

• Implementation

• Evaluation

Each step is essential for effective patient care and is continuously revisited as the patient's condition evolves.

Diagram: The Nursing Process Cycle

The process is cyclical, with each step informing the next:

• Assess: Gather information about the patient's condition.

• Diagnose: Identify the patient's problems.

• Plan: Set goals of care and desired outcomes; identify appropriate nursing actions.

• Implement: Perform the nursing actions identified in planning.

• Evaluate: Determine if goals and expected outcomes are achieved.

Assessment Phase

Purpose and Description

The assessment phase is the first step in the nursing process. It involves the systematic and continuous collection of data to establish a comprehensive database about the client's health status, needs, and challenges.

• Holistic and Comprehensive: Ensures safe and competent care by considering all aspects of the client's health.

• Continuous: Data collection occurs throughout all phases of the nursing process.

• Purpose: To establish a database for planning and addressing client needs.

Types of Data Collected

• Subjective Data: Information reported by the client, such as feelings, experiences, and perceptions. Example: "I am cold." Only the patient can describe or verify this data.

• Objective Data: Observable and measurable information obtained through physical examination, observation, or diagnostic tests. Example: Measuring oxygen saturation, inspecting an incision site.

Note: Some data can be both subjective and objective, such as a patient reporting vomiting and the nurse measuring the amount.

Sources of Data

• Primary Source: The patient themselves; considered the most accurate.

• Secondary Source: Family members, significant others, client records, charts, healthcare team notes, lab reports.

• Tertiary Source: Literature, nurse's experience, accepted commonalities in physical and emotional responses.

Methods of Data Collection

• Observation: Using senses (vision, hearing, smell, touch) to gather information.

• Examination: Includes inspection, palpation, auscultation, and percussion.

• Interviewing: Direct and indirect questioning to validate and clarify data.

Data Validation

Validation ensures the accuracy and completeness of collected data. It involves comparing information from different sources and clarifying vague or unclear data.

• Ensures completeness

• Confirms agreement between subjective and objective data

• Obtains additional information if needed

• Differentiates between cues (observed data) and inferences (conclusions)

Example: Observing a client crying and confirming the reason through conversation.

Data Analysis

After data collection, nurses analyze the information to identify significant cues, cluster related data, recognize patterns, compare findings to norms, and identify gaps.

• Cues: Observable signals or hints (e.g., crying).

• Inferences: Judgements or conclusions drawn from cues (e.g., crying due to sadness).

• Clustering Data: Grouping related signs and symptoms to form meaningful clusters.

• Identifying Patterns: Recognizing trends or repeated occurrences (e.g., vomiting after medication).

• Comparing to Norms: Assessing whether data falls within normal ranges for age, development, lab values, etc.

• Identifying Data Gaps: Noting missing or inconsistent information that requires further validation.

Nursing Diagnosis

Definition and Purpose

The nursing diagnosis is a clinical judgement about individual, family, or community responses to actual or potential health problems within the domain of nursing. It determines the health problem and provides the basis for client goals, outcomes, and nursing interventions.

• Focus: On the human response to health conditions, not just the physiological event or disease.

• Basis for Care: Guides selection of nursing orders and interventions.

Types of Nursing Diagnosis

Type	Description	Example
Actual Nursing Diagnosis	Response to health conditions present at the time of assessment; has defining characteristics (signs/symptoms).	Activity Intolerance related to abdominal pain following surgery; acute pain.
Risk Nursing Diagnosis	Human response that may develop in a vulnerable individual, family, or community; presence of risk factors.	Risk of Activity Intolerance related to abdominal surgery.
Health Promotion Nursing Diagnosis	Judgement about motivation and desire to increase well-being; readiness to learn or enhance health behaviors.	Readiness for enhanced coping related to successful hip surgery.
Wellness Nursing Diagnosis	Judgement about transition from one area of wellness to a higher level.	Readiness for enhanced knowledge regarding foods rich in iron.

Components of a Nursing Diagnosis

• Problem (Diagnostic Label): The client's response, stated specifically (e.g., altered, low, high).

• Related Factors: Probable causes or contributing factors; directs nursing actions.

• Defining Characteristics: Cluster of signs and symptoms that provide evidence of the problem.

Actual Nursing Diagnosis: Has three parts – problem, related factors, and defining characteristics. Risk Nursing Diagnosis: Has two parts – potential problem and related factors.

Guidelines for Writing a Nursing Diagnosis

• Reflect data collected

• State in terms of a problem, not a need

• Use legally advisable wording

• Ensure problem and related factors are distinct

• Use precise terminology for direction in goals and interventions

• Follow NANDA-I labels for consistency

NANDA-I Classification

• NANDA-I: North American Nursing Diagnosis Association International; standardizes nursing diagnoses globally.

• Over 200 approved diagnoses for clinical use (as of 2021).

Diagnostic Errors

• Errors in data collection

• Errors in interpretation and analysis

• Errors in data clustering

• Errors in diagnostic statements

Critical thinking and skillful assessment are essential to avoid diagnostic errors and ensure accurate nursing diagnoses.

Example Table: Comparison of Data Types

Data Type	Description	Example
Subjective	Reported by the patient; cannot be measured by others	"I feel dizzy"
Objective	Observed or measured by the nurse or others	Blood pressure 150/80 mmHg

Additional info:

• The nursing process is foundational in all areas of nursing, including anatomy and physiology, as it requires understanding of body systems, normal and abnormal findings, and clinical reasoning.

• Assessment and diagnosis are critical for identifying physiological changes and planning appropriate interventions.