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

Information in the client database is obtained primarily from the client (who is the most important source) and then from family members/significant others (secondary sources), as appropriate, through conversation and by observation during a structured interview. Clearly, the interview involves more than simply exchanging and processing data. Nonverbal communication is as important as the client’s choice of words in providing the data. The ability to collect data that are meaningful to the client’s health concerns depends heavily on the nurse’s knowledge base; on the choice and sequence of questions; and on the ability to give meaning to the client’s responses, integrate the data gathered, and prioritize the resulting information. Insight into the nature and behavior of the client is essential as well.

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 the interaction, because perceptions, judgments, and assumptions can easily color the assessment findings unless they are recognized.

The quality of a history improves with experience with the interviewing process. Tips for obtaining a meaningful history include the following:
• Be a good listener.
• Listen carefully and attentively for whole thoughts and ideas, not merely isolated facts.
• Use skills of active listening, silence, and acceptance to provide ample time for the person to respond. Be as objective as possible.
• Identify only the client’s or significant others’ contributions to the history.

The interview question is the major tool used to acquire information. How the question is phrased is a skill that is important in obtaining the desired results and in getting the information necessary to make accurate nursing diagnoses. Note: Some questioning strategies to avoid include closed-ended and leading questions, probing, and agreeing or disagreeing that implies the client is “right” or “wrong.” It is important to remember, too, that the client has the right to refuse to answer any question at all, no matter how reasonably phrased.

Nine effective data-collection questioning techniques include the following:
1. Open-ended questions allow clients maximum freedom to respond in their own way, impose no limitations on how the question may be answered, and can produce considerable information.
2. Hypothetical questions pose a situation and ask the client how it might be handled.
3. Reflecting or “mirroring responses” are useful techniques in getting at underlying meanings that might not be verbalized clearly.
4. Focusing consists of eye contact (within cultural limits), body posture, and verbal responses.
5. Giving broad openings encourages the client to take the initiative in what is to be discussed.
6. Offering general leads encourages the client to continue.
7. Exploring pursues a topic in more depth.
8. Verbalizing the implied gives voice to what has been suggested.
9. Encouraging evaluation helps clients to consider the quality of their own experiences.

The client’s medical diagnosis can provide a starting point for gathering data. Knowledge of the anatomy and physiology of the specific disease process/severity of the condition also helps in choosing and prioritizing precise portions of the assessment. For example, when examining a client with severe chest pain, it may be wise to evaluate the pain and the cardiovascular system in a focused assessment before addressing other areas, possibly at a later time. Likewise, the duration and length of any assessment depend on circumstances such as the client’s condition and the situation’s urgency.

The data collected about the client or significant others contain a vast amount of information, some of which may be repetitious. However, some of it will be valuable for eliciting information that was not recalled or volunteered previously. Enough material needs to be noted in the history so that a complete picture is presented, and yet not so much that the information will not be read or used.

The physical examination is performed to gather objective information and serves as a screening device. Four common methods used during the physical examination are inspection, palpation, percussion, and auscultation. These techniques incorporate the senses of sight, hearing, touch, and smell. For the data collected during the physical examination to be meaningful, it is vital to know the normal physical and emotional characteristics of humans well enough to be able to recognize deviations. To gain as much information as possible from the assessment procedure, the same format should be used each time a physical examination is performed to lessen the possibility of omissions.

Laboratory and other diagnostic studies are a part of the information-gathering stage providing supportive evidence. These studies aid in the management, maintenance, and restoration of health. In reviewing and interpreting laboratory tests, it is important to remember that the origin of the test material does not always correlate to an organ or body system (e.g., a urine test to detect the presence of bilirubin and urobilinogen could indicate liver disease, biliary obstruction, or hemolytic disease). In some cases, the results of a test are nonspecific, because they indicate only a disorder or abnormality and not the location of the cause of the problem (e.g., an elevated erythrocyte sedimentation rate suggests the presence but not the location of an inflammatory process).
In evaluating laboratory tests, it is advisable to consider which medications (e.g., heparin, promethazine) are being administered to the client, including over-the-counter and herbal supplements (e.g., vitamin E), because these have the potential to alter, blur, or falsify results, creating a misleading diagnostic picture.

The Nursing: Scope & Standard of Practice addresses the assessment process. The standard stipulates that the data-collection process is systematic and ongoing. The nurse collects client health data from the client, significant others, and healthcare providers when appropriate. The priority of the data-collection activities is determined by the client’s immediate condition or needs. Pertinent data are collected using appropriate assessment techniques and instruments. Relevant data are documented in a retrievable form.

The assessment step of the nursing process is focused on eliciting a profile of the client that allows the nurse to identify client problems or needs and corresponding nursing diagnoses, to plan care, to implement interventions, and to evaluate outcomes. This profile, or client database, supplies a sense of the client’s overall health status, providing a picture of the client’s physical, psychological, sociocultural, spiritual, cognitive, and developmental levels; economic status; functional abilities; and lifestyle. It is a combination of data gathered from the history-taking interview (a method of obtaining SUBJECTIVE information by talking with the client or significant other(s) and listening to their responses), from the physical examination (a “hands-on” means of obtaining OBJECTIVE information), and from the results of laboratory/diagnostic studies. To be more specific, subjective data are what the client/significant others perceive and report, and objective data are what the nurse observes and gathers from other sources.

Assessment involves three basic activities:
• Systematically gathering data
• Organizing or clustering the data collected
• Documenting the data in a retrievable format

The assessment step of the nursing process emphasizes and should provide a holistic view of the client. The generalized assessment done during the overall data-gathering creates a profile of the client. A focused, or more detailed, assessment may be warranted given the client’s condition or emergent time constraints, or it may be done to obtain more information about a specific issue that needs expansion or clarification. Both types of assessments provide important data that complement each other. A successfully completed assessment creates a picture of clients’ states of wellness, their response to health concerns or problems, and individual risk factors—this is the foundation for identifying appropriate nursing diagnoses, developing client outcomes, and choosing relevant interventions necessary for providing individualized care.