Thinking Critically to Analyze Data to Make Informed Clinical Judgements

Data Analysis

diagnostic or clinical reasoning phase

Diagnostic Reasoning

form of critical thinking

Critical Thinking

the way in which the nurse processes information using knowledge, past experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses.

• Step One – Identify Abnormal Data and Strengths

• Step Two – Cluster Data

• Step Three – Draw Inferences

• Step Four – Propose Possible Nursing Diagnoses

• Step Five – Check for Defining Characteristics

• Step Six – Confirm or Rule Out Diagnoses

• Step Seven – Document Conclusions

Steps in Making a Clinical Judgement

Identify Abnormal Data and Strengths

Uses knowledge of anatomy and physiology, psychology, and sociology

Identification of Subjective and Objective cues

Cluster Data

• Identify strengths and abnormal findings for cues that are related.

• Cluster both strength cues and abnormal cues

• Consider, again, if additional data are needed

Draw Interferences

• Write down “hunches” or assumptions about each cue cluster

• Consider nursing diagnosis, collaborative problem, referral.
  

Case study of Ms. Gutierrez

• Sleep deficit and emotional stress from husband’s accident.

Collaborative Problem

Certain physiological complications that nurses monitor to detect their onset or changes in status

Referring

as connecting clients with other professionals and resources.

Possible Nursing Diagnosis

• Identify possible client concerns

  • A wellness or health promotion diagnosis—opportunity for enhancement of health state

  • Risk diagnosis—potential noted

  • Actual diagnosis—currently noted

• A nursing diagnosis represents the culmination of diagnostic reasoning

Case study of Ms. Gutierrez

• Impaired sleep associated with prolonged time to fall asleep, early awakenings, inability to stay asleep, “susto,” and associated worry after husband’s accident.

Check for Defining Characteristics

• Use reference text such as NANDA Nursing Diagnoses: Definitions and Classifications.

• Compare your findings to NANDA.

Nursing Diagnoses

A clinical judgment concerning a human response to health conditions / life processes, or a susceptibility to that response, by an individual, family, or community. A __________ provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

Defining Characteristic

Observable cues / inferences that cluster as manifestations of a problem-focused, health promotion diagnosis or syndrome. This implies not only those things that the nurse can see, but also things that are touched, smelled, or heard (e.g., the patient / family tells us; listening to heart sounds with a stethoscope).

Related factor

Antecedent factor that appears to show some type of patterned relationship with the human response (etiological factors). These factors must be modifiable by autonomous nursing interventions, and whenever possible, interventions should be aimed at these etiological factors.

Risk Factor

Antecedent factor that increases the susceptibility of an individual, family, or community to an undesirable human response. These factors must be modifiable by autonomous nursing interventions, and whenever possible, interventions should be aimed at these factors.

At risk populations

Groups of people who share sociodemographic characteristics, health / family history, stages of growth / development, exposure to certain events / experiences that cause each member to be susceptible to a particular human response. These are characteristics that are not modifiable by ⁶ the professional nurse.

Associated Conditions

Medical diagnoses, diagnostic / surgical procedures, medical / surgical devices, or pharmaceutical preparations. These conditions are not independently modifiable by the professional nurse.

Ineffective Sleep Pattern

Difficulty experiencing natural, periodic suspension of relative consciousness, which negatively impairs function.

Confirm or Rule Out Diagnosis

• Validate diagnosis with client and other health care providers who are caring for the client.

• Validation is also important if client has collaborative problem or requires a referral.

Document Conclusions

• Wellness or health promotion diagnoses

• Risk diagnoses

• Collaborative problems and referrals

Actual Client Concerns

Client Concern + Associated with + cause or aggravating factors + As seen in identified cues

Opportunities to improve

Opportunity to promote + healthy behavior + associated with + client’s statement of desire to improve

Risk for Client Concerns

Risk for + client concern + associated with + possible cause

Collaborative Problems and Referrals

defined as physiologic problems that are at risk to occur or have occurred that require both medical and nursing interventions to treat

North American Nursing Diagnosis Association

NANDA meaning

Analysis of Data

is the second step of the nursing process. It is often called the clinical judgment phase because the purpose of this phase is identification of client concerns, collaborative problems, or the need for referral to another health care professional