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Health Assessment · Chapter 2

From Cue to Nursing Diagnosis

A cue is a single piece of relevant data; it means almost nothing alone. Sort the data in a real scenario into what matters and what does not, watch the cluster become a pattern, then write the diagnosis correctly — three parts for an actual problem, two parts for a risk — and decide which problem you handle first.
1 RECOGNIZE CUES 2 WRITE THE DX 3 PRIORITIZE
Choose a patient
The situation
Step 1 · Which of these are relevant cues?
Step 2 · Write the diagnosis
Step 3 · You now hold four diagnoses. Which do you act on first?

What the data is telling you

The two rules students break

1. The etiology can never be a medical diagnosis. You cannot independently treat pneumonia, so “related to pneumonia” leaves you nothing to do. Write the part you can treat — retained secretions, guarding with movement, immobility, unfamiliar environment.
2. A risk diagnosis has only two parts. Risk label plus risk factors. There is no “as evidenced by,” because if there were evidence the problem would already exist and it would no longer be a risk.