MyCLPNA
Observation, Assessment, and Diagnosis
Healthcare providers such as Licensed Practical Nurses (LPNs), Health Care Aides (HCAs), and physicians perform different activities in client care. This article describes the difference between observation, assessment, and diagnosis.
LPNs are authorized to carry out observation, assessment, and nursing diagnosis but are not authorized to make a medical diagnosis.
Observation
Observation involves using sight, hearing, smell, and touch to monitor changes in a client’s health or social well-being. Regular observation and documentation support client assessments and help identify changes in the client’s condition.
- colour, temperature to touch, circulation, and movement;
- signs and symptoms of infection (redness, swelling, warmth, or discharge);
- orientation (person, place, and time);
- odour (urine, feces, wounds, etc.);
- pupils equal and reactive to light;
- signs of neglect;
- changes in the client’s behaviour or health status;
- any adverse events, including rashes and other allergic reactions;
- unsafe conditions or environment; and
- gait and mobility.
LPNs may observe clients directly or rely on other health professionals, like HCAs, to report changes. If a client’s condition is observed to be abnormal or outside the client’s baseline, the LPN should conduct an assessment and report all relevant findings for further investigation.
Assessment
A client assessment involves organizing and analyzing information about a client’s condition. Only authorized health professionals, such as nurses, psychologists, or occupational therapists, can perform client assessments. For example, LPNs are authorized to perform assessments using their nursing knowledge, skill, and judgment. This is called a nursing assessment.
- medical history;
- diagnostic test results, e.g. labs, x-rays, and MRIs;
- observation findings;
- daily living tasks assessment;
- mental health evaluation; and
- social and life factors (such as family, housing, and available supports).
A nursing assessment involves using the client’s gathered health information to understand their overall health, symptoms, and concerns. This process includes evaluating the client’s individual physiological, psychological, sociological, and spiritual needs.
LPNs are expected to use critical thinking, clinical judgement, and decision-making skills to evaluate their assessments and determine the next steps of a client’s care. This includes documenting and reporting abnormal findings to the most responsible health provider as well as interpretation and analysis. Part of assessing is identifying patterns and trends to formulate a nursing diagnosis.
Diagnosis
A medical diagnosis identifies a disease, injury, or condition based on presenting signs and symptoms. Authorized health professionals like physicians, NPs, dentists, and physician assistants conduct this process by investigating observations, assessments, and diagnostic tests to distinguish one condition from others. Diagnosis aims to determine the cause of a client’s symptoms (e.g., pneumonia, diabetes) and guides the treatment plan and medical interventions.
LPNs are not authorized to make a medical diagnosis. However, they can make a nursing diagnosis.
Nursing Diagnosis
A nursing diagnosis is a clinical judgment concerning a human response (actual or potential) to health conditions/life processes. It focuses on the client’s response to illness, treatment, or life situations. It aims to provide an understanding of the client’s needs, enabling nurses to design and implement tailored care plans.
A client assessed to have dyspnea, coughing, and wheezing can receive a nursing diagnosis of being at risk for ineffective airway clearance related to decreased lung expansion. This nursing diagnosis is then used to plan a nursing intervention. A nursing diagnosis may complement a medical diagnosis by providing information about the client’s impairments and challenges, but it does not replace a medical diagnosis.