DATA INTERPRETATION AND ANALYSIS IN HEALTH ASSESSMENT

Health assessment

1. 3. DATA INTERPRETATION AND ANALYSIS DIAGNOSTIC PHASE

2. DIAGNOSTIC PHASE End result is to have a Nursing diagnosis -wellness, actual and potential. Use diagnostic reasoning skills to interprete data accurately Use critical thinking to interprete data accurately

3. Essential Element of Critial Thinking Keep an open mind Use rationale to support opinions or decisions Reflect on your thoughts before reaching a conclusion Use past clinical experience Have adequate knowledge base and continue building it Interact with others - Health team, patient, family Beaware of the environment.

4. 1. IDENTIFY NORMAL AND ABNORMAL DATA Analyze both the subjective and objective data Nurse’s vast knowledge is needed and references materials Pay attention to risk factors Identify abnormal findings

5. 2. CLUSTER DATA Look at the normal findings in all the systems Look at the abnormal findings in all the systems Cluster data together. Eg swelling on the face, hands and legs. Re-assess or confirm assessments done

6. 3. DRAW INFERENCES Draw conclusions from the data you have collected Decide what needs immediate intereventions and do so soonest Refer what needs to be to refered to the right people eg Doctors, Nutritionist etc Familiarize yourself with referal system

7. 4. PROPOSE NURSING DIAGNOSIS If resolutionof the situation requires primarily nursing intervetions the nurse generates possible nursing diagnosis. There are different types of diagnosis Wellness diagnosis - improve one’s health. Nurse supports the patient to move to better health Risk diagnosis - is at high risk for developing problem. Actual Nursing diagnosis - Have a problem or dysfunction pattern.

8. 5. CHECK DEFINING CHARATERISTICS NANDA diagnosis will help Write down the defining characteristics of the problem listed Eg. For respiratory infection - high temperature, positive sputum test for bacterial infection, body weakness,

9. 6. Check and Confirm Diagnosis Recheck the Nursing diagnosis done. If it is not working with the rest of the findingd, the nurse can rule it out.

10. Documentation Document your assessment in chronological and logical manner. Document both subjective and objective data Document the Nursing diagnosis Prepare to communicate the findings with the relevant people.

11. 2. NURSING DIAGNOSIS a  concrete and evidence-based way  for nurses to communicate their  professional judgments  to everyone who is involved in the care of the patient. Including the patient

12. Definition NANDA 1 “Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.” NANDA International  also referred to as NANDA-I, is the international organization in charge of defining, distributing, and integrating the process of standardized nursing diagnosis worldwide

13. Characteristics: 1. Second Part of the Nursing process

14. 2. Based on the data collected from the patient:. Patient’s history Physical Assessment Investigations: Laboratory, Radiology, diagnostic procedures

15. 3. Basis for Nursing Intervention Help nurse create the nursing care plan. Set health promotion goal with/for the patient Measure the patient’s health outcome

16. Types of Diagnosis Nursing Diagnosis Medical Diagnosis Collaborative Diagnosis

17. Nursing Diagnosis Second part of Nursing process Applies to the label when nurses assign meaning to collected data appropriately labeled with NANDA-I-approved nursing diagnosis. It is based upon the patient’s response to the medical condition

18. Matters that hold a distinct and precise action associated with what nurses have the autonomy to take action about with a specific disease or condition Focused on care Directed towards the patient and his physiological and psychological response. The label (NANDA-1)nurses use to assign meaning to patient data collected in the Assessment phase Based on the patient’s current situation and health assessment, allowing nurses and other healthcare providers to see a patient's care from a holistic perspective

19. History Response to a need - t he demand for a standardized language from nurses. Biggest win: the standardization of nursing language through nursing diagnosis was the first step toward having insurance companies pay nurses directly for their care  Nurses felt increased pressure to redefine their unique status and value.

20. Was seen as the approach that could provide the “frame of reference from which nurses could determine what to do and what to expect” in a clinical practice situation. Were also intended to define nursing’s unique boundaries concerning medical diagnoses Formal development 1973 by nurse faculty and incoprated to nursing process 1990 – 9 th conference formal definition of the NANDA Nursing diagnosis 2002 – NANDA became NANDA-International (NANDA-1)

21. Examples instance, while assessing a patient, the nurse may notice that the patient coughs prior to swallowing any food, displays inadequate laryngeal elevation, and repeatedly reports “something stuck” in their throat. The nurse can conclude a nursing diagnosis based on these symptoms:  impaired swallowing Ineffective airway clearance Muscle weakness

22. Medical diagnosis Most popular. Made by the doctor or the advanced health practitioner. It is a one time diagnosis and does not change. It is embedded in the patient’s medical history. Focuses on the patient’s disease, or pathological state. Centers on illness Examples of Medical diagnosis: Pneumonia, Cancer, Amputation, surgeries

23. Collaborative diagnosis require both nursing and medical interventions potential problems that nurses manage using both independent and physician-prescribed interventions Nurses keep an eye on the health problems- aspect focused on monitoring the client’s condition and preventing the development of the potential complication. T he medical professionals prescribe drugs and more diagnostic tests and monitor patient Examples: Renal insufficieny , Potential head injury: increased intercranial pressure

24. CATEGORIES OF NURSING DIAGNOSIS Problem focused Risk Health Promotion Syndrome

25. Problem focused Patient’s issues or problems that are discovered during the process of data collection Also known as actual diagnosis They have three parts The problem or nursing judgement The related to or the cause The evidence or signs and symptoms or defining characteristics First line diagnosis of the patient The nurse should be able to take care of the ‘related to or the cause’

26. Examples: Decreased cardiac out put Decrease renal output Impared gas exchange Decisional conflict

27. Risk Nursing Diagnosis Relys on the clinical judgement of the nurse or members of the healthcare team to see the possibility of the of a problem developing and putting measures to prevent it from occuring. Assess/identify the risk factors that could lead to a certain problem developing. It is two part: The problem or the nursing judgement Evidence/ risk factors Eg. Risk for impaired fluid balance as evidecned by patient’s refusal to take water frequently.

28. Health Promotion Also called wellness diagnosis Desire for the nurse or patient or community to enhance their wellbeing. Either a specific health behaviour or a general one It has two component The wellness goal and the evidence/nuysing judgement present Examples readiness for enhanced weight loss Readiness for breastfeeding infant

29. Syndrome A cluster of several nursing diagnosis that have the same intervention Post traumatic stress syndrome Decreased cardiac output Chronic pain syndrome List the syndrome

30. Possible(suspected) Nursing Diagnosis Not usually included. Due to some risk factors present and other nursing judgement, the nurse sees a potential nursing diagnosis however, it needs frther investigation for it to be confirmed.

31. HOW TO WRITE A NURSING DIAGNOSIS Problem list Possible Causes Defining Characteristics

32. STEP 1. PROBLEM LIST Summarize the patient data collected classifying the problem/issues according to Gordon’s health patterns to help identify the Nursing diagnosis Present the impression/Nursing judgement/ List of issues presented EG. Difficulty in breathing, High temperature of 42 O C, mild diarhoea , pain of 8 Prioritize the problem list Neccesities of survival Acute vs Chronic ABCD Maslow Heirachy of needs/Virginia Handerson’s Needs Theory

33. STEP 2: POSSIBLE CAUSES Each problem should have a possible cause or causes. Narrow down the cause of the problem according to the individual patient. Eg: Difficulty in breathing can be caused by any of the following Cardiovascular dieases, Respiratory infection, anxiety or panic attack, deformities of respiratory organs.

34. STEP 3: DEFINITING CHARACTERISTICS Write down the defining characteristics of the problem listed Eg. For respiratory infection - high temperature, positive sputum test for bacterial infection, body weakness,

35. Example of Nursing Diagnosis Difficulty in breathing related to Respiratory infection as evidenced by high temperature, positive sputum test for bacterial infection, body weakness,