Nursing Health Assessment Notes PDF

Chapter 1 Nurse’s Role in Health Assessment: Collecting and Analyzing Data  Assessment: Important for Every Situation  Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse. o Acute care o Criti...

Chapter 1 Nurse’s Role in Health Assessment: Collecting and Analyzing Data  Assessment: Important for Every Situation  Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse. o Acute care o Critical care o Ambulatory care o Home health  Assessment  Holistic nursing assessment o Collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment  Physical medical assessment o Focuses primarily on the client’s physiologic development status Holistic nursing assessment collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment. Physical medical assessment focuses primarily on the client’s physiologic development status.  Phases of Nursing Process  Assessment: Collecting subjective and objective data  Diagnosis: Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral)  Planning: Determining outcome criteria and developing a plan  Implementation: Carrying out the plan  Evaluation: Assessing whether outcome criteria have been met and revising the plan as necessary A. Collect subjective and objective data. Assessment is collection of subjective and objective data. Planning is determining outcome criteria and developing a plan. Implementation is carrying out the plan. Evaluation is assessing whether outcome criteria have been met and revising the plan as necessary. Steps of Health Assessment #1  Preparing for the assessment o Review client’s record o Review client’s status with other health care team members o Educate about client’s diagnosis and tests performed  Collection of Subjective Data  Biographical information  History of present health concern; physical symptoms related to each body part or system  Personal health history  Family history   Health and lifestyle practices  Review of systems  Collection of Objective Data  Physical characteristics  Body functions  Appearance  Behavior  Measurements  Results of laboratory testing Steps of Health Assessment #2  Validation of assessment data  Documentation of data  Analysis of data  Analysis Phase of Nursing Process  Identify abnormal data and strengths.  Cluster the data.  Draw inferences and identify problems.  Propose possible nursing diagnoses.  Check for defining characteristics of those diagnoses.  Confirm or rule out nursing diagnoses.  Document conclusions. Types of Assessment  Initial comprehensive assessment: Collection of subjective data about the client’s perception of health of all body parts or systems, past medical history, family history, and lifestyle and health practices.  Ongoing or partial assessment: Data collection that occurs after the comprehensive database is established.  Focused/problem-oriented assessment: Thorough assessment of a particular client problem, which does not cover areas not related to the problem.  Emergency assessment: Very rapid assessment performed in life-threatening situations. Subjective data are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Evolution of the Nurse’s Role in Health Assessment: Past  Physical assessment integral part of nursing  Nurses relied on natural senses  Palpation  Movement of health care from acute care setting to community care and proliferation of baccalaureate and graduate education  Advanced practice nurses Evolution of the Nurse’s Role in Health Assessment: Present  Managed care and internal case management has impact on assessment role of the nurse o Acute care nurses o Critical care outreach nurses o Ambulatory care nurses o Home health nurses o Public health nurses o School and hospice nurses Evolution of the Nurse’s Role in Health Assessment: Future  Rising educational cost  Increasing complexity of acute care  Growing aging population with complex comorbidities  Expanding health care needs of single parents  Increasing impact of children and homeless  Intensifying mental health issues  Expanding health services network  Increasing reimbursement for health promotion and preventive care services  Limited number of medical students pursuing practice in primary care settings  Aging of the baby boomer generation Chapter 2 Collecting Subjective Data: The Interview and Health History Interviewing In the Pre-introductory phase the nurse reviews the medical record which may reveal the client's past health history and reason for seeking health care before meeting with the client to assist with conducting the interview. o Introductory o Working o Summary and closing Introductory Phase ❖ Introduction ❖ Explaining the purpose of the interview ❖ Discussing the types of questions that will be asked ❖ Explaining the reason for taking notes ❖ Assuring the client that confidential information will remain confidential ❖ Making sure that the client is comfortable and has privacy ❖ Developing trust and rapport using verbal and nonverbal skills Working Phase ❖ Biographical data ❖ Reasons for seeking care  ❖ History of present health concern ❖ Past health history ❖ Family history ❖ Review of body systems for current health problems ❖ Lifestyle and health practices and developmental level ❖ Listening, observing cues, and using critical thinking skills to interpret and validate information received from the client ❖ Collaborating with the client to identify the client’s problems and goals Summary and Closing Phase ❖ Summarizing information obtained during the working phase ❖ Validating problems and goals with the client ❖ Identifying and discussing possible plans to resolve the problem with the client ❖ Making sure to ask if anything else concerns the client and if there are any further questions Types of Communication 1. Nonverbal Communication -is as important as verbal communication, the appearance, demeanor, posture, facial expression and attitude strongly influence how client perceives the questions you ask. 1. Appearance-the client is expecting a health professional; therefore, you should look as one 2. Facial Expression- is often an overlooked aspect of communication. Facial expression often shows what you are truly thinking 3. Attitude-one of the most important non-verbal skills to develop as a healthcare professional is a non-judgmental attitude 4. All clients should be accepted, regardless of beliefs, ethnicity, lifestyle, and health care practices. Do not act as though you feel superior to the client or appear shocked, disgusted, or surprised at what you are told. These attitudes will cause the client to feel uncomfortable about opening up to you, and important data concerning their health status could be withheld. 5. Silence-Periods of silence allow you and the client to reflect and organize thoughts which facilitate a more accurate reporting and data collection 6. Listening- most important skills to learn and develop fully to collect complete and valid data from your client *Nonverbal Communication to Avoid ❖ Excessive or insufficient eye contact ❖ Distraction and distance ❖ Standing 2. Verbal Communication- effective verbal communication is essential to a client interview. The goal of the interview process is to elicit as much data about the client health status as possible. 1. Open-ended questions - elicit the client’s feelings begins with how or what and perception. Ex. How have you been feeling lately?  2. Close-ended questions - focus on specific information. Ex. When did the pain started 3. Laundry list provide the client with a choice of words to choose. a. Ex. Is the pain severe/dull/sharp? 4. Well-place phrases - listen closely to the client during his or her description and use phrases such as “um-um”, “yes”, or I agree” to encourage the patient to continue 5. Rephrasing - This technique helps to clarify information the client has stated. It enables you and the client to reflect on what has been said. Ex. The patient tells you that she is scared because she fears that she has some horrible disease. You may rephrase the information by saying, “You are thinking that you have a serious illness 6. Providing information-Another important thing to consider throughout the entire interview is to provide the client with information as questions and concerns arise. Make sure you answer every question *The nurse should use open-ended questions to elicit the client’s feelings and perceptions. Closed-ended questions should be used to obtain facts and to focus on specific information. Verbal Communication to Avoid ❖ Biased or leading questions ❖ Rushing through the interview ❖ Reading the questions Special Considerations ❖ Gerontologic variations ❖ Cultural variations ❖ Emotional variations Interacting with an Anxious Client ❖ Provide the client with simple, organized information in a structured format. ❖ Explain who you are and your role and purpose. ❖ Ask simple, concise questions. ❖ Avoid becoming anxious like the client. ❖ Do not hurry. ❖ Decrease any external stimuli. Interacting with an Angry Client ❖ Approach the client in a calm, reassuring, in-control manner. ❖ Allow the client to vent feelings. ❖ Avoid any arguments with or touching the client. ❖ Obtain help from other health care professionals as needed. ❖ Facilitate personal space so that the client does not feel threatened or cornered. ❖ Never allow the client to position him or herself between you and the door. Interacting with a Depressed Client ❖ Express interest in and understanding of the client and respond in a neutral manner. ❖ Take care not to communicate in an upbeat, encouraging manner. Interacting with a Manipulative Client  ❖ Provide structure and set limits. ❖ Differentiate between manipulation and a reasonable request. ❖ Obtain an objective opinion from other nursing colleagues. Interacting With a Seductive Client ❖ Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors. ❖ Encourage client to use more appropriate methods of coping in relating to others. ❖ If the overt sexuality continues, do not interact without a witness. ❖ Report inappropriate behavior to a supervisor Discussing Sensitive Issues ❖ Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality. ❖ Ask simple questions in a nonjudgmental manner. ❖ Allow time for ventilation of client’s feelings as needed. ❖ If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate. Types of Communication Verbal Communication  Several types of questions and techniques to use during an interview: Health History Interviewing ❖ Biographical data ❖ Reasons for seeking health care ❖ History of present health concern ❖ Past health history ❖ Family health history ❖ Review of systems for current health problems ❖ Lifestyle and health practices ❖ Developmental level 1.Biographical Data ❖ Name ❖ Address ❖ Phone ❖ Gender ❖ Provider of history (patient or other) ❖ Birth date ❖ Place of birth ❖ Race or ethnic background ❖ Primary and secondary languages (spoken and read) ❖ Marital status ❖ Religious or spiritual practices ❖ Educational level ❖ Occupation ❖ Significant others or support persons (availability)  ❖ Review of Body Systems SOURCES DATA Primary -Patient herself Secondary-Maybe her spouse, children if the client has forgetfulness or mentally incapacitated 2. Reasons for Seeking Health Care Includes Two Questions: 1. What is your major health problem or concern at this time?  This question will assist the client to focus on his most significant health concern 2. Why are you here? Or how can I help you?  This question encouraged the client to discuss fears or other feeling about having to seek a health care provider 3. History of Present Health Concerns  Encourage the client to explain the health problem or symptom in as much as detail as possible by focusing in the onset, progression, and duration of the problems, signs and symptoms and related problems, and what the client perceives as causing the problem  Because there are many characteristics to be explored for each symptom, a memory helper—known as a mnemonic—can help the nurse to complete the assessment of the sign, symptom, or health concern  You may also ask the client to evaluate what makes the problem worse, what makes it better, which treatments have been tried, what affect the problem has had on daily life or lifestyle, what expectations are held about recovery and what is the client ability to provide self-care.   Health history focuses on questions related to the client’s past, from the earliest beginnings to the present  The information gained from these assist the nurse to identify risk factors that stem from previous health problems. Risk may be to the client or to his significant others 4. Past Health History The family health history assumes greater importance. In other health problems that may have affected the client by virtue of having grown up in the family and being exposed to these problems 5. Family Health History The family health history assumes greater importance. In other health problems that may have affected the client by virtue of having grown up in the family and being exposed to these problems 6. Review of Systems for current health problems When reviewing body systems with the client, it is important to include only the client’s subjective information and the examiner’s observations. There is a tendency especially with more experienced nurses, to fill up the observations such as “erythema of the right eye” or “several vesicles on the client’s upper extremities”; the nurse should avoid this inclination. Skin, hair, nails Head, neck Eyes Ears Mouth, throat, nose, sinuses Thorax, lungs Breasts, regional lymphatics Heart, neck vessels Peripheral vascular Abdomen Genitalia Anus, rectum, prostate Musculoskeletal Neurologic 7. Lifestyle and Health Practices Profile (activities of daily living) Here clients describe how they are managing their lives, their awareness of healthy versus toxic living patterns, and the strengths and supports they have or use. When assessing this area, use open-ended questions to promote a dialogue with the client.  Description of Typical Day  Nutrition and Weight Management  Activity Level and Exercise  Sleep and Rest  Substance Use Self-Concept and  Self-Care Responsibilities   Social Activities  Relationships Values and Belief System  Education and Work  Stress Levels and Coping Styles  Environment Chapter 3 Collecting Objective Data: Physical Exam Techniques 1.Physical Examination  Preparation Client, Equipment & Environment  Positioning Different types of Positions  Techniques IPPA Preparing the Physical Setting The physical examination may take place in a variety of settings, such as a hospital room, outpatient clinic, physician’s office, school health office, employee health office, or a client’s home Physical setting MUST - Comfortable, room temperature: - Provide a warm blanket if the room temperature cannot be adjusted. - Private area free of interruptions from others: Close the door or pull the curtains if possible. - Quiet area free of distractions: Turn off the radio, television, or other noisy equipment.  Physical setting MUST - Adequate lighting: It is best to use sunlight (when available). However, good overhead lighting is sufficient. A portable lamp is helpful for illuminating the skin and for viewing shadows or contours. - Firm examination table or bed at a height that prevents stooping: A roll-up stool may be useful when it is necessary for the examiner to sit for parts of the assessment. A bedside table/tray to hold the equipment needed for the examination. Prepare yourself  Careful preparation of yourself as an examiner is essential to be able to gather objective data to elicit sound clinical judgments.  Another important aspect of preparing yourself for the physical examination is preventing the transmission of infectious agents Preparing the Client  Establish Rapport and trust   Explain each step  Should explain when and where the examination will take place, why it is important and what will happen.  Privacy & Confidentiality  Nurse should determine in advance any positions that are contraindications for a particular client  Should assist the client as needed to undress and put on gown  Client should empty their bladder before examination Positioning  It is important to consider the client’s ability to assume a position  The client’s physical condition, energy level, and age should be taken consideration Some positions are embarrassing and uncomfortable and therefore should not be maintained for long 1. Sitting Position Head, chest, back, lungs, neck, breast, axilla, heart, vital signs and upper extremities 2. Supine Position Head, neck, chest, breast, axillae, abdomen, heart, lungs, and all extremities 3. Dorsal Recumbent Head, neck, chest, axillae, lungs, heart, extremities, breast and peripheral pulses 4. Sim’s Position Rectal and vaginal areas 5. Standing Position Posture, balance, gait and male genital 6. Prone Position Hip joint Clients with Cardiac and respiratory cannot tolerate this position 7. Knee-Chest Position Rectum *Embarrassing position and should be use for limited time as possible 8. Lithotomy Position Female genitalia, reproductive tracts, and the rectum Equipment/Instruments for Physical Examination: EQUIPMENTS Prior to the examination, collect the necessary equipment and place it in the area where the examination will be performed. This promotes organization and prevents the nurse from leaving the client to search for a piece of equipment. Each part of the physical examination requires specific pieces of equipment. LIST EQUIPMENTS Gloves – used to protect examiner in any part of examination when the examiner may have contact with blood, fluids, secretions, and contaminated items or when disease-causing agents could be transmitted to or from the client Equipments/Instruments for Examination: For Vital Signs  Sphygmomanometer – to measure diastolic and systolic blood pressure  Stethoscope – to auscultate blood sound when measuring blood pressure and lung/breath sounds  Thermometer (oral/rectal/axilla) – to measure body temperature  Watch with second hand – to time heart rate, pulse rate and cycles of respiration For Anthropometric Measurements:  Skin Fold Caliper – to measure skin fold thickness of subcutaneous tissue Flexible tape measure – to measure circumference  Platform Scale with weight attachment – to measure height and weight For eye examination  Penlight – to test pupillary constriction  Snellen Chart – to test distant vision  Ophthalmoscope – to view the red reflex and to examine the retina of the eye  Newspaper or Rosenbaum Pocket Screener—to test for near vision For Ear Examination  Otoscope – to view the ear canal and tympanic membrane  Tuning Fork – to test for bone and air conduction of sound Tongue depressor Gauze Bell and Diaphragm of Stethoscope For Female genitalia  Vaginal Speculum and lubricant- to inspect cervix through dilation of the vaginal canal  Slides or Specimen Container – to obtain endocervical swab and cervical scrape and vaginal pool sample For Anus, Rectum, Prostate Examination  Lubricating Jelly – to promote comfort to client PHYSICAL EXAMINATION TECHNIQUES IPPA INSPECTION Guidelines/Techniques in Inspection:  Make sure the room is at a comfortable temperature. A too cold or too hot room can alter the normal behavior of the client and the appearance of the client’s skin  Use good lighting, preferably sunlight. Fluorescent lights can alter the true color of the skin. In addition, abnormalities may be overlooked with dim lighting  Look and observe before touching. Touch can alter appearance and distract you from a complete, focused observation  Completely expose the body part that you are inspecting while draping the rest of the client as appropriate  Note the following characteristics while inspecting the client, color, pattern, size, location, consistency, symmetry, movement, behavior, odors or sound  Compare the appearance of symmetric body parts (eyes, ears, arms, hands) or both sides of any individual body part PALPATION -involves or consists of using parts of the hand to touch and feel for the following characteristics.  Texture - rough/smooth  Temperature - warm/cold  Moisture - dry/wet  Mobility - fixed/movable/still/vibrating  Consistency - soft/hard/fluid/filled  Strength - strong/weak/thread/bounding  Size - small/medium/large  Shape - well defined/irregular  Degree of tenderness Hand Part used to Palpate  Finger pad -sensitive to fine discriminations, pulses, texture, size, shape, crepitus, consistency  Dorsal surface - (back) temperature  Ulnar or palmar surface -Vibrations, thrills, fremitus Types of Palpation 1. Light palpation - safest and the most comfortable, place your dominant hand lightly on the surface of the structure. There should be little or no depression (less than 1 cm). Feel the surface structure using circular motion.  2. Moderate Palpation – depress the skin surface 1 to 2 cm with your dominant hand and use a circular motion to feel for easily palpate body organs and masses. Note the size, consistency, and ability of structures you palpate. 3. Deep palpation: Place your dominant hand on the skin surface and your nondominant hand on top of your dominant hand to apply pressure. This should result in a surface depression between 2.5 and 5 cm (1 and 2 in.). This allows you to feel very deep organs or structures that are covered by thick muscle. 4. Bimanual Palpation – using 2 hands, placing one on each side of the body part. Use one hand to apply pressure and other hand to feel the structure PERCUSSION -involves tapping body parts to produce sound waves 3 Types of Percussion: 1. Direct percussion – direct tapping of a body part with one or two finger tips to elicit possible tenderness 2. Blunt percussion – detect tenderness over organs (kidney) by using on hand flat on the surface and using the fist of the other hand to strike the back 3. Indirect or mediate tones (sounds) – as the density increases, the sound of the tone becomes quieter AUSCULTATION – it requires the use of stethoscope to listen for heart sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract Techniques of Auscultation:  Eliminates distracting or competing noises from the environment  Expose the body part you are going to auscultate. Do not auscultate through the client’s clothing or gown. Rubbing the against the clothing obscures the body sounds  Use the diaphragm of the stethoscope to listen for high-pitch sounds, such as normal heart sounds, breath sounds, and bowel sounds and press the diaphragm firmly on the body part being auscultated  Use the bell of the stethoscope to listen for low pitch sounds such as abnormal heart sounds and bruits (abnormal loud, blowing or murmuring sounds heard during auscultation). Hold the bell lightly on the body part being auscultated.  Chapter 4 Validating and Documenting Data Validation of Data  Verify that subjective and objective data are reliable and accurate.  Steps of Validation  Deciding whether data require validation  Determining ways to validate the data  Identifying areas where data are missing Data Requiring Validation  Discrepancies or gaps between subjective and objective data  Discrepancies in what the client says at one time versus another time  Abnormal and/or inconsistent findings Methods of Validation  Repeat assessment.  Clarify data with client.  Verify with another health care professional.  Compare objective findings with subjective findings. Purposes for Documentation  Provides a chronologic source of client assessment data and a progressive record of assessment findings that outline the client’s course of care.  Ensures that information about the client and family is easily accessible to members of the health care team; provides a vehicle for communication; and prevents fragmentation, repetition, and delays in carrying out the plan of care.  Establishes a basis for screening or validating proposed diagnoses.  Acts as a source of information to help diagnose new problems.  Offers a basis for determining the educational needs of the client, family, and significant others.  Provides a basis for determining eligibility for care and reimbursement. Careful recording of data can support financial reimbursement or gain additional reimbursement for transitional or skilled care needed by the client.  Constitutes a permanent legal record of the care that was or was not given to the client.  Forms a component of client acuity system or client classification systems. Numeric values may be assigned to various levels of care to help determine the staffing mix for the unit.  Provides access to significant epidemiologic data for future investigations and research and educational endeavors.   Promotes compliance with legal, accreditation, reimbursement, and professional standard requirements. Documenting Data  Keep confidential all documented information in the client record.  Document legibly or print neatly in nonerasable ink.  Use correct grammar and spelling.  Avoid wordiness that creates redundancy.  Use phrases instead of sentences to record data.  Record data findings, not how they were obtained.  Write entries objectively without making premature judgment.  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.  Include additional assessment content when applicable.  Support objective data with specific observations obtained during the physical examination. Question #1 Which guideline should the nurse follow for documentation? a) Write “normal” for normal finding b) Use phrases instead of sentences c) Exclude client’s understanding d) Describe how data were obtained Answer to Question #1 B. Use phrases instead of sentences. When documenting, the nurse should remember to use phrases instead of sentences, avoid using the word “normal” for normal findings, include the client’s understanding, and record data findings, not how they were obtained. Assessment Forms for Documentation  Initial assessment form: nursing admission or admission database  Frequent or ongoing assessment form: flow charts that help staff to record and retrieve data for frequent reassessments  Focused or specialty area assessment form: focused on one major area of the body for clients who have a particular problem Question #2 Which is a feature of an open-ended documentation form? a) Consists of check boxes b) Promotes use by different caregivers c) Promotes rapid documentation  d) Provides narrative description Answer to Question #2 D. Provides narrative description. An open-ended documentation form provides a narrative description of problems. A checklist form uses check boxes and promotes rapid documentation. An integrated cued checklist and a nursing minimum data set promote use by different caregivers. Question #3 Is the following statement true or false? In a cued or checklist form, there is a possibility of missing a significant piece of information? Answer to Question #3 True. In a cued or checklist form, there is a possibility of missing a significant piece of information because the checklist does not include the area of concern. Interdisciplinary Verbal Communication of Assessment findings (Using SBAR)  Use a standardized method of data communication such as SBAR (Situation, Background, Assessment, Recommendation).  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 the receiver to summarize your report.  When reporting over a telephone, ask the receiver to read back what the receiver heard you report and document the phone call with time, receiver, sender, and information shared. Chapter 5 Thinking Critically to Analyze Data and Make Informed Nursing Judgments Analysis of Data and Critical Thinking  Data analysis: diagnostic or clinical reasoning phase  Diagnostic reasoning: form of critical thinking  End result or purpose is the identification of a nursing diagnosis, collaborative problem, or need for referral to another health care professional.  Critical thinking is the way in which the nurse processes information using knowledge, past experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses.  Characteristics a nurse must develop to be able to think critically. Questions That are a Litmus Test of a Critical Thinking Mindset  Do you reserve your final opinion or judgment until you have collected  more or all of the information?  Do you support your opinion or comments with supporting data, sound rationale, and literature?  Do you explore and consider alternatives before making a decision?  Can you distinguish between a fact, opinion, cue, or inference?  Do you ask your client for more information or clarification when you do not understand?  Do you validate your information and judgments with experts in the field?  Do you use your past knowledge and experiences to analyze data?  Do you try to avoid biases or preconceived ways of thinking?  Do you try to learn from past mistakes in your judgments?  Are you open to the fact that you may not always be right?  Seven Essential Critical Thinking Characteristics 1. Keep an open mind. 2. Use rationale to support opinions or decisions. 3. Reflect on thoughts before reaching a conclusion. 4. Use past clinical experiences to build knowledge. 5. Acquire an adequate knowledge base that continues to build. 6. Be aware of the interactions of others. 7. Be aware of the environment. Six Essential Components of the Diagnostic Phase  Group and organize data.  Validate data and compare with normal findings/values.  Cluster data to make inferences.  Generate hypotheses regarding client’s problems.  Formulate a professional clinical judgment.  Validate the judgment with the client. The Diagnostic Reasoning Process  Step one—Identify strengths and abnormal data  Subjective data  Objective data  Step two—Cluster data  Identify strengths and abnormal findings for cues that are related.  Cluster both strength cues and abnormal cues  Consider, again, if additional data are needed. Question #1 Is the following statement true or false? Identified strengths are used in formulating health promotion diagnoses. Answer to Question #1 True. *Identified strengths are used in formulating health promotion diagnoses.  Step three—Draw inferences o Write down “hunches” or assumptions about each cue cluster o Consider nursing diagnosis, collaborative problem, referral.  Step four—Propose possible nursing diagnoses o A wellness or health promotion diagnosis—opportunity for enhancement of health state o Risk diagnosis—potential noted o Actual diagnosis—currently noted Question #2 Is the following statement true or false? An actual nursing diagnosis indicates that the client has the opportunity for enhancement of a health state. Answer to Question #2 False. An actual nursing diagnosis indicates that the client is currently experiencing the stated problem or has a dysfunctional pattern. A health promotion diagnosis indicates that the client has the opportunity for enhancement of a health state. Question #3 Is the following statement true or false? A risk diagnosis describes a situation in which an actual diagnosis will most likely occur if the nurse does not intervene. Answer to Question #3 True A risk diagnosis describes a situation in which an actual diagnosis will most likely occur if the nurse does not intervene.  Step five—Check for defining characteristics o Use reference text such as NANDA Nursing Diagnoses: Definitions and Classifications 2015–2017. o Compare your findings to NANDA.  Step six—Confirm or rule out diagnosis  o Validate diagnosis with client and other health care providers who are caring for the client. o Validation is also important if client has collaborative problem or requires a referral. Document conclusions o Wellness or health promotion diagnoses o Risk diagnoses o Collaborative problems and referrals  Define Wellness of Health Promotion Nursing Diagnosis o Format that is used when documenting these diagnoses, with an example o Format for health promotion diagnoses other than those for which NANDA has labels, with an example  Definition of Risk Nursing Diagnoses o Format that is used for these diagnoses, with an example o Format for actual nursing diagnoses, with an example  The documentation of collaborative problems with referrals  The documentation of nursing goals for collaborative problems  The documentation of parameters that nurses monitor Nursing responsibilities  Documentation of a referral Developing Diagnostic Reasoning Expertise and Avoiding Pitfalls  Expertise comes with knowledge and experience, time, and practice.  Pitfalls occur during the assessment phase and the analysis-of-data phase.  Too many or too few data  Unreliable or invalid data  Insufficient number of cues available to support the diagnoses  Clustering cues that are unrelated to each other  Quickly diagnosing without hypothesizing several diagnoses  Incorrectly wording the diagnostic statement Ways to Increase Accuracy of Diagnostic Reasoning Skills  Identify abnormal data and strengths.  Cluster data.  Draw inferences.  Propose possible nursing diagnoses.  Check for presence of defining characteristics.  Confirm or rule out nursing diagnoses.  Document conclusions.