Assessment, Clinical Judgment, and Nursing Diagnoses: How to Determine Accurate Diagnoses

Assessment was identified as the first part of the nursing process. The nursing process is a theory of how nurses organize the care individuals, families, and communities. The theory of nursing process has been broadly accepted by nurses since 1967 (Yura and Walsh, 1967). In the 1960s, it was thought that the nursing process was a four-part process of assessment, planning, implementation, and evaluation. But, soon after the first description of the nursing process, nurse leaders recognized that assessment data must be clustered and interpreted before nurses could plan, implement, or evaluate a plan to help patients.

The need to interpret data derives from the fact that short-term memory only holds 7 ± 2 bits of data (Newell and Simon, 1972). Thus nurses, like other human beings, continuously convert data into interpretations. For example, people interpret whether a person is female or male, based on over 20 bits of data, e.g., hair and dress style, body language, facial structure, name and voice. If a nurse decides to assist a patient to move from a bed to chair, it is based on an interpretation of data showing that the patient wants or needs to be out of bed and needs assistance with moving from bed to chair. Some of the data that a nurse might use for this interpretation is that the patient is one day post-abdominal surgery, the patient has expressed pain, and the patient said that she or he felt "shaky". Nursing Diagnoses are scientific interpretation of assessment data that are used to guide nurses planning, implementation, and evaluation.

Only 6 years after Yura and Walsh's description of the nursing process in 1967, two nurses from St Louis (USA), organized the first conference to identify the interpretations of data that represent the phenomena of concern to nurses. These nurses, Mary Ann Lavin and Kristine Gebbie, invited 100 nurses from the United States and Canada to participate in this event (Gebbie, 1998). This was the first conference on nursing diagnosis, out of which 80 nursing diagnoses were identified and defined. Since then, the list of approved diagnoses has been steadily grown and been refined through research-based submissions by nurses and the work of members of the nursing diagnosis association that sponsors this book, now known as NANDA International (NANDA-I).

Margaret Lunney, RN, PhD
NURSING DIAGNOSES
Definitions and Classification 2009-2011

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Nurses are Diagnosticians
Intellectual, Interpersonal and Technical Competencies
Personal Strengths: Tolerance for Ambiguity and Reflective Practice
Assessment and Nursing Diagnosis
Assessment Framework
Validating Diagnoses