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Process of Diagnoses

  1. Conduct a nursing assessment - collection of subjective and objective data relevant to the care recipient's (person, family, group, community) human responses to actual or potential health problems / life processes.
  2. Cluster and interpret cues/patterns - Assessment data must be clustered and interpreted before the nurse can plan, implement or evaluate a plan to support patient care
  3. Generate Hypotheses - possible alternatives that could represent the observed cues/patterns.
  4. Validation & Prioritization of Nursing Diagnoses - taking necessary steps to rule out other hypotheses, to confirm with the patient(s) the validity of the hypotheses, and to prioritize the list of diagnoses. A focused assessment may be needed to obtain data for one or more diagnoses
  5. Planning - Determining appropriate (realistic) patient outcomes and interventions most likely to support attainment of those outcomes through evidence-based practice
  6. Implementation - Putting the plan of care (nursing diagnoses - outcomes - interventions) into place, preferably in collaboration with the care recipient(s)
  7. Evaluation - Movement toward identified outcomes is continually evaluated, with changes made to interventions as necessary. When no positive movement is occurring, reassessment to reevaluate appropriateness of diagnoses and/or achievability of outcomes must occur.
Lunney, M. (2009) Assessment, clinical judgment, and nursing diagnoses: how to determine accurate diagnoses. In Herdman, TH (Ed.), Nursing diagnoses: definitions and classification 2009-2011. Wiley-Blackwell: Singapore.



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