VALIDATION OF DATA

• PURPOSE: process of confirming or verifying that

the subjective and objective data are reliable
and accurate
• Steps include:
• Deciding whether the data require validation
• Determining ways to validate the data
• Identifying area for which data are missing
• Data requiring validation:
• Discrepancies or gaps between subjective and
objective data
• Discrepancies or gaps between what the client says
at one time versus the other time
• Findings that are highly abnormal and or inconsistent
with other findings
METHODS OF VALIDATION
✓ Recheck your own data through a repeat
assessment

✓ Clarify data with the client by asking additional

questions

✓ Verify the data with another health care

professional

✓ Compare your objective findings with your

subjective findings
DOCUMENTING DATA
• PURPOSE: promote effective communication
among multidisciplinary health team members
to facilitate safe and efficient client care. It
provides a legal record of a client’s care while in the
facility.

• Electronic Medical Record EMR VS Electronic Health

Record EHR
DIAGNOSING
• A process which results to a diagnostic statement or
NURSING DIAGNOSIS.
• It is the clinical act of identifying problems.
• To diagnose in NURSING, it means to ANALYZE
ASSESSMENT INFORMATION and derive meaning
from this analysis.
• PURPOSE: To identify the patient’s health care needs
and to prepare DIAGNOSTIC STATEMENTS.

• NURSING DIAGNOSIS is a statement of

patient’s POTENTIAL or ACTUAL ALTERATION of
health status. It uses critical-thinking skills of analysis
and synthesis.
DIAGNOSING
• NURSING DIAGNOSIS (NURSING DIAGNOSES) uses
the PRS/ PES format.
• Problem
• Related to factors
• Signs and Symptoms

• Problem
• Etiology (study of causation, or origination)
• Signs and Symptoms
DIAGNOSING
1. ORGANIZING DATA. Clustering facts into groups of
information.

EXAMPLE: Data about patient’s NUTRITIONAL

STATUS…
• Subjective Data:
• “ I have no appetite to eat.”
• “I feel dizzy most of the time.”
• “I feel nauseated”
• “Foods and fluids taste bitter.”
• “I feel weak and tired most of the time.”
DIAGNOSING
• Objective Data:
• Weight loss ( 2kilos in 2 weeks)
• Poor skin turgor
• Walks slowly and holds into furniture
• Cracked lips and dry mucous membrane
• RBC = 3 million/ cu mm (Low RBC count)
• Serum albumin level – 2.5 mg/dL (Low albumin)
DIAGNOSING
2. COMPARING DATA gathered during assessment
against standard.
• STANDARDS are accepted norms, measures or
patterns for purposes of comparison.
DIAGNOSING
3. ANALYZING DATA after comparing with standard.
• Passage of frequent watery stools may lead to
DEHYDRATION and loss of electrolytes (Na+ and K+)
• Pallor, dyspnea, weakness, fatigue indicate
inadequate oxygenation.
• Noisy breathing respiratory muscle weakness,
unable to cough up thick mucous secretions
indicate inability to clear airways.
DIAGNOSING
4. IDENTIFYING GAPS and INCONSISTENCIES IN DATA.
• EXAMPLE: Patient claims she is gaining too much
weight but actually is underweight.

5. DETERMINING THE PATIENT’S HEALTH PROBLEMS,

HEALTH RISKS AND STRENGTHS
• EXAMPLE: Inadequate nutrition
• EXAMPLE: Altered Body image

6. FORMULATING NURSING DIAGNOSES statements

What is the difference between a
NURSING diagnosis and a
MEDICAL diagnosis?
FORMULATING NURSING
DIAGNOSES STATEMENTS

 CORRECT: Acute Pain related to physical

exertion.
 INCORRECT: Acute pain related to Myocardial
Infarction
FORMULATING NURSING
DIAGNOSES STATEMENTS

 CORRECT: Ineffective breathing pattern related

to increased airway secretions
 INCORRECT: Ineffective breathing pattern
related to pneumonia
FORMULATING NURSING
DIAGNOSES STATEMENTS
 CORRECT: Anxiety related to lack of
knowledge about cardiac catheterization
 INCORRECT: Cardiac catheterization related to
angina

 CORRECT: Diarrhea related to food intolerance

 INCORRECT: Diarrhea related to colon cancer
LEARNING OBJECTIVES
1. Discuss the purpose for each of the four
phases of a client interview
2. Describe effective verbal and nonverbal
communication techniques to collect
subjective data
3. Identify major categories of a complete client
health history
COMPLETE HEALTH
HISTORY
1- Biographical Data
2- Reasons for seeking Health Care
3- History of present health concern
4- Personal health history
5- Family health history
6- ROS for current health problems
7- Lifestyle and health practices profile
8- Developmental level
BIOGRAPHICAL DATA
✓Includes information that identifies the client –
name, address, phone number, gender, birth
date, SSS number, PHIC number, health
insurance information

✓PRIMARY VS SECONDARY SOURCES

REASONS FOR SEEKING
HEALTH CARE
✓TWO Questions:

✓What is your major health problem or concern at this

time?

✓How do you feel about having to seek health care?

HISTORY OF PRESENT
HEALTH CONCERN
✓Comprehensive explanation of the health
problem
PERSONAL HEALTH
HISTORY
✓Childhood illnesses
✓Past surgeries or accidents
✓Episodes of pain
✓Allergies
✓Growth and Development
✓Previous health problems
✓Hospitalizations
✓Pregnancies
✓Medication use
FAMILY HEALTH HISTORY
✓Should include as many genetic relatives as
possible

ROS FOR CURRENT

HEALTH PROBLEM
✓Each body system is addressed and the client is
asked specific questions to elicit further details
LIFESTYLE AND HEALTH
PRACTICES PROFILE
✓Description of a typical day
✓Nutrition and weight management
✓Activity level and exercise
✓Sleep and rest
✓Substance use
✓Social activities
✓Relationships
✓Values and belief system
✓Education and work
✓Stress level and Coping styles
DEVELOPMENTAL LEVEL
✓Sigmund Freud’s Stages of Psychosexual
Development
✓Erickson Theory of Psychosocial Development
✓Piaget Theory of Cognitive Development
✓Kohlberg Theory of Moral Development