Nursing Assessment and Diagnosis: Direct Care Part 1

Have you ever watched a seasoned nurse seamlessly take over patient care, seemingly knowing exactly what to do within moments of receiving a report? It’s not magic; it’s the nursing process in action. This systematic approach is the bedrock of modern nursing, acting as a critical thinking roadmap that guides nurses in delivering safe, patient-centered care. This article, the first in our “Direct Care” series, will delve into the initial crucial phases of this process: assessment and diagnosis. Understanding these steps is fundamental to providing effective and personalized patient care.

Grasping the Core Concepts: Thinking Like a Nurse

Before we dive into the specifics of the nursing process, it’s essential to understand the cognitive tools that nurses rely on: critical thinking and clinical reasoning. These aren’t just academic buzzwords; they are the daily drivers of safe and effective nursing practice.

Critical Thinking: The Foundation of Sound Nursing Judgment

Critical thinking in nursing goes beyond simply following protocols. It’s about actively and thoughtfully engaging with clinical situations, considering all angles, and making informed decisions. It’s defined broadly as “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”¹ A critical thinking nurse doesn’t just execute tasks; they validate information, ensure accuracy, and tailor care plans to individual patient needs, always grounded in current best practices and research.

“Critical thinkers” in nursing share a set of key attitudes that promote rational and effective decision-making. These include:

• Independent Thinking: Nurses must be able to think for themselves, question assumptions, and not blindly follow orders.
• Fairness: Approaching every patient and situation with an unbiased and unprejudiced perspective is paramount.
• Awareness of Self and Others (Insight into Egocentricity and Sociocentricity): Recognizing personal biases and considering the broader impact of decisions, ensuring actions are for the patient’s benefit and the greater good, not self-serving.
• Intellectual Humility: Acknowledging the limits of one’s knowledge and being open to learning and seeking guidance when needed.
• Non-Judgmental Approach: Applying professional and ethical standards, avoiding personal moral judgments in patient care.
• Integrity: Maintaining honesty and strong ethical principles in all nursing actions.
• Perseverance: Continuing to seek solutions and provide care even when faced with challenging or difficult situations.
• Confidence: Trusting in one’s ability to provide competent care and make sound judgments.
• Openness to New Ideas (Interest in exploring thoughts and feelings): Being receptive to different perspectives and approaches to patient care.
• Curiosity: A constant desire to learn more, asking “why” to understand the root causes of patient issues and improve care.

Clinical Reasoning: Putting Knowledge into Action

Clinical reasoning takes critical thinking a step further, focusing specifically on patient care scenarios. It’s “a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”² Effective clinical reasoning allows nurses to generate potential solutions, evaluate them against available evidence, and select the most appropriate course of action for each patient. This skill is honed over time, built on a foundation of nursing knowledge and practical experience.³

Inductive and Deductive Reasoning: Tools for Clinical Judgment

Nurses utilize both inductive and deductive reasoning as essential critical thinking skills within the nursing process. These reasoning types are crucial for developing sound clinical judgment.

Inductive reasoning is about moving from specific observations to broader generalizations. It’s often described as “bottom-up thinking.” It involves:

• Noticing Cues: Recognizing subtle changes or deviations from expected patient findings. Cues are pieces of patient data that stand out as potentially significant.
• Making Generalizations: Organizing these cues into patterns to form a broader understanding of the patient’s situation. A generalization is like assembling pieces of a puzzle to see a clearer picture.
• Creating Hypotheses: Based on these patterns, formulating potential explanations for the patient’s problem. A hypothesis is an educated guess about “why” something is happening, guiding further investigation and intervention.

Strong inductive reasoning is vital for nurses, especially in fast-paced environments. Like a detective piecing together clues, nurses use their senses to gather data and identify patterns that indicate potential patient problems.

Figure 4.1 Inductive Reasoning Includes Looking for Cues

Example of Inductive Reasoning: A nurse observes a patient’s surgical site exhibiting redness, warmth, and tenderness. These cues form a pattern suggestive of infection. The nurse generalizes that these signs point towards a potential infection and hypothesizes that the incision is infected. This leads to notifying the provider and initiating treatment.

Deductive reasoning, conversely, is “top-down thinking.” It starts with a general rule or standard and applies it to a specific situation. Nurses use established standards and guidelines – like Nurse Practice Acts, hospital policies, and professional guidelines – to guide their decisions and problem-solving.

Example of Deductive Reasoning: Hospital policy dictates “quiet zones” at night to promote patient rest, based on research showing improved recovery with adequate sleep. This is a general rule. Nurses deductively apply this rule to all patients by minimizing noise, dimming lights, and organizing care to ensure uninterrupted rest periods, regardless of individual sleep patterns.

Figure 4.2 Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy

Clinical judgment is the culmination of critical thinking, clinical reasoning, and both inductive and deductive approaches. The National Council of State Boards of Nursing (NCSBN) defines clinical judgment as “the observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”⁶ It’s the ability to synthesize information, identify patient needs, and act decisively to promote positive outcomes.

Evidence-based practice (EBP) is integral to clinical judgment. The American Nurses Association (ANA) defines EBP as “a lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.”⁷ EBP ensures that nursing care is informed by the most current and reliable knowledge available, combined with clinical expertise and patient preferences.

The Nursing Process: A Step-by-Step Guide to Patient Care

The nursing process is a structured, patient-centered method for delivering nursing care. It’s a dynamic and cyclical process, constantly adapting to the patient’s changing health status. It’s based on the American Nurses Association (ANA) Standards of Professional Nursing Practice, which outline the expected actions and behaviors of all registered nurses.⁸ The mnemonic ADOPIE is a helpful way to remember the six steps: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.

Figure 4.3 The Nursing Process

Let’s illustrate the nursing process with a scenario:

Patient Scenario A: Applying the Nursing Process

A patient in the hospital is prescribed Lasix 80mg IV daily for heart failure. During the morning assessment, the nurse notes: blood pressure 98/60, heart rate 100, respirations 18, temperature 98.7F. Reviewing the patient’s record reveals a baseline BP around 110/70 and HR in the 80s. The nurse recognizes cues of low blood pressure and increased heart rate, forming a generalization related to fluid imbalance. The nurse hypothesizes potential dehydration. Gathering further data, the nurse notes a 4-pound weight loss since yesterday and confirms with the patient who reports dry mouth and lightheadedness.

Based on this clinical judgment, the nurse formulates the nursing diagnosis of Fluid Volume Deficit. Outcomes are established to restore fluid balance. The nurse plans to withhold the Lasix, contacts the provider to discuss the patient’s status, and implements interventions to increase oral intake and monitor hydration. By the end of the shift, the nurse evaluates the patient and determines that fluid balance has been improved.

In this scenario, the nurse used clinical judgment and the nursing process to prioritize patient safety over simply “following orders.” This proactive approach highlights the critical role of assessment and diagnosis in guiding effective nursing care.

Let’s now delve deeper into the first two crucial steps of the nursing process: Assessment and Diagnosis.

Step 1: Assessment – Gathering Patient Data

The first Standard of Practice, Assessment, is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”¹¹ This is the foundation of the entire nursing process. A thorough and systematic assessment involves gathering a wide range of data, including physical, psychological, sociocultural, spiritual, economic, and lifestyle factors. For instance, assessing a patient in pain goes beyond just noting the pain level; it includes understanding how pain impacts their daily life, emotions, and relationships.¹²

Patient assessment data falls into two main categories: subjective and objective.

Subjective Data: The Patient’s Perspective

Subjective data is information reported by the patient and/or family members. It provides valuable insights into their experiences and perspectives. When documenting subjective data, it’s crucial to use quotation marks and phrases like “The patient reports…” Building rapport is key to obtaining accurate and meaningful subjective data, especially regarding sensitive mental, emotional, and spiritual aspects of their health.

Subjective data can be primary or secondary. Primary data comes directly from the patient – the most reliable source for their feelings and experiences. Secondary data is gathered from other sources like family members, medical records, or previous caregivers. Secondary data is particularly important for patients who cannot communicate for themselves, such as infants, children, or those with cognitive impairments.

Figure 4.5 Nurse Obtaining Subjective Data and Establishing Rapport

Example of Subjective Data Documentation: “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”

Objective Data: What the Nurse Observes

Objective data is observable and measurable information gathered through the nurse’s senses – sight, hearing, touch, and smell – during patient assessment. Objective data is reproducible, meaning another healthcare professional should be able to obtain the same findings. Examples include vital signs, physical examination findings, and laboratory results.

Figure 4.6 Nurse Performing a Physical Examination

Example of Objective Data Documentation: “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Sources of Assessment Data: A Multifaceted Approach

Assessment data is gathered from three primary sources: interviews, physical examinations, and review of diagnostic test results.

Interviewing: Engaging with the Patient

Interviewing involves asking patients targeted questions, actively listening to their responses, and observing both verbal and nonverbal cues. Reviewing the patient’s chart beforehand can streamline the interview, allowing the nurse to focus on key areas and clarify existing information. However, it’s crucial to verify chart data with the patient during the interview to ensure accuracy.

Starting an interview by introducing yourself, explaining your role, and outlining the interview’s purpose builds trust and rapport. Beginning with questions about the patient’s medical diagnoses can provide context about their health journey and its impact on their life. Active listening and clarifying unclear points are crucial. Patients might not always realize what information is relevant, so skillful interviewing can uncover valuable cues for care planning.

Nonverbal communication, like body language and tone, provides additional cues that need further exploration. It’s important to validate inferences to avoid assumptions. For example, a patient avoiding eye contact might be misinterpreted as disinterest, but could be a cultural norm.

Physical Examination: A Hands-On Approach

A physical examination is a systematic method of collecting objective data using techniques like inspection, auscultation, palpation, and percussion. Inspection involves visual observation of the patient’s body. Auscultation is listening to body sounds with a stethoscope, such as heart, lung, and bowel sounds. Palpation uses touch to assess organ size, location, and tenderness. Percussion, typically performed by advanced practitioners, involves tapping body parts to assess underlying structures. Vital signs collection is also a key component of the physical examination.

Registered Nurses (RNs) are responsible for the initial comprehensive physical examination and data analysis. Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs) and Unlicensed Assistive Personnel (UAPs) can be delegated specific tasks like follow-up data collection or vital signs, but the RN remains responsible for overseeing, interpreting, and documenting all findings.

Physical examinations can be comprehensive (head-to-toe) or focused on a specific problem or body system. All assessment data is documented in the patient’s Electronic Medical Record (EMR).

Reviewing Laboratory and Diagnostic Tests: Objective Insights

Reviewing laboratory and diagnostic test results provides crucial objective data about the patient’s health status. Understanding normal and abnormal ranges and their clinical significance is essential for informed care planning and medication administration. Nurses must promptly report concerning results to the provider and verify prescriptions against the patient’s current condition before implementation.

Types of Nursing Assessments: Tailoring the Approach

Different situations call for different types of nursing assessments:

• Primary Survey: A rapid initial assessment used in every patient encounter, focusing on level of consciousness, airway, breathing, and circulation (ABCs). It’s used to identify and address immediate life-threatening issues.
• Admission Assessment: A comprehensive assessment performed upon a patient’s entry into a healthcare facility. It gathers extensive data using a structured approach to establish a baseline.
• Ongoing Assessment: Regular, often shift-based, head-to-toe assessments in acute care settings like hospitals. These monitor for changes in patient condition and inform ongoing care adjustments.
• Focused Assessment: A targeted assessment concentrating on a specific problem or system, used to monitor known issues or evaluate new concerns.
• Time-Lapsed Reassessment: Periodic comprehensive assessments, like those in long-term care, conducted at intervals (e.g., every 3 months) to evaluate progress towards long-term goals.⁴

Putting Assessment Together: Scenario C

Let’s apply these assessment concepts to a patient scenario:

Scenario C

Ms. J., 74, is admitted for shortness of breath, increased ankle and calf swelling, and fatigue. Her history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). Medications: aspirin 81 mg daily, metoprolol 50 mg twice daily, furosemide 40 mg daily, metformin 2000 mg daily.

Admission vital signs: BP 162/96 mm Hg, HR 88 beats/min, SpO2 91% on room air, RR 28 breaths/minute, Temp 97.8°F orally. Weight up 10 pounds in 3 weeks.

Patient statements: “I am so short of breath,” “My ankles are so swollen I have to wear my house slippers,” “I am so tired and weak I can’t get out of the house to shop,” “Sometimes I’m afraid to get out of bed because I get so dizzy,” “I would like to learn more about my health.”

Physical findings: Bilateral basilar crackles, bilateral 2+ pitting edema ankles and feet. Labs: Serum potassium 3.4 mEq/L (low).

Patient’s daughter: “We are so worried about mom living alone when she is so tired!”

Critical Thinking Questions:

1. Identify subjective data.
2. Identify objective data.
3. Provide an example of secondary data.

(Answers in the Answer Key)

Step 2: Diagnosis – Identifying Patient Problems

The second Standard of Practice, Diagnosis, is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.”¹³ This step involves critical analysis of the collected assessment data to arrive at nursing diagnoses. It’s about interpreting the “story” the patient’s data tells and identifying areas where nursing interventions can make a positive impact.

Analyzing Assessment Data: From Clues to Diagnoses

After gathering assessment data, the RN analyzes it to form generalizations and hypotheses that lead to nursing diagnoses. The process typically involves:

1. Data Analysis: Examining the data to identify “expected” vs. “unexpected” or “normal” vs. “abnormal” findings for this specific patient, considering their age, baseline health, and developmental stage.³
2. Clustering Information: Grouping relevant cues into patterns. Frameworks like Gordon’s Functional Health Patterns can guide this clustering, organizing data into logical categories of human responses.⁴
3. Identifying Hypotheses: Based on the clustered data, formulating potential nursing diagnoses.
4. In-Depth Assessment: Conducting further focused assessments to validate or refine initial hypotheses and gather more specific data.
5. Establishing Nursing Diagnosis Statements: Formulating clear and concise nursing diagnosis statements that will guide care planning.
6. Prioritization: Prioritizing the identified nursing diagnoses based on patient needs and urgency, which then directs the development of the nursing care plan.²

Example of Data Analysis and Clustering: In Scenario C, the nurse analyzes vital signs and identifies elevated BP, RR, HR, and decreased SpO2 as “relevant cues.” Clustering these with crackles, edema, weight gain, shortness of breath, and heart failure history points to a pattern related to fluid balance, fitting into Gordon’s “Nutritional-Metabolic” pattern. The nurse then hypothesizes “excess fluid volume.”

Gordon’s Functional Health Patterns⁵

This framework provides a systematic way to organize and cluster assessment data:

• Health Perception-Health Management: Patient’s view of their health and how they manage it.
• Nutritional-Metabolic: Food and fluid intake in relation to metabolic needs.
• Elimination: Bowel, bladder, and skin excretory functions.
• Activity-Exercise: Exercise routines and daily activity levels.
• Sleep-Rest: Sleep patterns, rest, and relaxation.
• Cognitive-Perceptual: Sensory and cognitive functions.
• Self-perception and Self-concept: Self-esteem, body image, and mood.
• Role-Relationship: Social roles and relationships.
• Sexuality-Reproductive: Reproductive health and sexual satisfaction.
• Coping-Stress Tolerance: Stress management and coping mechanisms.
• Value-Belief: Values, beliefs (including spiritual), and guiding life principles.

Identifying Nursing Diagnoses: Naming the Patient’s Response

After data analysis and clustering, the key question becomes: “What are my patient’s human responses (nursing diagnoses)?” A nursing diagnosis is “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”⁶ These diagnoses are patient-specific and form the basis of the nursing care plan. Nurses consult resources to verify definitions, defining characteristics, and related factors of hypothesized diagnoses before making a final selection.

NANDA International (NANDA-I) is a globally recognized organization that develops and refines standardized nursing diagnoses. They maintain a list of over 220 research-based diagnoses, continuously updated to reflect current evidence. These diagnoses are categorized into 13 domains, mirroring Gordon’s Functional Health Patterns, to aid in selection.

Nursing Diagnoses vs. Medical Diagnoses: Different Focus, Shared Goal

It’s crucial to distinguish between nursing diagnoses and medical diagnoses. Medical diagnoses identify diseases or medical conditions made by physicians or advanced practitioners. Nursing diagnoses, on the other hand, focus on the patient’s response to health conditions and are made independently by RNs. Patients with the same medical diagnosis can have vastly different nursing diagnoses based on their individual responses.

Example: Two patients with the medical diagnosis of heart failure might have different nursing diagnoses. One might be Deficient Knowledge about managing their condition, while another experiences Anxiety related to their prognosis. Nursing diagnoses consider the patient’s unique needs, strengths, challenges, and resources for holistic and individualized care.

Example: For Ms. J. in Scenario C, heart failure is a medical diagnosis. It cannot be a nursing diagnosis, but it’s an “associated condition.” The nursing diagnosis will address Ms. J.’s response to heart failure, such as fluid overload.

Key Terms in NANDA-I Diagnoses

Understanding these terms is essential for using NANDA-I effectively:

• Patient: NANDA-I’s “patient” encompasses individuals, caregivers, families, groups (e.g., ethnic groups), and communities.⁸
• Age: NANDA-I uses specific age categories: fetus, neonate, infant, child, adolescent, adult, and older adult.⁹
• Time (Duration): Diagnoses can be described as acute (less than 3 months), chronic (more than 3 months), intermittent, or continuous.¹⁰
• At-Risk Populations: Groups sharing characteristics that increase vulnerability to specific human responses (e.g., based on demographics, health history).¹¹
• Associated Conditions: Medical diagnoses, injuries, treatments, or devices that are not nurse-modifiable but contribute to diagnostic accuracy.¹²

Types of Nursing Diagnoses: Classifying Patient Problems

NANDA-I recognizes four main types of nursing diagnoses:¹³

• Problem-Focused: Describes an existing undesirable human response to a health condition. Requires presence of related factors (causes) and defining characteristics (signs/symptoms).¹⁴
• Health Promotion-Wellness: Focuses on a patient’s desire to improve well-being and health. Applies when a patient is ready to enhance specific health behaviors.¹⁶
• Risk: Describes vulnerability to developing an undesirable human response. Supported by risk factors that increase susceptibility. A risk diagnosis addresses potential problems before they occur.¹⁷
• Syndrome: A cluster of nursing diagnoses that frequently occur together and are best addressed with similar interventions.¹⁹

Establishing Nursing Diagnosis Statements: Clear and Concise Language

NANDA-I recommends structuring nursing diagnosis statements to include the nursing diagnosis, related factors, and defining characteristics. This provides a clear and complete picture of the patient’s problem.

Traditionally, this structure was referred to as “PES format,” though NANDA-I terminology has evolved. The core components remain:

• Problem (P): The nursing diagnosis itself.
• Etiology (E): Related factors or causes, linked with “related to” or “R/T”.
• Signs and Symptoms (S): Defining characteristics, evidenced by “as manifested by” or “as evidenced by.”

Let’s examine examples of each type of nursing diagnosis statement.

Problem-Focused Nursing Diagnosis Statement

Includes all three PES components: Problem, Etiology, Signs/Symptoms.

Sample Problem-Focused Statement

For Ms. J. (Scenario C), the data cluster (elevated BP, RR, crackles, edema, weight gain, shortness of breath) points to Excess Fluid Volume. The definition: “surplus intake and/or retention of fluid.” A related factor could be “excessive fluid intake.”²³

Example Statement:

Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

Health-Promotion Nursing Diagnosis Statement

Includes Problem (P) and Signs/Symptoms (S), with defining characteristics starting with “expresses desire to enhance.”²⁴

Sample Health-Promotion Statement

Ms. J. in Scenario C expressed a desire to “learn more about my health to take better care of myself.” This is a defining characteristic of Readiness for Enhanced Health Management, defined as “a pattern of regulating and integrating into daily living a therapeutic regimen…which can be strengthened.”²⁵

Example Statement:

Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”

Risk Nursing Diagnosis Statement

Includes Problem (P) and Risk Factors, often linked with “as evidenced by.”²⁶

Sample Risk Statement

Ms. J.’s dizziness and weakness increase her Risk for Falls. Risk for Falls is defined as “increased susceptibility to falling, which may cause physical harm…”²⁷

Example Statement:

Risk for Falls as evidenced by dizziness and decreased lower extremity strength.

Syndrome Diagnosis Statement

Includes Problem (P) – the syndrome name – and Signs/Symptoms (S), where defining characteristics are two or more related nursing diagnoses. Related factors can be added for clarity.²⁸

Sample Syndrome Statement

For Ms. J., Activity Intolerance (“insufficient energy for daily activities”) and Social Isolation (“aloneness perceived as negative”) can be clustered under Risk for Frail Elderly Syndrome, defined as “a dynamic state of unstable equilibrium…leading to increased susceptibility to adverse health effects…”²⁹

Example Statement:

Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling.

Prioritization: Addressing the Most Critical Needs First

After identifying multiple nursing diagnoses, prioritization is essential. Prioritization is the process of ranking nursing problems and interventions by urgency and importance. It ensures that the most critical patient needs are addressed first.

In emergencies, prioritization is rapid and instinctive. For routine care, frameworks like Maslow’s Hierarchy of Needs, the ABCs (Airway, Breathing, Circulation), and considering acute vs. chronic conditions guide prioritization.

Figure 4.7 The How To of Prioritization

Maslow’s Hierarchy of Needs ranks needs from basic physiological survival to self-actualization. Physiological and safety needs are the highest priorities. In crises, safety might even precede immediate physiological needs (e.g., moving a patient from a burning building before addressing breathing).

Figure 4.8 Maslow’s Hierarchy of Needs

ABCs (Airway, Breathing, Circulation): In any acute situation, ensure a patent airway, adequate breathing, and effective circulation are maintained first.

Acute vs. Chronic, Actual vs. Risk: Acute, uncompensated problems usually take priority over chronic issues. Actual problems are generally prioritized over potential risks, but high-risk situations may warrant immediate attention.

Example: For Ms. J., Fluid Volume Excess is the highest priority due to its impact on breathing and homeostasis. Risk for Falls is a close second due to safety concerns.

This concludes Part 1 of our “Direct Care” series, focusing on assessment and diagnosis. These initial steps of the nursing process are vital for understanding your patient and setting the stage for effective, patient-centered care. In Part 2, we will explore the subsequent steps: outcome identification, planning, implementation, and evaluation, completing the ADOPIE cycle and showcasing how these steps work together to deliver holistic nursing care.

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^[53] Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.

^[54] Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.

^[55] “The How To of Prioritization” by Valerie Palarski for Chippewa Valley Technical College is licensed under CC BY 4.0

^[56] “Maslow’s hierarchy of needs.svg” by J. Finkelstein is licensed under CC BY-SA 3.0