Chapter Two

Assessment, Clinical Judgment

and Nursing Diagnoses

Assessment, Clinical Judgment

and Nursing Diagnoses

Contributor
Margaret Lunney

Nursing Process
Conceptual Description of What Nurses Do
Broadly Accepted Worldwide
Five Phases, Cyclical:
Nursing
Assessment

Assessment
Diagnosis
Planning
Implementation
Evaluation

Evaluation

Implementa
tion

Nursing
Diagnosis

Planning

Continuous Clinical Judgment

Definition
Interpretation or Conclusion About a Patients
Needs, Concerns, or Health Problems, and/or the
Decision to Take Action (or Not), Use or Modify
Standard Approaches, or Improvise New Ones as
Deemed Appropriate by the Patients Response
(Tanner, 2006, p.204)

Assessment Data are Interpreted

What Happens?
Nurses Convert Data to Interpretations

Why?
Nurses, as Other People, Have Limited Space in
Short-Term Memory, Cannot Remember All Data
But Remember Interpretation

How?
Connect Patient Data with Knowledge in Memory

1973: First Conference to Identify the

Names for Data Interpretations
80 Nursing Diagnoses First Identified
Evolved to NANDA International (I)
Purpose of NANDA-I: Approve Nurse-Developed
Research-Based Names for Data Interpretations,
Labels and Descriptions

Nurses are Diagnosticians

Nurses Use a Diagnostic Process in
Partnership with Patients
Why?
Focus is Health
People Make Themselves Healthy

Diagnostic Competencies
Intellectual
Interpersonal
Technical
Personal Strengths:
Tolerance of Ambiguity
Use of Reflective Practice

Intellectual Competencies
Knowledge
Mental Processes

Mental Processes: Cognitive Skills and

Habits of the Mind
Examples of Cognitive Skills:
Analyzing
Logical Reasoning
Applying Standards

Studies Show That:

Adults Vary in Cognitive Abilities
Thinking Processes can be Improved

To Develop Thinking Abilities

Use Thinking
Think About Nursing Concepts, e.g.:
Health Management
Sleep

Seek Support
Develop Confidence

Interpersonal Competencies
Trust Enables Patients to Share Valid and
Reliable Data with Nurses
Communication Skills Enhance Trust
Work in Partnership with Patients
Listen

Technical Competencies
Nursing Assessment:
Health History
Physical Examination

Use a Framework That Yields Nursing Concepts,

e.g. Functional Health Patterns

Personal Strength: Tolerance of Ambiguity

Why?
Numerous Factors Influence Clinical
Situations
Human Beings are Complex and
Unique
Enables Consideration of Many Factors

Reflective Practice
Re-examine Feelings and Behaviors
Reflection Needed for Self-Evaluation

Assessment and Nursing Diagnosis

Units of Analysis: Individual, Family or
Community
Books That Appropriately Link Assessment to
Nursing Diagnosis

Principles of Diagnostic Reasoning

and Assessment
Work in Partnership with Individual, Family or
Community
Think About Diagnostic Hypotheses; Collect Data
to Support or Reject Hypotheses
Complete Data Collection Before Deciding on
Diagnoses
Validate Diagnoses with Patients

Recognize Cues
Cues: Units of Data That Have Meaning in Relation
to Diagnoses, e.g. Rate of Breathing and Ineffective
Breathing Pattern
Recognition of a Cue and Its Meaning Depends on
Knowledge in Memory
For Meaning: Compare Cues to Knowledge and the
Individual Patient

Mentally Generate Possible Diagnoses

Consider Context of Situation
Compare Cues with Knowledge in Memory
Consider Multiple Possible Explanations
Avoid Deciding Too Soon (Premature Closure)
Be Flexible in Thinking

Conduct Focused Data Collection

Collect Additional Data to Support Diagnostic
Hypotheses
Collect Data to Rule Out Competing Hypotheses
Summarize Data with a Possible Explanation or
Diagnosis

Validate Diagnoses with Patients and Others

Collaborate with Patient and Family
If Patient is Unable to Validate, Collaborate
with Other Nurses or Providers

Name Diagnoses Using NANDA-I

References
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