Chapter 5 Study Guide Assessmemt PDF

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Nursing...

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Ch. 5 Thinking Critically to Analyze Data and Make Informed Nursing Judgments -

Analysis of data > Health promotion diagnoses  Health promotion diagnoses represent those situations in which the client may or may not have a problem but now desires to attain a higher level of health. > Risk diagnoses  A risk diagnosis describes a situation in which the client is vulnerable to an actual diagnosis that will most likely occur if the nurse does not intervene. > Collaborative problems and referrals  Collaborative problems should be documented as risk for complications (or RC): ______ (what the problem is). > Actual nursing diagnoses  The most useful format for an actual nursing diagnosis is: NANDA-label (for problem) + related to (r/t) + etiology + as manifested by (AMB) + defining characteristics

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Essential elements of critical thinking BOX 5-1 ESSENTIAL ELEMENTS OF CRITICAL THINKING -

Keep an open mind. Use rationale to support opinions or decisions. Reflect on thoughts before reaching a conclusion. Use past clinical experiences to build knowledge. Acquire an adequate knowledge base that continues to build. Be aware of the interactions of others. Be aware of the environment.

> Ask yourself the following questions to determine your critical thinking skills: 

Do you reserve your final opinion or judgment until you have collected more or all of the information?

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Do you support your opinion or comments with supporting data, sound rationale, and literature?

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Do you explore and consider other alternatives before making a decision?

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Can you distinguish between a fact, opinion, cue, or inference?

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Do you ask your client for more information or clarification when you do not understand?

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Do you validate your information and judgments with experts in the field?

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Do you use your past knowledge and experiences to analyze data?

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Do you try to avoid biases or preconceived ways of thinking?

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Do you try to learn from past mistakes in your judgments? Are you open to the fact that you may not always be right?

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Before the diagnostic reasoning process > Make sure your data is sound > Make sure your data is complete

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Diagnostic reasoning process > STEP 1: Identify strengths and abnormal data 

Have and use a knowledge base of anatomy and physiology, psychology, and sociology.

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Compare collected assessment data with findings in reliable charts and references that provide standards and values for physical and psychological norms (i.e., height, nutritional requirements, growth and development).

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Have a basic knowledge of risk factors for the client. Risk factors are based on client data such as gender, age, ethnic background, genetic predisposition, family history, lifestyle, health practices, and occupation.

 Analyze both subjective and objective data when identifying strengths and abnormal findings. > STEP 2: Cluster data 

Cluster both abnormal cues and strength cues.

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May find that certain cues support a problem but that more data are needed to support the determination of that problem

 May need to go back and gather more data. > STEP 3: Draw inferences 

Write down what you think these data are saying and determine whether it is something that the nurse can treat independently.

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If the inference you draw from a cue cluster suggests the need for both medical and nursing interventions to resolve the problem, you would attempt to identify collaborative problems.

The referral of identified problems for which the nurse cannot prescribe definitive treatment. Referring can be defined as connecting clients with other professionals and resources. > STEP 4: Propose possible nursing diagnoses  Hypothesize and generate possible nursing diagnoses.  A wellness diagnosis, or a health promotion nursing diagnosis, indicates that the client (individual, family, community) has the motivation to increase well-being and enhance health behaviors.  “readiness for enhanced” sleep pattern  A risk diagnosis indicates the client does not currently have the problem but is vulnerable to developing it 

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 “risk for” impaired skin integrity related to immobility, poor nutrition, and incontinence An actual nursing diagnosis indicates that the client is currently experiencing the stated problem or has a dysfunctional pattern  “impaired” skin integrity: reddened area on right buttocks. On occasion, a syndrome diagnosis is appropriate. When a cluster of nursing diagnoses is related in a way that they occur together, a syndrome diagnosis is made.  Disuse syndrome  Frail elderly syndrome  Pain syndrome  Posttraumatic syndrome  Rape trauma syndrome  Relocation trauma syndrome  Sudden infant death syndrome

> STEP 5: Check defining characteristics 

Check for defining characteristics for the data clusters and hypothesized diagnoses in order to choose the most accurate diagnoses and delete those diagnoses that are not valid or accurate for the client.

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This step is often difficult because diagnostic labels overlap, making it hard to identify the most appropriate diagnosis.

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Definitions of each diagnoses and defining characteristics should be compared with the client’s data (cues) to make sure the correct diagnoses are chosen.

 Both the definition and defining cues help rule a diagnosis out or in > STEP 6: Confirm or rule out diagnoses 

If the cue cluster data do not meet the defining characteristics, you can rule out that particular diagnosis.

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If the cue cluster data do meet the defining characteristics, the diagnosis should be verified with the client and other health care professionals who are caring for the client.

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Tell the client what you perceive the diagnosis to be. Often nursing diagnosis terminology is difficult for the client to understand.

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When the client is not cognitively impaired, it is important to promote patient understanding of the problem so that mutual goal setting can be promoted.

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If the client is not in a coherent state of mind to help validate the problem, consult with family members or significant others, or even other health care professionals.

Validation is also important with the client who has a collaborative problem or who requires a referral. If the client has a collaborative problem, you need to inform the client about which signs you are monitoring. > STEP 7: Document conclusions 

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Follow hospital policy for documenting nursing diagnoses.

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NANDA format calls for 3 parts for actual diagnosis:  Problem…  r/t (cause)…  as manifested by = amb (evidence) - this last part is sometimes omitted.

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Risk diagnoses only have “Problems” … “r/t” (cause).

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Collaborative problems and referrals start with “r/c” = risk for complications... may be followed by “r/t” Health promotions diagnoses start with “Readiness for enhanced” … and may be followed by “r/t”

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CLINICAL TIP Identified strengths are used in formulating health promotion diagnoses and to minimize potential and/or actual weaknesses. Identified potential weaknesses are used in formulating risk diagnoses, and actual weaknesses/abnormal findings are used in formulating actual nursing diagnoses. -

Developing clinical expertise and avoiding pitfalls > Accurate diagnosis: precise and supported by relevant cues. > Beginning nurses lack knowledge and expertise, tend to focus on details and rules, missing the big picture. > Experts know when exceptions can be applied to rules. > Beginners can improve their performance by avoiding diagnostic pitfalls.

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Diagnostic pitfalls > Too many or too few data > Unreliable or invalid data > Insufficient cues to support to diagnosis > Clustered cues may actually be unrelated > Diagnosis may be too quick without considering other possibilities

> Diagnosis may be poorly worded and not very communicative > Diagnosis may fail to take cultural considerations into account...