data validation and organization

• Validating data


  The act of "double-checking" or verifying data to confirm that it is accurate and factual
• Purposes of data validation

  • Ensure that data collection is complete
  • Ensure that objective and subjective data agree
  • Obtain additional data that may have been overlooked
  • Avoid jumping to conclusion
  • Differentiate cues and inferences
• Not every piece of data you collect must be verified
• Conditions that require data to be rechecked and validated

  • Discrepancies or gaps between the subjective and objective data
  • Findings that are very abnormal and 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 to uncover discrepancies
• Organizing data


  The nurse uses a written or computerized format that organizes the assessment data systematically
• Body systems model


  • Focuses on the client's major anatomic systems
  • Allows nurses to collect data about past and present condition of each organ or body system and to examine thoroughly all body systems for actual and potential problems
• Nursing diagnosis


  A clinical judgment about individual family or community responses to actual and potential health problems/life processes
• Purpose of nursing diagnosis

  • Focuses on client's response to a healing problem rather than on the problem itself, and it provides the structure through which nursing care can be delivered
  • Provides a means for effective communication
  • Facilitates holistic client, family, and community – focused care
  • Enhances quality care and community of care
  • Provides an avenue for theory development and nursing research
  • Has an important impact on the health care delivery system
• Categories of nursing diagnosis

  • Actual diagnoses
  • Risk diagnoses
  • Wellness diagnoses
• Types of nursing diagnoses

  • Actual diagnosis
  • Risk diagnosis
  • Possible diagnosis
  • Wellness diagnosis
  • Collaborative problem
• Diagnosis must be based on data collected during assessment of client, validated with client, significant others, and health care providers, and documented so that they can be used in further development of expected outcomes and plan of care
• Steps in developing a nursing diagnosis

  1. Data cues are collected from the assessment phase

  2. Data cues are validated and examined

  3. Data cues are interpreted and assigned a meaning through the use of critical thinking

  4. Data and grouped into clusters

  5. The NANDA list is consulted

  6. The first part of the nursing diagnosis statement is written

  7. Related to (RT) factors are identified

  8. Phrases from steps 6 and 7 are combined to form a two-part nursing diagnosis
• Classification of nursing diagnosis

  • High priority - life threatening and requires immediate attention
  • Medium priority - resulting to unhealthy consequences
  • Low priority - can be resolve with minimal interventions
• Outcome identification


  Formulating and documenting measurable, realistic, client-focused goals
• Purposes of outcome identification

  • To provide individualized care
  • To promote client participation
  • To plan care that is realistic and measurable
  • To allow involvement of support people
• Process of outcome identification and planning

  1. Critical thinking

  2. Establishing priorities
• Guidelines for establishing priorities

  • Consider Maslow's hierarchy of needs
  • Consider client preferences
  • Consider anticipation of future diagnoses
• Nursing diagnoses


  Formulated into an operational format for the planning of nursing care
• Nursing diagnoses

  Mutually ranked by the nurse and client or family and significant others
• Establishing priorities for nursing diagnoses

  1. Consider the client's basic needs, safety, and desires

  2. Anticipate future diagnoses
• Maslow's hierarchy of needs


  Requires that a life-threatening diagnosis be given more urgency than a non-life-threatening diagnosis
• Client preferences


  The client should always be involved in the decision-making process of establishing priorities
• If the nurse and the client do not mutually set priorities

  There may be a contradictory course of direction and motivation, which may lead to noncompliance and nonresolution of the client's nursing diagnoses
• Potential nursing diagnoses


  May not be a current threat to the client, but their seriousness may require that the nurse consider the development of nursing interventions directed toward prevention of the problem
• Goal


  An aim, an intent, or an end. A broad or globally written statement describing the intended or desired change in the client's behavior, response, or outcome
• Expected outcome


  A detailed, specific statement that describes the methods through which the goal will be achieved. Includes aspects such as direct nursing care and client teaching
• Written goals


  • Need to be constructed clearly. Clear, precise terminology improves the chances that goals will be achieved
  • Provide direction for the nursing plan of care and for determination of effectiveness in the evaluation of nursing interventions
  • Establish appropriate evaluation criteria to measure the effectiveness of planned nursing interventions for the resolution of the client's individual nursing diagnoses
• Short-term goal


  A statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis in a short period of time, usually in a few hours or days
• Long-term goal


  A statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis over a longer period of time, usually over weeks or months
• Expected outcomes


  • Realistic
  • Mutually desired by the client and nurse
  • Attainable within a defined time period
  • Depict measurable behavioral change or evidence of change in the client when the goal has been met
  • Used in the evaluation process by providing a standard for comparison to determine if the client successfully accomplished the goal
• Nursing Diagnosis: Disturbed Sleep Pattern


  • Goal: Client will sleep uninterrupted for 6 hours
  • Expected Outcomes: Client will request back massage for relaxation
  • Client will set limits to family and significant other's visits
• Nursing Diagnosis: Ineffective Tissue Perfusion: Peripheral


  • Goal: Client will have palpable peripheral pulses in 1 week
  • Expected Outcomes: Client will identify three factors to improve peripheral circulation
  • Client's feet will be warm to touch
• Components of goals and expected outcomes

  • Subject
  • Task statement
  • Criteria
  • Conditions (if necessary)
  • Time frame
• Subject


  The person who will perform the desired behavior or meet the goal
• Task statement or action verb


  Describes what the client (or subject) will do to obtain an expected change in behavior
• Criteria


  Standards used to evaluate whether the behavior demonstrated indicates accomplishment of the goal
• Conditions


  The situations under which the client should perform or demonstrate mastery of the task
• Time frame


  The period in which the client should perform or demonstrate mastery of the task
• Characteristics of outcome criteria

  • Specific
  • Measurable
  • Attainable
  • Realistic
  • Time-framed