Chapter 7 ATI: The Nursing Process- ANALYSIS/DIAGNOSIS/DATA COLLECTION

Analysis/Diagnosis/Data Collection

Nurses use critical thinking skills, which involve a diagnostic reasoning process, to determine the health status or issues of their clients. They analyze and monitor collected data, make nursing judgments regarding health status or coping mechanisms, and use critical thinking to guide nursing care.

Analysis/diagnosis /data collection requires nurses to look at the data and

Identify patterns or trends.

Analysis/diagnosis /data collection requires nurses to look at the data and

Compare the data with expected standards or reference ranges.

Analysis/diagnosis /data collection requires nurses to look at the data and

Arrive at conclusions to guide nursing care.

RNs make multiple analyses

Based on their interpretations of collected data. They decide, using reasoning and judgment, which data account for clients’ health status or problems. At times, this requires further data collection and analysis. As nurses cluster the collected data, a specific finding might serve as an alert to a specific problem that requires planning and intervention.

Documentation during analysis/diagnosis/data collection

Complete and accurate documentation is essential. Documentation should focus on facts and should be highly descriptive.

Analysis/ Diagnosis/Data Collection

The newly licensed nurse documents that the client’s pain is causing the client to take shallow breaths and could lead to complications such as atelectasis.

Analysis/ diagnosis/data collection step

Documenting that the client’s pain is causing the client to take shallow breaths and could lead to complications such as atelectasis is part of the analysis/ diagnosis/data collection step of the nursing process. The newly licensed nurse clusters and interprets data to determine a conclusion.

Analysis/ Diagnosis/Data Collection

“I will review objective and subjective client data to identify a potential client problem.”

Analysis/ diagnosis/data collection step

Reviewing objective and subjective client data to identify a potential client problem is part of the analysis/ diagnosis/data collection step of the nursing process. The newly licensed nurse clusters and interprets data to determine a conclusion.