Understanding the Nursing Process and Diagnostic Reasoning

Nursing Process

Systematic method for planning patient care.

Assessment

Data collection regarding client's health status.

Diagnosis

Analysis of data to identify key health issues.

Planning

Prioritizing strategies and creating care plans.

Implementation

Execution of the nursing care plan.

Evaluation

Assessment of outcomes to determine effectiveness.

Nursing Care Plan (NCP)

Document outlining nursing diagnosis and interventions.

Collaborative Problems

Issues requiring interdisciplinary team involvement.

Diagnostic Reasoning

Process of analyzing data to reach conclusions.

Diagnostic Errors

Mistakes in identifying patient health issues.

Critical Thinking

Objective analysis to make informed decisions.

Clinical Judgment

Nurse's decision-making based on patient data.

Three-part Diagnostic Statement

Format including problem, etiology, and symptoms.

Two-part Diagnostic Statement

Format including problem and etiology only.

Actual Nursing Diagnosis

Current health issues identified in patients.

Potential Nursing Diagnosis

Possible future health issues based on risk.

At-risk Nursing Diagnosis

Identified risks for developing health issues.

Health Promotion Diagnosis

Focus on enhancing patient well-being.

Wellness Diagnosis

Diagnosis indicating optimal health status.

Nursing Intuition

Nurse's instinctive understanding of patient needs.

Evidence-informed Practice

Care based on research and clinical evidence.

Client-centered Approach

Care tailored to individual patient needs.

Assessment

Process of gathering client information for understanding.

Data Collection Tool

Framework used to gather assessment data.

Subjective Data

Information reported by the client about feelings.

Objective Data

Observable and measurable data collected by the nurse.

Primary Sources

Direct information from the client.

Secondary Sources

Information from family and healthcare team.

Tertiary Sources

Data from medical records and literature.

Interview

Conversation to gather information from the client.

Nursing Health History

Comprehensive account of client's health background.

Physical Examination

Assessment of the body for health status.

Comprehensive Assessment

Detailed evaluation of all human functioning spheres.

Problem Based Assessment

Focused assessment on a specific health issue.

Cues

Observations or signs indicating client's condition.

Inferences

Conclusions drawn from collected assessment data.

Emerging Patterns

Trends identified from assessment data analysis.

Mrs. Brady

Case study patient with hip fracture and confusion.

Fluid Intake

Amount of fluids consumed by the client.

Dietary Preferences

Client's specific likes or dislikes regarding food.

Allergy Information

Known allergies to peanuts and shellfish.

Height and Weight

Mrs. Brady is 1.6 meters tall and weighs 50 kg.

Appetite Issues

Client reports decreased appetite since her fall.

Skin Condition

Thin and dry skin resembling tissue paper.

Data Validation

Verifying data accuracy before analysis begins.

Data Clustering

Organizing data into meaningful groups for analysis.

Inferential Reasoning

Attaching meaning to clinical data through analysis.

Normal Values

Client's baseline data for comparison during analysis.

Diagnostic Phase

Identifying and analyzing patient information for conclusions.

Diagnostic Reasoning

Using assessment data to explain clinical judgments.

Clinical Inference

Drawing conclusions from evidence before diagnosis.

Nursing Diagnosis

Clinical judgment on responses to health problems.

Medical Diagnosis

Identifying disease based on signs and tests.

Collaborative Problems

Monitoring potential physiological complications in clients.

Data Interpretation

Understanding data patterns to identify problems.

Reasoned Conclusion

Logical deduction based on data analysis.

Interrelationships

Connections between different data points in analysis.

Positive Functioning Areas

Identified strengths in patient health during assessment.

Risk of Problems

Identified areas where health issues may arise.

Plan of Care

Strategy based on identified patient problems.

Cues

Data points that indicate patient health status.

Evidence-Based Practice

Using research evidence to inform clinical decisions.

Assessment Data

Information collected to evaluate patient health.

Health Problems

Actual or potential issues affecting patient well-being.

Nursing Interventions

Actions taken to achieve desired patient outcomes.

Collaborative Problems

Issues managed with health care team collaboration.

Diagnostic Process

Steps include data clustering and inferential reasoning.

Data Clustering

Grouping cues to identify patterns in assessment.

Defining Characteristics

Clinical criteria confirming a nursing diagnosis.

Accepted Norms

Standard values for comparison in client data.

NANDA

Taxonomy for nursing diagnoses by North American Nursing Diagnosis Association.

Diagnostic Label

Name of the nursing diagnosis in two-part format.

Related Factors

Etiology or facts related to the nursing diagnosis.

Actual Nursing Diagnosis

Response to existing health conditions in individuals.

Risk Nursing Diagnosis

Potential responses to health conditions in vulnerable clients.

Health Promotion Nursing Diagnosis

Judgment on motivation to enhance health behaviors.

Wellness Nursing Diagnosis

Judgment to enhance levels of wellness.

Nursing Diagnostic Statement

Two-part statement linking diagnostic label and related factors.

Acute Pain

Example of an actual nursing diagnosis.

Vulnerable Individual

Client at risk for developing health conditions.

Physiological Factors

Body-related aspects increasing health condition risk.

Psychological Factors

Mental aspects affecting health condition vulnerability.

Health Behaviors

Actions taken to improve or maintain health.

Optimal Level of Health

Desired state of health for clients.

Readiness for Enhanced Coping

Example of a wellness nursing diagnosis.

Lack of Exposure to Instruction

Example of related factor in nursing diagnosis.

Surgical Incision

Example of risk factor for infection.

Nursing Diagnostic Statement

Describes patient response to health condition.

Descriptors

Words like impaired or decreased to clarify meaning.

Related Factors

Etiology or cause of patient response.

NANDA dx statement

Standardized language for nursing diagnoses.

Treatable Etiology

Identifiable cause that can be addressed.

Client's Problem

Focus on patient's issues, not nurse's.

Legally Suspect Statements

Avoid ambiguous or judgmental language.

Single Problem Statement

Refer to one issue per nursing diagnosis.

Activity Intolerance

Inability to perform activities due to health issues.

Inactivity

Lack of movement due to lifestyle choices.

Lack of Motivation

Reduced drive to engage in activities.

Increased Metabolic Demands

Higher energy needs due to assistive devices.

Decreased Muscle Strength

Reduction in muscle power and flexibility.