Nursing Dx

The nurse’s initial responsibility is to observe, collect, and record data without drawing conclusions or making judgments/assumptions. Self-awareness is a crucial factor in this interaction, because perceptions, judgments, and assumptions can easily color the assessment findings.

Validation is an ongoing process that occurs during the data-collection phase and upon its completion, when the data are reviewed and compared. The nurse should review the data to be sure that the recordings are factual, to identify errors of omission, and to compare the objective and subjective data for congruencies or inconsistencies that require additional investigation or a more focused assessment. Data that are grossly abnormal are rechecked, and any temporary factors that may affect the data are identified/noted. Validation is particularly important when the data are conflicting, when the data’s source may be unreliable, or when serious harm to the client could result from any inaccuracies. Validating the information can avoid the possibility of making wrong inferences or conclusions that could result in inaccurate nursing diagnoses, incorrect outcomes, or inappropriate nursing actions. This can be done by sharing the assumptions with the individuals involved (e.g., client, significant other/family) and having them verify the accuracy of those conclusions. Sharing pertinent data with other healthcare professionals, such as the physician, dietician, or physical therapist can aid in collaborative planning of care. Data given in confidence should not be shared with other individuals (unless withholding that information would hinder appropriate evaluation or care of the client).