Steps for making a clinical judgment are outlined in Table 3-1. Data analysis, which is the second step of the nursing process, can be challenging because the nurse is required to use diagnostic reasoning skills to interpret cues accurately to make an informed clinical judgment. This requires critical thinking skills. Because of the complex nature of nursing as both a science and an art, the nurse must think critically-in a rational, self-directed, intelligent, and purposeful manner.
Subjective and objective data collected are used to identify and cluster client strengths and abnormal cues to assist the nurse in identifying client concerns and/or collaborative problems. A client concern may fall into one of three categories: actual, risk, or opportunity to improve health. An "actual" client concern indicates that the client is currently experiencing the issue (e.g., poor skin integrity: reddened area on right buttocks). A "risk" for client concern indicates that the client does not currently have the problem but is vulnerable to developing it. An "opportunity for health promotion" means that the client is ready or motivated to learn about or take action to improve their health (see Table 3-2).
The most useful format for an actual client concern is:
Client Concern + associated with + underlying cause + as seen in
Example: Fatigue associated with increased job demands and stress as seen in client’s statements of feeling exhausted all of the time and lack of energy to perform usual work and home responsibilities (e.g., cooking, cleaning)
The most useful format for a risk for client concern is:
Risk for + client concern + associated with + underlying cause
Example: Risk for infection associated with the presence of dirty knife wound, leukopenia, and lack of client wound care knowledge
The most useful format for an opportunity to improve health is:
Opportunity to improve + client concern +associated with + statement of desire to improve etiology
Example: Opportunity to improve sleep pattern associated with request to improve sleep by learning ways to stay asleep throughout night
Collaborative problems are equivalent in importance to client concerns but represent the interdependent or collaborative role of nursing, whereas client concerns represent the independent role of the nurse. Collaborative problems are defined as "certain physiologic complications that nurses monitor to detect their onset or changes in status; nurses manage collaborative problems using physician-prescribed and nursing- prescribed interventions to minimize the complications of events" (Carpenito-Moyet, 2017). The definitive treatment for a client concern is developed by the nurse; the definitive treatment for a collaborative problem is developed by both the nurse and the physician. Not all physiologic complications are collaborative problems. If the nurse can prevent the complication or provide the primary treatment, then the problem may very well be a client concern. For example, nurses can prevent and treat pressure injury. Therefore, "risk for poor skin integrity" is the client concern.
Table 3-2 compares the three types of client concerns: (1) opportunities to improve health, (2) risks for client concern, and (3) actual client concerns. The nurse can use this model to decide whether the identified problem can be treated independently as a client concern or whether the nurse will monitor and use both medical and nursing interventions to treat or prevent the problem. Table 3-3 compares and differentiates client concerns and collaborative problems.
If collaborative and nursing interventions are not enough to resolve the problem, the problem requires medical diagnoses and intervention to resolve, so the nurse should refer these situations to the client’s primary care provider. Table 3-4 gives examples of client concerns, collaborative problems, and medical diagnoses.