Potter: Canadian Fundamentals of Nursing, 6th Edition

Chapter 13: Nursing Assessment, Diagnosis, and Planning

Key Points – Printable

• The nursing process employs critical thinking to identify, diagnose, and treat patients’
responses to health and illness.
• Nursing assessment involves the collection and verification of data and the analysis of all
data to establish a database about a patient’s perceived needs, health problems, and responses
to those problems.
• By interpreting cues, the nurse forms an inference, which then enables the nurse to identify
meaningful clusters of information.
• To conduct a comprehensive assessment, nurses use a structured database format or a
problem-oriented approach.
• The interview is an organized conversation with a patient that begins by establishing a
therapeutic relationship with the patient and that aids in the investigation and discussion of
the patient’s health care needs.
• Open-ended questions encourage patients to describe their health histories in detail, whereas
closed-ended questions may elicit only limited responses by the patient.
• An interview includes three phases: orientation, working, and termination.
• Once a patient provides subjective data, the nurse considers exploring the findings further by
collecting objective data.
• During assessment, nurses critically anticipate and use an appropriate branching set of
questions or observations to collect data, and cues of assessment information are clustered to
identify emerging patterns and problems.
• Written data statements are descriptive, concise, and complete; they do not include inferences
or interpretative statements.
• Family members and friends sometimes offer observations about the patient’s needs; these
observations will affect the way the nurse delivers care.
• During assessment, nurses encourage patients to describe their histories of illnesses or health
care problems.
• To form a nursing judgement, nurses critically assess a patient, validate the data, interpret the
information gathered, and look for diagnostic cues that will lead them to identify the patient’s
problems.
• NANDA International has developed a common language that enables all members of the
health care team to understand a patient’s needs.
• The analysis and interpretation of data requires nurses to validate data, recognize patterns or
trends, compare data with healthful standards, and then form diagnostic conclusions.

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. All rights reserved.
Key Points 13-2

• The absence of defining characteristics of a proposed diagnosis suggests that the nurse reject
that diagnosis.
• Four types of nursing diagnoses exist: those for actual disorders, those concerning risk for
disorders, wellness diagnoses, and those for health promotion.
• A nursing diagnosis is written in a two-part format, including a diagnostic label and an
etiological or related factor.
• The “related to” factor of the diagnostic statement assists nurses in individualizing a patient’s
nursing diagnoses and provides direction for their selection of appropriate interventions.
• The presence of risk factors indicates that an at-risk nursing diagnosis applies to a patient’s
condition.
• Concept mapping is a visual representation of a patient’s nursing diagnoses and their
relationship with one another.
• Nursing diagnostic errors occur through errors in data collection, in interpretation and
analysis of data, in clustering of data, or in the diagnostic statement.
• Nursing diagnoses improve communication between nurses and other health providers.
• During planning, nurses determine patient-centred goals, set priorities, develop expected
outcomes of nursing care, and develop a nursing care plan.
• Priority setting helps nurses anticipate and sequence nursing interventions when a patient has
multiple nursing diagnoses and collaborative problems exist.
• Multiple factors in the nursing care environment influence a nurse’s ability to set priorities.
• Goals and expected outcomes provide clear direction for the selection and use of nursing
interventions and provide focus for evaluation of the effectiveness of the interventions.
• In goal setting, the time frame depends on the nature of the problem, etiology, overall
condition of the patient, and treatment setting.
• A patient-centred goal is singular, observable, measurable, time-limited, mutual, and realistic.
• An expected outcome is an objective criterion for goal achievement.
• Care plans and critical pathways increase communication among nurses and facilitate the
continuity of care from one nurse to another and from one health care setting to another.

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. All rights reserved.