Nursing Dx

 Data gathered during the interview and physical examination, and from other records/sources are organized and recorded in a concise, systematic way and clustered into similar categories. Various formats have been used to accomplish this, including a review of body systems. This approach has been utilized by both medicine and nursing for many years but was initially developed to aid the physician in making medical diagnoses. Currently, nursing is developing and fine-tuning its own tools for recording and clustering data. Several nursing models available to guide data collection include Doenges and Moorhouse Diagnostic Divisions (Table 3–1), Gordon’s Functional Health Patterns, and Guzzetta’s Clinical Assessment Tool.
The use of a nursing model as a framework for data collection (rather than a body-systems approach [assessing the heart, moving on to the lungs] or the commonly known head-to-toe approach) has the advantage of focusing data collection on the nurse’s phenomena of concern—the human responses to health and illness. This facilitates the identification and validation of nursing diagnosis labels to describe the data accurately.

TABLE 3–1
GENERAL ASSESSMENT TOOL
This is a suggested guideline/tool applicable in most care settings for creating a client database. It provides a nursing focus (Doenges & Moorhouse’s Diagnostic Divisions of Nursing Diagnoses) that will facilitate planning client care. Although the sections are alphabetized here for ease of presentation, they can be prioritized or rearranged to meet individual needs.
Adult Medical/Surgical Assessment Tool
General Information

Name:                                          Age:                        DOB:                 Gender :                       Race:                   

Admission Date:                                           Time:                             From:                                                    
Reason for this visit/admission (primary concern):                                                                                            
Source of Information: Reliability (1–4 with 4 = very reliable):                                                                         
A