Diagnostic reasoning the process of analyzing health data and drawing conclusions to identify
diagnoses. 4 parts.
1. attending to available cues (signs, symptoms, labs)
2. Formulating diagnostic hypotheses (tentative explanations for further
investigation
3. gathering data
4. evaluating each hypothesis which leads to final diagnosis
Subjective data things a person tells you about that you cannot observe through your senses;
symptoms
Objective data What you as the health professional observe by inspecting, percussing,
palpating, and auscultating during a physical examination.
The Nursing Process six phases: 1. assessment
2. diagnosis
3. outcome identification
4. planning
5. implementation
6. evaluation
Assessment the collection of subjective and objective data about a patients health
purpose: make a judgment or diagnosis
, Diagnosis identification of a disease
- compare clinical findings with normal and abnormal variations and
developmental events
- interpret data
- validate diagnoses
- document diagnoses
Outcome Identification Identify expected outcomes, individualize to the person, culturally appropriate,
realistic and measurable, include a timeline
Planning It involves determining outcome criteria and developing a plan.
Implementation involves carrying out the plan.
Evaluation Involves assessing whether outcome criteria have been met and revising the
plan as necessary.
First-level priority problems emergent, life threatening, and immediate, such as establishing an airway or
supporting breathing.
diagnoses. 4 parts.
1. attending to available cues (signs, symptoms, labs)
2. Formulating diagnostic hypotheses (tentative explanations for further
investigation
3. gathering data
4. evaluating each hypothesis which leads to final diagnosis
Subjective data things a person tells you about that you cannot observe through your senses;
symptoms
Objective data What you as the health professional observe by inspecting, percussing,
palpating, and auscultating during a physical examination.
The Nursing Process six phases: 1. assessment
2. diagnosis
3. outcome identification
4. planning
5. implementation
6. evaluation
Assessment the collection of subjective and objective data about a patients health
purpose: make a judgment or diagnosis
, Diagnosis identification of a disease
- compare clinical findings with normal and abnormal variations and
developmental events
- interpret data
- validate diagnoses
- document diagnoses
Outcome Identification Identify expected outcomes, individualize to the person, culturally appropriate,
realistic and measurable, include a timeline
Planning It involves determining outcome criteria and developing a plan.
Implementation involves carrying out the plan.
Evaluation Involves assessing whether outcome criteria have been met and revising the
plan as necessary.
First-level priority problems emergent, life threatening, and immediate, such as establishing an airway or
supporting breathing.
