Assessment and Diagnosis
What to know
A med-surg nurse synthesizes subjective and objective data into a working diagnosis and a safety-focused plan. Core content includes focused and head-to-toe assessment, vital-sign interpretation, pain assessment, laboratory trends (CBC, BMP, coagulation studies, ABG, cardiac markers), ECG and imaging findings, and risk recognition. Age-related changes and comorbidities matter: older adults, patients with diabetes, and immunosuppressed patients may lack fever or classic pain. Diagnostic reasoning means clustering cues, comparing with baseline, and identifying red flags rather than reacting to one number. Document findings and communicate with SBAR.
Traps
- Atypical presentation: absence of fever does not rule out infection.
- Anchoring on the admission diagnosis and missing a new complication.
- Treating a risk factor as a diagnosis.
- Choosing an intervention before completing a focused assessment, unless the finding is immediately life-threatening.
- Assuming a single normal value is reassuring; trends and clusters are stronger.
Worked example
Postoperative day 1: HR 118, BP 102/60, urine output 15 mL/hr, restlessness. Do not label this anxiety first. The cluster suggests hypovolemia or bleeding. Assess the dressing, drain, abdomen, and mental status; notify the provider and anticipate fluid resuscitation. Rule of thumb: a new change in mental status or urine output is a safety cue, and cluster plus trend beats a single value.