make up session

• Data validation


  Process of confirming or verifying that the subjective and objective data are reliable and accurate
• Data documentation


  Act of recording the client assessment findings
• Failure to validate data may result in premature closure of the assessment or collection of inaccurate data
• Purposes of documentation


  • Provides the healthcare team with a database that becomes the foundation for the care of the client
  • Identifies health problems, formulate nursing diagnoses and plan immediate and ongoing interventions
  • Promotes effective communication among the multidisciplinary health team members for the facilitation of safe and efficient client care
  • Eliminates repetition of similar data collected by other health team members
• Information requiring documentation


  • Nursing history (Subjective Data)
  • Physical assessment (Objective Data)
• Documentation guidelines


  • Keep confidential all documented information in the client record
  • Document legibly or print in nonerasable ink
  • Use correct grammar and spelling
  • Avoid wordiness that creates redundancy
  • Use phrases instead of sentences to record data
  • Record data findings
  • Write entries objectively without making premature judgments or diagnoses
  • Record the client's understanding and perception of problems
  • Avoid recording the word "normal" for normal findings
  • Record complete information and details for all client symptoms and experiences
  • Include additional assessment content when applicable
  • Support objective data with specific observations obtained during the physical examination
• Assessment forms used for documentation

  • Initial Assessment Form
  • Frequent/Ongoing Assessment Form
  • Focused/Specialty Area Assessment Form
• Features of initial assessment documentation forms

  • Open-Ended Forms (Traditional Form)
  • Cued or Checklist Forms
  • Integrated Cued Checklist
  • Nursing Minimum Data Set
• Verbal documentation of data

  • Use the standardized method of data communication
  • Communicate face-to-face with good eye contact
  • Allow time for the receiver to ask questions
  • Provide documentation of the data you are sharing
  • Validate what the receiver has heard by questioning or asking him or her to summarize your report
• Data requiring validation


  • Discrepancies or gaps between the subjective and objective data
  • Discrepancies or gaps between what the client says at one time versus another time
  • Findings that are highly abnormal and or inconsistent with other findings
• Methods of validation


  • Recheck own data through a repeat assessment
  • Clarify data with the client by asking for additional examples
  • Verify the data with another healthcare professional
  • Compare objective findings with subjective findings to uncover discrepancies
• Identification of areas with missing data

  • Additional information is needed as data are examined in a group format
  • Certain questions are overlooked and require area identification
  • Identification of areas requiring more data occurs once the initial database is finally established
• Analysis of data


  Second step of the nursing process, is the purpose and the end result of the assessment
• Diagnostic reasoning


  The thought process required for data analysis, a form of critical thinking
• Characteristics of critical thinking in diagnostic reasoning

  • Developing expertise in formulating nursing diagnoses requires background and expertise as professionals on the field of practice
• Key steps for the analysis of data

  • Identify abnormal data and strengths
  • Cluster data
  • Draw inferences
  • Propose possible nursing diagnosis
  • Check for the presence of defining characteristics
• Identifying abnormal data and strengths

  • Remember to analyze both subjective and objective data
  • Compare collected assessment data with findings in reliable charts and reference resources
  • Have a basic knowledge of risk factors for clients
  • Identifying abnormal findings and client strengths requires the nurse to have and use a knowledge base of sociology, psychology, physiology, and anatomy
• Clustering of data


  Nurses look at the identified abnormal findings and strengths for cues that are related
• Drawing inferences


  • Requires the nurse to write down hunches about each cue cluster
  • Determine whether is something that the nurse can treat independently
  • The inference the nurse may draw from a cue cluster suggests the need for both medical and nursing interventions to resolve the problem leading to generating collaborative problems
• Types of nursing diagnoses

  • Wellness Diagnosis
  • Risk Diagnosis
  • Actual Nursing Diagnosis
  • Syndrome Diagnosis
• Checking for defining characteristics

  • Reference texts such as the NANDA: Definitions and Classifications, may assist the nurse in determining when and when not to use each nursing diagnostic category and in ruling out invalid diagnoses and selecting valid diagnoses
• Nursing diagnoses


  • Wellness or health promotion diagnosis
  • Risk diagnosis
  • Actual nursing diagnosis
  • Syndrome diagnosis
• Wellness Diagnosis


  Indicates that the client has the motivation to increase well-being and enhance health behaviors
• Risk Diagnosis


  Indicates that the client does not currently have the problem but is at high risk of developing it
• Actual Nursing Diagnosis


  Indicates that the client is currently experiencing the stated problem or has a dysfunctional pattern
• Syndrome Diagnosis


  Occurs when a cluster of nursing diagnoses is related in a way that they occur together
• Confirming nursing diagnoses


  1. Check for the presence of defining characteristics

  2. Compare definition and defining characteristics with client data

  3. Rule out diagnoses if cue cluster data do not meet defining characteristics

  4. Verify diagnosis with client and healthcare professionals

  5. Validate diagnosis with client who has a collaborative problem or requires a referral
• Documenting conclusions


  1. Document professional judgments and supporting data

  2. Document nursing diagnoses in different formats
• Critical thinking


  • Keep an open mind
  • Use a rationale to support opinions or decisions
  • Reflect on thoughts before reaching conclusions
  • Use past clinical expertise to build knowledge
  • Acquire an adequate knowledge base that continues to build
  • Be aware of the interactions of others
  • Be aware of the environment
• Diagnostic reasoning process


  1. Accurately perform assessment phase

  2. Analyze data through 7 key steps
• Pitfalls decrease the reliability of cues and decrease diagnostic accuracy
• Pitfalls


  • Occur during assessment phase (too many/few data, unreliable/invalid data, insufficient cues)
  • Occur during analysis phase (cues clustered yet unrelated)
• Avoid quickly diagnosing the client without taking sufficient time to process data
• Avoid incorrectly wording the diagnosis statement which leads to an inaccurate picture of the client
• Do not overlook the consideration of the client's cultural background when analyzing data
• Mental status


  State of well-being in which an individual realizes their own abilities, can cope with normal stresses, work productively, and contribute to their community
• Aspects of mental status

  • Cognitive functioning (thinking, knowledge, problem-solving)
  • Emotional functioning (feelings, mood, behaviors, stability)
• Healthy mental status is needed to think clearly and respond appropriately to function effectively in all activities of daily living
• Aspects of appearance


  • Hygiene
  • Grooming
  • Appropriate dress
  • Posture
  • Gait
  • Activity
  • Eye contact
  • Use of cosmetics
  • Facial expressions
  • Unusual movements or mannerisms
• Automatisms


  Repeated purposeless behaviors often indicative of anxiety (e.g. drumming fingers, twisting hair, pacing)