Clinical Reasoning and Nursing Process, Study Guide 2024

Clinical Reasoning and Nursing Process, Study Guide 2024 Assessment - The process of collecting data about an individual's health state to make clinical judgments or diagnoses. Subjective data - Information obtained from what the person says during history taking. Objective data - Information obtained from what the health professional observes during the physical examination. Database - The combination of subjective and objective data, patient's record, and laboratory studies used for clinical judgments. Diagnostic reasoning - The process of analyzing health data to identify diagnoses. Nursing process - A five-step process including assessment, diagnosis, planning, implementation, and evaluation. Clinical Judgment Model - A model developed to enhance clinical judgment skills of novice practitioners in nursing education. First-level priority problems - Emergent and life-threatening issues such as airway or breathing problems. Second-level priority problems - Urgent issues like mental status changes, acute pain, or abnormal lab values. Third-level priority problems - Important but less urgent problems that can be addressed after more critical issues. Evidence-based practice (EBP) - Practice based on research utilization involving asking clinical questions, gathering evidence, synthesizing findings, and applying relevant evidence. Holistic health - Views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Social determinants of health (SDoH) - Factors like environment, access to healthcare, community, education, and economic stability that influence health and well-being. Epigenetics - The study of how environment and behaviors impact gene expression. Life cycle factors - Considerations such as developmental tasks and age-related changes during health assessments. Cross-cultural factors - Aspects that may influence health beliefs, practices, and outcomes from different cultural backgrounds. Factors Affecting Communication - Various sender-related, receiver-related, environmental, and message-related factors that influence communication. Ten Traps of Interviewing - Common pitfalls in interviewing including leading questions, interrupting, and focusing on negatives. Being too formal or informal - The tone should be appropriate for the situation. Not listening actively - Failing to pay attention and understand the interviewee's perspective. Being unprepared - Lack of planning can lead to missed opportunities and wasted time.