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2026
,Complete assessment
A review and physical examination of all body systems, for stable patients only
clinical judgment
"Thinking Like A Nurse". integral to the Safety of pt. Interpretation or conclusion about a
patient's needs, concerns, or health problems, and/or the decision to take action (or
not), use or modify standard approaches, or improvise new ones as deemed appropriate
by the patient's response.
Database
Completed health history and physical examination, large store or bank of info
clinical reasoning
is the thinking process by which a nurse reaches a clinical judgement. an iterative
process of noticing, interpreting, and responding- reasoning in transition with a fine
attunement to the patient and how the patient responds to the nurses action
Psychosocial history
Psychological and social factors
, evidence-based practice
clinical decision making that integrates the best available research with clinical
expertise and patient characteristics and preferences
1st method of data collection
Interiew patient, health history. Patient is your primary source
Tanner's Model
Noticing
Interpreting
Responding
Reflecting
2nd method of data collection
Physical examination ( guided by subjective and objective)
noticing (tanners model)
identify s/s, gather complete and accurate data, assessing systematically and
comprehensively, *predicting (and managing) potential complications, identifying
assumptions