NCM 101 Health Assessment
Chapter 3: Validating and Documenting Data
4.1 Define related terms
Diagnostic reasoning - form of critical thinking
Critical thinking - way in which the nurse processes information using knowledge, past
experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses
4.2 Discuss the steps of diagnostic reasoning process
Identify abnormal data and strengths
- Subjective data
- Objective data
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
Draw inferences and identify problems
- Write down “hunches” or assumptions about each cue cluster
- Consider nursing diagnosis, collaborative problem, referral
Propose possible nursing diagnoses
- Wellness nursing diagnosis
- Risk nursing diagnosis
- Actual nursing diagnosis
Check for defining characteristics of those diagnoses
- Use reference text such as NANDA Nursing Diagnoses: Definitions and Classifications 2015-
2017
- Compare your findings to NANDA
Confirm or rule out nursing diagnoses
- Validate diagnosis with client and other health care providers who are caring the client
- Validation is also important if client has collaborative problem or requires a referral
Document conclusions
- Wellness nursing diagnosis
- Risk nursing diagnosis
- Actual nursing diagnosis
4.3 Enumerate the essential elements of critical thinking
- Keep an open mind
- Use rationale to support opinions or decisions
- Reflect on thoughts before reaching a conclusion
- Use past clinical experiences to build knowledge
- Acquire an adequate knowledge base that continues to build
- Be aware of the interactions of others
- Be aware of the environment
Chapter 3: Validating and Documenting Data
4.1 Define related terms
Diagnostic reasoning - form of critical thinking
Critical thinking - way in which the nurse processes information using knowledge, past
experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses
4.2 Discuss the steps of diagnostic reasoning process
Identify abnormal data and strengths
- Subjective data
- Objective data
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
Draw inferences and identify problems
- Write down “hunches” or assumptions about each cue cluster
- Consider nursing diagnosis, collaborative problem, referral
Propose possible nursing diagnoses
- Wellness nursing diagnosis
- Risk nursing diagnosis
- Actual nursing diagnosis
Check for defining characteristics of those diagnoses
- Use reference text such as NANDA Nursing Diagnoses: Definitions and Classifications 2015-
2017
- Compare your findings to NANDA
Confirm or rule out nursing diagnoses
- Validate diagnosis with client and other health care providers who are caring the client
- Validation is also important if client has collaborative problem or requires a referral
Document conclusions
- Wellness nursing diagnosis
- Risk nursing diagnosis
- Actual nursing diagnosis
4.3 Enumerate the essential elements of critical thinking
- Keep an open mind
- Use rationale to support opinions or decisions
- Reflect on thoughts before reaching a conclusion
- Use past clinical experiences to build knowledge
- Acquire an adequate knowledge base that continues to build
- Be aware of the interactions of others
- Be aware of the environment
