Nursing Assessment, Diagnosis, and Process: Key Steps for Effective Patient Care (2024)

Learn how to apply the nursing process for accurate nursing assessment and diagnosis. Explore each step to ensure comprehensive patient care and better outcomes.

Nursing Assessment:

1. Definition

• Nursing assessment is the first and essential step in the nursing process. It involves the deliberate and systematic collection of data about a patient’s current health status. It also includes data about past health status. This information forms a basis for nursing diagnosis and interventions.

1. Purpose of Nursing Assessment

• Gather information about the patient’s health.
• Identify normal functions and health issues.
• Organize data for diagnosis.
• Aid in formulating nursing diagnoses.
• Recognize the patient’s strengths and areas needing health education.
• Provide data for the diagnostic phase and improve problem-handling skills.

Process of Data Collection

• Involves patient observation, interviews with the patient and family, physical examinations, and review of medical records.
• Collects both subjective (perceived needs, health beliefs) and objective (vital signs, physical findings) data.

Types of Assessments

• Initial Assessment: Conducted at admission to establish a comprehensive baseline for problem identification and care planning.
• Problem-Focused Assessment: Ongoing, narrow-focused assessments to monitor specific identified issues.
• Emergency Assessment: Quick, focused assessment during life-threatening situations to identify immediate health needs.
• Time-Lapsed Assessment: Periodic re-evaluation to monitor changes from baseline data over time.

Assessment Components

• Health History: In-depth interview for past and current health status.
• Physical Examination: Head-to-toe assessment of physical health.
• Vital Signs & Observations: Includes listening to patient comments, observing reactions and interactions, and assessing physical signs.

Types of Data

• Subjective Data (Symptom/Covert Data): Information provided by the patient or their family, including feelings, perceptions, and sensations that only the patient can describe (e.g., pain, nausea).
• Objective Data (Sign/Overt Data): Observable, measurable data obtained through physical examination or diagnostic testing (e.g., blood pressure, lab results).

Sources of Data

• Primary Source: Direct information from the patient through interviews and physical examinations, providing insights into health needs, lifestyle, and perceptions.
• Secondary Source: Information from family, medical records, and other healthcare professionals.

Components of Nursing Assessment

• Nursing Health History: A structured interview collects detailed patient history. It covers biographic data and chief complaint. It also includes the history of present illness, past health history, and family history. Additionally, it examines lifestyle, social data, psychological data, and pattern of health care.
• Psychological and Social Examination: Evaluates emotional, social, and intellectual health. It covers mental state, coping styles, relationships, support networks, and spiritual beliefs.
• Physical Examination: Observation and measurement of physical signs and symptoms using inspection, palpation, percussion, and auscultation techniques.

1. Techniques in Physical Examination

• Inspection: Visual examination of body parts to observe details such as skin color, respiratory effort, and wound size.
• Palpation: Using touch to assess temperature, pulse, texture, moisture, masses, and tenderness.
• Percussion: Tapping the body to assess underlying structures, checking for fluid or air presence.
• Auscultation: Listening to internal sounds (e.g., heart, lung, bowel) with a stethoscope to detect abnormalities.

Methods of Data Collection

1. Observation: Gathering data through the senses to note physical appearance, behavior, and environment.
2. Interview: Planned communication with the patient to obtain subjective data.
3. Examination: Systematic physical assessments, such as head-to-toe, body system, or focused area examinations.

Organizing Data

Organizing frameworks like Gordon’s Functional Health Patterns (e.g., health perception, nutrition, activity patterns) or the Body System Model help structure data collection for comprehensive assessment.

Validating Data

Validation confirms data accuracy, ensuring collected information is reliable. Techniques include rechecking measurements, confirming subjective data with objective findings, consulting with other healthcare professionals, and clarifying ambiguous statements.

Analyzing Data

Data analysis involves clustering related signs and symptoms. It focuses on identifying patterns and comparing with norms. This process helps in drawing reasoned conclusions to inform nursing care decisions.

Documenting Data

Accurate documentation is essential and must be factual, complete, accessible, and legible. Data can be recorded on paper or electronically, with specific data requiring immediate reporting based on the patient’s condition.

Purposes of Documentation in Nursing

1. Chronological Record: Maintains a sequential log of client assessment data, providing a clear outline of the care process.
2. Communication Tool: Ensures accessibility of information to all healthcare team members, aiding collaboration and preventing fragmentation, delays, and repetitive procedures.
3. Diagnostic Validation: Serves as a basis for screening and validating potential diagnoses.
4. Problem Identification: Helps identify emerging health problems, supporting continuous assessment and care adaptation.
5. Educational Basis: Identifies educational needs for the client, family, or caregivers.
6. Eligibility and Reimbursement: Supports eligibility determination and documentation for care and reimbursement, providing evidence for financial claims.
7. Legal Record: Acts as a permanent legal record, demonstrating care provided or omitted.
8. Epidemiological and Research Data: Supplies valuable data for research, public health studies, and education.

Guidelines for Effective Documentation

1. Legibility: Write legibly or print neatly in non-erasable ink.
2. Grammar and Brevity: Use correct grammar and spelling; avoid unnecessary words that create redundancy.
3. Concise Language: Use phrases instead of complete sentences for brevity.
4. Data Focus: Record findings rather than how they were obtained.
5. Objective Reporting: Document without judgment or premature diagnoses.
6. Client Perception: Include the client’s understanding and perception of issues.
7. Avoid “Normal”: Avoid labeling findings as “normal”; be specific.
8. Detail and Completeness: Provide comprehensive details of symptoms and observations.
9. Supportive Evidence: Back up objective data with specific observations.

Nursing Diagnosis:

Definitions

• NANDA: NANDA provides a definition for a nursing diagnosis. It is “a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.” This definition provides a foundation for nursing interventions.
• Gordon (1976): Describes it as “an actual or potential health problem that nurses are educated and licensed to treat.”
• Carpenito (1997): Defines it as a “statement that describes the human response (actual/potential) of an individual or group. The nurse can legally identify and address this response through specific nursing interventions.”

Characteristics of Nursing Diagnosis

1. Clearly states a concise health problem.
2. Identifies the client’s normal level of function.
3. Highlights client strengths and weaknesses.
4. Derives from existing evidence about the client.
5. Is potentially treatable through nursing interventions.
6. Provides a basis for planning nursing care.

Structure of Nursing Diagnosis Statements: PES Format

Nursing diagnoses are formulated using the PES format, developed by NANDA, which stands for:

1. Problem Statement (P): Identifies the client’s current health issue (e.g., impaired skin integrity, imbalanced nutrition).
2. Etiology (E): Lists the probable cause(s) or related factors of the problem, guiding appropriate nursing interventions.
3. Defining Characteristics (S): It indicates the observable signs and symptoms. These are, or risk factors when considering risk diagnoses, that support the chosen diagnosis.

Types of Nursing Diagnosis Statements

1. Problem-Focused Diagnosis: Describes a current health problem requiring intervention.
2. Risk Diagnosis: Indicates potential health issues that could develop without preventive measures.
3. Health Promotion Diagnosis: Focuses on improving overall wellness and health behavior.

Formulating Nursing Diagnosis Statements

The process of creating nursing diagnoses involves interpreting data based on nursing knowledge. It also relies on experience. This results in statements that reflect the client’s health status and contributing factors.

Guidelines for Formulating Nursing Diagnoses:

1. Use Clear and Concise Language: Avoid ambiguous terms.
2. Base on Evidence: Ensure diagnoses are supported by client data.
3. Consider Client Strengths and Weaknesses: Include factors that can support or hinder recovery.
4. Identify Treatable Conditions: Ensure the diagnosis is amenable to nursing intervention.
5. Individualize Care: Tailor the diagnosis to the client’s specific situation, allowing for personalized interventions.

Types of Nursing Diagnoses

1. 1. Actual Nursing Diagnosis: Identifies current health issues based on patient assessment. It has three components:

• Problem: The issue itself.
• Related Factors: Causes contributing to the problem.
• Defining Characteristics: Observable signs and symptoms.
• Examples:
  • Ineffective Breathing Pattern r/t pain, evidenced by pursed-lip breathing.
  • Impaired Physical Mobility r/t decreased muscle control, evidenced by lack of control in extremities.

1. 2. Risk Nursing Diagnosis: Addresses potential health problems. It includes:

• Problem and Risk Factors that increase the likelihood of the problem.
• Examples:
  • Risk for Infection due to immunosuppression.
  • Risk for Impaired Skin Integrity related to decreased circulation.

1. 3. Possible Nursing Diagnosis: Used when incomplete information is available but suggests a potential problem.

• Composed of Problem and Etiology (suspected cause).
• Examples:
  • Possible Nutritional Deficit.
  • Possible Low Self-Esteem r/t job loss.

1. 4. Wellness Nursing Diagnosis: Identifies opportunities for improved health and well-being.

• Uses phrases like “Readiness for Enhanced” to indicate a positive health behavior.
• Examples:
  • Readiness for Enhanced Immunization Status.
  • Potential for Enhanced Nutrition.

1. 5. Syndrome Nursing Diagnosis: Involves a group of related diagnoses, useful when multiple health problems present as a pattern.

• Examples:
  • Chronic Pain Syndrome.
  • Risk for Disuse Syndrome.

---

Formulating Nursing Diagnoses

Nursing diagnoses can be written in one, two, or three-part statements based on the type of diagnosis:

1. 1. One-Part Statement: Primarily for wellness and syndrome diagnoses. It only contains the problem.

• Examples:
  • Readiness for Enhanced Breastfeeding.
  • Risk for Impaired Skin Integrity.

1. 2. Two-Part Statement: Used for risk diagnoses. It includes the Problem and Etiology (contributing factors).

• Examples:
  • Risk for Infection r/t compromised immunity.
  • Activity Intolerance r/t generalized weakness.

1. 3. Three-Part Statement: Also called the PES Format. Used for actual diagnoses with Problem, Etiology, and Signs/Symptoms.

• Examples:
  • Acute Pain r/t myocardial ischemia as evidenced by severe chest pain.
  • Fluid Volume Excess r/t compromised regulatory mechanisms as evidenced by edema and jaundice.

---

Guidelines for Writing Nursing Diagnoses

1. Focus on the Problem: State the diagnosis based on the patient’s problem, not their needs.
2. Use Legal Terminology: Ensure that terms are legally sound (e.g., “Impaired Skin Integrity” rather than “poor skin care”).
3. Be Specific: Clearly define the issue and its cause to guide effective interventions.
4. Avoid Judgmental Language: Use neutral statements (e.g., “Spiritual Distress r/t chronic illness”).
5. Ensure Correct Cause and Effect: Confirm that the relationship between elements is accurate.
6. Avoid Redundancy: Don’t repeat the same concept within the diagnosis.
7. Use Nursing Terminology: Describe the patient’s response rather than medical conditions.
8. Clarify Probable Causes: Use nursing terms to explain potential causes, avoiding medical terminology.

---

NANDA Approved Diagnosis

NANDA International (NANDA-I) was originally known as the North American Nursing Diagnosis Association. It plays a central role in developing standardized nursing diagnoses. These diagnoses are crucial for effective patient care. They also facilitate communication among healthcare professionals. Since its inception, NANDA-I has evolved, incorporating a global perspective and contributing significantly to the classification of nursing diagnoses.

Evolution of NANDA-I

• Formation: In 1973, NANDA held its first conference to formally define nursing diagnoses. The association was initially focused on North America. It expanded and adopted the name NANDA International in 2002 to reflect its growing global membership.
• Collaboration: NANDA-I developed Taxonomy II, a structured system that organizes nursing diagnoses. This taxonomy was created with the National Library of Medicine. It aligns with the International Standards Organization (ISO) for healthcare terminology.

NANDA-I Taxonomy II Structure

NANDA-I Taxonomy II classifies nursing diagnoses across three levels: domains, classes, and specific nursing diagnoses. This framework is based on patients’ responses to health conditions and organizes diagnoses under human response categories. There are 13 domains and 47 classes in total, each encompassing unique aspects of patient care.

The 13 NANDA-I Domains:

1. Domain 1: Health Promotion: Focuses on maintaining and enhancing well-being.
2. Domain 2: Nutrition: Involves nutrient intake and usage for energy and tissue repair.
3. Domain 3: Elimination: Addresses the body’s excretion of waste products.
4. Domain 4: Activity/Rest: Concerns the production, conservation, and balance of energy.
5. Domain 5: Perception/Cognition: Encompasses information processing, including senses and cognition.
6. Domain 6: Self-Perception: Centers on self-awareness.
7. Domain 7: Role Relationships: Covers connections between individuals or groups.
8. Domain 8: Sexuality: Addresses sexual identity, function, and reproduction.
9. Domain 9: Coping/Stress Tolerance: Relates to managing life events and stress.
10. Domain 10: Life Principles: Encompasses beliefs and behaviors with intrinsic value.
11. Domain 11: Safety/Protection: Focuses on freedom from harm and injury.
12. Domain 12: Comfort: Concerns mental, physical, and social well-being.
13. Domain 13: Growth/Development: Relates to physical and developmental milestones.

Latest NANDA-I Nursing Diagnoses (2018-2020 Edition)

In its 2018-2020 edition, NANDA-I introduced seventeen new diagnoses to address emerging healthcare needs. It also removed eight previous diagnoses. Additionally, seventy-two were revised to enhance clarity and relevance.

New Nursing Diagnoses Include:

• Readiness for enhanced health literacy
• Ineffective adolescent eating dynamics
• Acute substance withdrawal syndrome
• Risk for surgical site infection
• Risk for dry mouth
• Risk for metabolic imbalance syndrome
• Risk for venous thromboembolism
• Risk for unstable blood pressure
• Risk for complicated immigration transition

These additions reflect the evolving scope of nursing care, responding to diverse patient needs and global health concerns.

Retired NANDA Nursing Diagnosis

In the latest NANDA-I nursing diagnosis list (2018-2020 edition), eight nursing diagnoses were retired from the previous list (2015-2017 edition). These retirements reflect shifts in clinical focus. They also indicate updates in the taxonomy based on the changing needs and relevancy within nursing practice. Here’s an organized overview of these retired nursing diagnoses:

Retired NANDA Nursing Diagnoses (2018-2020 Edition)

1. Risk for Disproportionate Growth
2. Noncompliance (Nursing Care Plan)
3. Readiness for Enhanced Fluid Balance
4. Readiness for Enhanced Urinary Elimination
5. Risk for Impaired Cardiovascular Function
6. Risk for Ineffective Gastrointestinal Perfusion
7. Risk for Ineffective Renal Perfusion
8. Risk for Imbalanced Body Temperature

---

Nursing Diagnoses Categories and Classes

These diagnoses span across various domains and classes, including Health Promotion, Nutrition, and Elimination. They reflect changes in terminology and understanding. Some diagnoses were retired due to overlap or redundancy. Others were incorporated into different diagnostic categories or refined for more accuracy.

---

Domain 1: Health Promotion

Class 1: Health Awareness

• Decreased Diversional Activity Engagement (Nursing Care Plan)
• Readiness for Enhanced Health Literacy
• Sedentary Lifestyle (Nursing Care Plan)

Class 2: Health Management

• Frail Elderly Syndrome (Nursing Care Plan)
• Risk for Frail Elderly Syndrome
• Deficient Community Health
• Risk-Prone Health Behavior
• Ineffective Health Maintenance (Nursing Care Plan)
• Ineffective Health Management
• Readiness for Enhanced Health Management
• Ineffective Family Health Management
• Ineffective Protection

---

Domain 2: Nutrition

Activities involving the intake, assimilation, and use of nutrients for tissue maintenance, repair, and energy production.

Class 1: Ingestion

• Imbalanced Nutrition: Less Than Body Requirements (Nursing Care Plan)
• Readiness for Enhanced Nutrition
• Insufficient Breast Milk Production
• Ineffective Breastfeeding (Nursing Care Plan)
• Interrupted Breastfeeding (Nursing Care Plan)
• Readiness for Enhanced Breastfeeding
• Ineffective Adolescent Eating Dynamics
• Ineffective Child Eating Dynamics
• Ineffective Infant Feeding Dynamics
• Ineffective Infant Feeding Pattern (Nursing Care Plan)
• Obesity Overweight
• Risk for Overweight
• Impaired Swallowing (Nursing Care Plan)

Class 2: Digestion

No diagnoses currently listed.

Class 3: Absorption

No diagnoses currently listed.

Class 4: Metabolism

• Risk for Unstable Blood Glucose Level (Nursing Care Plan)
• Neonatal Hyperbilirubinemia
• Risk for Neonatal Hyperbilirubinemia
• Risk for Impaired Liver Function
• Risk for Metabolic Imbalance Syndrome

Class 5: Hydration

• Risk for Electrolyte Imbalance
• Risk for Imbalanced Fluid Volume
• Deficient Fluid Volume (Nursing Care Plan)
• Risk for Deficient Fluid Volume
• Excess Fluid Volume (Nursing Care Plan)

---

Domain 3: Elimination

Processes of secretion and excretion of body waste.

Class 1: Urinary Function

• Impaired Urinary Elimination
• Functional Urinary Incontinence
• Overflow Urinary Incontinence
• Reflex Urinary Incontinence
• Stress Urinary Incontinence
• Urge Urinary Incontinence
• Risk for Urge Urinary Incontinence
• Urinary Retention

Class 2: Gastrointestinal Function

• Constipation (Nursing Care Plan)
• Risk for Constipation
• Perceived Constipation
• Chronic Functional Constipation
• Risk for Chronic Functional Constipation
• Diarrhea
• Dysfunctional Gastrointestinal Motility
• Risk for Dysfunctional Gastrointestinal Motility
• Bowel Incontinence

Class 3: Integumentary Function

No diagnoses currently listed.

Class 4: Respiratory Function

• Impaired Gas Exchange

---

Domain 4: Activity/Rest

Balance and management of energy resources.

Class 1: Sleep/Rest

• Insomnia
• Sleep Deprivation
• Readiness for Enhanced Sleep
• Disturbed Sleep Pattern

Class 2: Activity/Exercise

• Risk for Disuse Syndrome
• Impaired Bed Mobility
• Impaired Physical Mobility
• Impaired Wheelchair Mobility
• Impaired Sitting
• Impaired Standing
• Impaired Transfer Ability
• Impaired Walking

Class 3: Energy Balance

• Imbalanced Energy Field
• Fatigue
• Wandering

Class 4: Cardiovascular/Pulmonary Responses

• Activity Intolerance
• Risk for Activity Intolerance
• Ineffective Breathing Pattern
• Decreased Cardiac Output
• Risk for Decreased Cardiac Output
• Impaired Spontaneous Ventilation
• Risk for Unstable Blood Pressure
• Risk for Decreased Cardiac Tissue Perfusion
• Risk for Ineffective Cerebral Tissue Perfusion
• Ineffective Peripheral Tissue Perfusion
• Risk for Ineffective Peripheral Tissue Perfusion
• Dysfunctional Ventilatory Weaning Response

Class 5: Self-Care

• Impaired Home Maintenance
• Bathing Self-Care Deficit
• Dressing Self-Care Deficit
• Feeding Self-Care Deficit
• Toileting Self-Care Deficit
• Readiness for Enhanced Self-Care
• Self-Neglect

---

Domain 5: Perception/Cognition

Human information processing, including attention, orientation, and memory.

Class 1: Attention

• Unilateral Neglect

Class 2: Orientation

No diagnoses currently listed.

Class 3: Sensation/Perception

No diagnoses currently listed.

Class 4: Cognition

• Acute Confusion
• Risk for Acute Confusion
• Chronic Confusion
• Labile Emotional Control
• Ineffective Impulse Control
• Deficient Knowledge
• Readiness for Enhanced Knowledge
• Impaired Memory

Class 5: Communication

• Readiness for Enhanced Communication
• Impaired Verbal Communication

Domain 6: Self-Perception

Awareness about the self.

Class 1: Self-Concept

• Hopelessness
• Readiness for enhanced hope
• Risk for compromised human dignity
• Disturbed personal identity
• Risk for disturbed personal identity
• Readiness for enhanced self-concept

Class 2: Self-Esteem

• Risk for chronic low self-esteem
• Chronic low self-esteem
• Situational low self-esteem
• Risk for situational low self-esteem

Class 3: Body Image

• Disturbed body image

---

Domain 7: Role Relationship

The positive and negative connections between individuals or groups and the demonstration of those connections.

Class 1: Caregiving Roles

• Caregiver role strain
• Risk for caregiver role strain
• Impaired parenting
• Risk for impaired parenting
• Readiness for enhanced parenting

Class 2: Family Relationships

• Risk for impaired attachment
• Dysfunctional family processes
• Interrupted family processes
• Readiness for enhanced family processes

Class 3: Role Performance

• Ineffective relationship
• Risk for ineffective relationship
• Readiness for enhanced relationship
• Parental role conflict
• Ineffective role performance
• Impaired social interaction

---

Domain 8: Sexuality

Sexual identity, function, and reproduction.

Class 1: Sexual Identity

• This class currently does not include any diagnoses.

Class 2: Sexual Function

• Sexual dysfunction
• Ineffective sexuality pattern

Class 3: Reproduction

• Ineffective childbearing process
• Risk for ineffective childbearing process
• Readiness for enhanced childbearing process
• Risk for disturbed maternal-fetal dyad

---

Domain 9: Coping/Stress Tolerance

Managing life events and processes effectively.

Class 1: Post-Trauma Responses

• Risk for complicated immigration transition
• Post-trauma syndrome
• Risk for post-trauma syndrome
• Rape-trauma syndrome
• Relocation stress syndrome
• Risk for relocation stress syndrome

Class 2: Coping Responses

• Risk for ineffective activity planning
• Anxiety (nursing care plan)
• Defensive coping
• Ineffective coping
• Readiness for enhanced coping
• Ineffective community coping
• Readiness for enhanced community coping
• Compromised family coping
• Disabled family coping
• Readiness for enhanced family coping
• Death anxiety
• Ineffective denial
• Fear Grieving
• Complicated grieving
• Risk for complicated grieving
• Impaired mood regulation
• Powerlessness
• Risk for powerlessness
• Readiness for enhanced power
• Impaired resilience
• Risk for impaired resilience
• Readiness for enhanced resilience
• Chronic sorrow
• Stress overload

Class 3: Neurobehavioral Stress

• Acute substance withdrawal syndrome
• Risk for acute substance withdrawal syndrome
• Autonomic dysreflexia
• Risk for autonomic dysreflexia
• Decreased intracranial adaptive capacity
• Neonatal abstinence syndrome
• Disorganized infant behavior
• Risk for disorganized infant behavior
• Readiness for enhanced organized infant behavior

Domain 10: Life Principles

Principles that give meaning to life and guide decision-making.

Class 1: Values

• Impaired religiosity
• Risk for impaired religiosity
• Readiness for enhanced religiosity

Class 2: Beliefs

• Moral distress

---

Domain 11: Safety/Protection

Freedom from harm or danger, both physical and psychological.

Class 1: Infection

• Risk for infection

Class 2: Physical Injury

• Risk for injury
• Risk for falls
• Impaired oral mucous membrane
• Risk for impaired oral mucous membrane
• Risk for perioperative positioning injury
• Risk for thermal injury
• Risk for vascular trauma
• Risk for suffocation
• Risk for trauma

Class 3: Violence

• Risk for self-directed violence
• Risk for suicide
• Risk for other-directed violence

Class 4: Environmental Hazards

• Contamination
• Risk for contamination
• Risk for occupational injury

Class 5: Defensive Processes

• Ineffective airway clearance
• Risk for aspiration
• Risk for adverse reaction to iodinated contrast media

Class 6: Security

• Risk for poisoning

---

Domain 12: Comfort

The sense of physical, emotional, and social ease.

Class 1: Physical Comfort

• Acute pain
• Chronic pain
• Labor pain
• Nausea

Class 2: Environmental Comfort

• Impaired comfort
• Readiness for enhanced comfort

Class 3: Social Comfort

• Social isolation

---

Domain 13: Growth/Development

The process of becoming physically, emotionally, and socially mature.

Class 1: Growth

• Risk for disproportionate growth

Class 2: Development

• Delayed development
• Risk for delayed development

---

COURSES

GNM

BSC NURSING

---