MURARI LAL COLLEGE OF NURSING,

OACHGHAT, SOLAN

SUBJECT: ADVANCED NURSING PRACTICE

TOPIC: METHOD OF DATA COLLECTION,

ANALYSIS AND UTILIZATION OF DATA
RELEVANT TO NURSING PROCESS.
SUBMITTED TO: Mrs. UPMA SHARMA
ASSISTANT PROFESSOR, (CHN)
SUBMITTED BY: Ms. POONAM CHAUHAN
M.Sc NURSING 1ST YEAR.
SUBMITTED ON: 25 /05/2021
INTRODUCTION:
Nursing process data that is related to the client, family members and significant others, are
collected during the assessment phase of the nursing process and then data is also organized and
documented. Data organization and analysis are also the responsibility of the nurse that requires
the critical thinking skills. After analysis data is used for conclusions and decision making in
terms of the client and their healthcare needs and problem.
STEPS OF ASSESSMENT:
1. Collection of data:
 Subjective Data.
 Objective Data
2. Validation of data
3. Organization of data
4. Recording/documentation of data
METHOD OF DATA COLLECTION:
1. Interview.
2. Observation.
3. Examination.
1) Interview: A planned purposeful conversation/communication with the client to get
information, identify problems, evaluate change, to teach, or to provide support or
counseling. Interviewing, an essential skill for obtaining information for the nursing
history, consists of asking question designed to elicit subjective data from the client or
family members. Main focus on client’s actual and potential health problem and impact
on health status.
 There are two approaches to interviewing: Directive and Nondirective.
 The Directive interview is highly structured and elicit specific information.
Nurse directly ask the questions. And the nurse controls the interview atleast at
the outset.
  The Nondirective interview, or rapport building interview and the nurse allows
the client to control the interview, rapport is an understanding between two or
more peoples.
TYPES OF INTERVIEW QUESTIONS:
1. Closed question: used in the directive interview, are restrictive and generally require
only ‘yes’ or ‘no’ or short factual answers giving specific information.
 Example: Are you having pain now?
2. Open- ended question: associated with the nondirective interview, invite clients to
discover and explore, elaborate, clarify, or illustrate their thoughts or feelings.
 Example: what brought you to the hospital?
3. Neutral question: is aquestion the client can answer without direction or pressure from
the nurse, is open ended and is used in nondirective interviews.
 Example: how do you feel about that?
4. Leading question: by contrast, is usually closed, used in a directive interview, and thus
directs the client’s answer.
 Example: you’re stressed about surgery tomorrow, aren’t you?
PLANNING THE INTERVIEW AND SETTING:
 Before interview beginning, the nurse reviews available information.
 The nurse which data must be collected and which data are within the nurse’s
discretion to collect based on a specific client.
 Nurse prepare an interview guide to help them remember area of information and
determine what question to ask.
 The guides includes a list of topics and subtopic rather than a series of question.
 Each interview is influenced by time, place, seating arrangement or distance, and
language.
STAGES OF AN INTERVIEW:
 The opening or introduction.
 The body or development.
 The closing.
2) Observation: It used to gather data by using the 5 senses and instruments.
 Used to obtain following types of data:
 Skin color(vision).
 Body or breath odors (smell).
 Lung or heart sounds (hearing)
 Skin temperature (touch)
3) Examination: Systematic data collection to detect health problems using unit of
measurements, physical examination techniques and interpretation of laboratory results.
ANALYSIS & UTILIZATION OF DATA IN NURSING PROCESS:
INTRODUCTION:
Analysis of subjective and objective data to make nursing diagnosis. After completing the
nursing assessment, the nurse proceeds to the process of forming appropriate nursing diagnosis.
A nursing diagnosis is a clinical judgement about individual, family or community responses to
actual health problem or life processes.
 In the assessment phase, data are initially collected from a variety of source & validated.
 The nurse then applies reasoning & begins to look for patterns in the assessment data.
 To arrive at nursing diagnosis we must go through the steps of data analysis.
 This process requires diagnostic reasoning skills, often called critical thinking.
STEPS OF DATA ANALYSIS:
1. IDENTIFY ABNORMAL DATA & STRENGTHS:
 Identifying abnormal findings & strengths requires the nurse to have and use a
knowledge base of anatomy and physiology, psychology and sociology.
 The collected data should be reliable and compared with findings in reliable chart and
references sources that provide standards and values for physical and psychological
norms.
 The nurse should also have basic knowledge of risk factors for the client (risk factors are
based on client data such as gender, age, cultural background and occupation).
 The nurse’s should have basic theoretical knowledge which helps to identify the
strengths, risks and abnormal finddings.
 Identified strengths are used to formulate wellness diagnosis.
 Identified potential weaknesses are used in formulating the risk diagnosis & abnormal
findings are used in formulating actual nursing diagnosis.
2. CLUSTER THE DATA STEPS OF DATA ANALYSIS:
1) Nurse looks at the Identified abnormal data & strengths for cues that are related:
 SUBJECTIVE: Hair falling out in chunks.
Red rash on face & chest.
So ugly.
 OBJECTIVE: Anxious appearing, Patchy alopecia, Red raised plaques on face,
neck, shoulders, back & chest.
 While clustering the data, we may find that certain cues are pointing towards a
problem but that more data are required to support the problem.
 Determining patient’s strength.
 Determining patient’s problem areas.
 Determining problems the patient is likely to experience.
3. DRAW INFERENCES & IDENTIFY THE PROBLEM:
 The nurse will write what she think the data is saying & determine where she can
treat independently i.e. something that the nurse would intervent & treat
independently.
 Another purpose of this step is the referral of identified problems for which she
cannot prescribe a definite treatment.
 Referring can be defined as connecting the clients with other professionals and
resources.
 Example: diabetic client who is having trouble with understanding the exchange
diet. Although the nurse has knowledge in this area, referral to a dietician can
provide the client with updated material and allow the nurse more time to deal with
client problems within the nursing domain.
4. PROPOSE POSSIBLE NURSING DIAGNOSIS:
 If the situation requires primarily nursing intervention then the nursing diagnosis
may be wellness diagnosis, risk diagnosis or actual diagnosis.
 A wellness diagnosis indicate that the client has the opportunity for enhancement
of the health status.
 A risk diagnosis indicate the client does not currently have the problem but is at
high risk for developing it.
 An actual nursing diagnosis indicates the client is currently experiencing the stated
problem or has a dysfunctional pattern.
5. CHECK FOR DEFINING CHARACTERISTICS:
 To choose the most accurate diagnosis & to delete the diagnosis which are not
valid for the client.
 Example: the diagnostic categories of impaired gas exchange, ineffective airway
clearance & ineffective breathing pattern, all reflect respiratory problems but each
is used to describe a very different human response pattern & set of defining
characteristics.
 6. CONFIRM OR RULE OUT:
 The nurse can rule out that particular diagnosis with the other health care professionals
who are caring for the client.
 The nurse should tell the client what she perceive his or her diagnosis to be.
 Often nursing diagnosis terminology is difficult for the client to understand.
 Example: nurse would not tell the client that you believe that he has impaired nutrition
less than body requirement. Instead, nurse might say that she believe that current
nutritional intake Is not adequate to promote healing of body tissues.
7. DOCUMENT THE CONCLUSION:
Be sure to document all professional judgements and the data that supports those
judgments. Nursing diagnosis can be documented and worded in different formats like:
 Wellness Diagnosis.
 Risk Diagnosis.
 Actual Nursing Diagnosis
DOMAIN-1: Health Promotion DOMAIN-2: Nutrition DOMAIN-3: Elimination DOMAIN-4:
Activity/Rest
DOMAIN-5: Perception/Cognition DOMAIN-6: Self Perception DOMAIN-7: Role
Relationships DOMAIN-8: Sexuality
DOMAIN-9: Coping/stress tolerance DOMAIN-10: Life principles DOMAIN-11:
Safety/protection DOMAIN-12: Comfort DOMAIN-13: Growth/development.
8. SOURCES OF DIAGNOSTIC ERRORS:
A diagnosis should be consistent highly accurate with all the cues, supported with highly
relevant cues.
9. DATA COLLECTION ERRORS:
The type of error occurs in assessment phase. The nurse must be knowledgeable and
skilled in physical examination. If data are incomplete, omitted or inaccurate, nursing
diagnosis may be missed. If data collection is disorganized, the diagnostic process is
scattered.
The following practices are essential during assessment to avoid data collection errors:
 Nurse critically reviews his or her level of comfort & competence with interview &
physical assessment skills.
 Nurse must determine the accuracy of data collected.
 Nurse must check the completeness of assessment data. Data should not be incomplete,
omitted, or inaccurate & disorganized.
10. ERRORS IN INTERPRETATION & ANALYSIS OF DATA:
Nurse reviews the data to Validate that subjective data are supported by measurable
objective physical findings when necessary.
11. DATA CLUSTERING ERRORS:
 Premature closure of clustering: when the nurse makes the nursing diagnosis before all
the data has been grouped.
 Incorrect clustering: when nurse tries to make the nursing diagnosis fit the signs and
symptoms obtained.
12. DIAGNOSTIC STATEMENT ERRORS:
 Appropriate, concise & precise language which involves correct terminology reflecting
the client’s response to the illness.
 A diagnostic statement such as unhappy and worried about health can lead to errors.
 The language needs to be more precise
 Wellness, Risk, Potential & Actual diagnosis.
CONCLUSION:

Nursing process is a critical thinking process that professional nurses use to apply the best
available evidence to caregiving and promoting human functions and responses to health and
illness. Data are the observable and measurable facts that provide information about the
phenomenon. It provide a framework for planning and implementing nursing care. This involves
a problem-solving approach that enables the nurse to identify patient problems and potential at
risk needs and to plan, deliver, and evaluate the care in an orderly, scientific manner.

SUMMARY:

In this method of data collection, analysis and utilization of data relevant to nursing process,
discuss about the different method use for collection of data from client, family to make the care
effective. After the data collection by using different techniques, analysis and interpretation done
of the data to remove the irrelevant data.
 BIBLIOGRAPHY:

BOOK REFERENCE:
 B.K.Navdeep & H.C.Rawat”, “Advanced Nursing Practice ”,“2015: 1st edition”, “Jaypee
Publications”, “page no.117-119”.
 Basher. P.Shabeer and Khan Yaseen .S, “Advanced Nursing Practice”, “2017: second edition”,
“EMMESS Medical Publishers”, “page no.107-110.
 Stanley M. Joan,”Advanced practice Nursing”Edition 2”united states of America printed”, “page
no.121-122”.

INTERNET REFRENCES:
 https://en.wikipedia.org › wiki › method of data collection
 http://nursing.uokerbala.edu.
 https://www.slideshare.net
 https://www.scribd.com