Complete assessment A review and physical examination of all body systems, for stable patients only
Database Completed health history and physical examination, large store or bank of info
Psychosocial history Psychological and social factors
1st method of data collection Interiew patient, health history. Patient is your primary source
2nd method of data collection Physical examination ( guided by subjective and objective)
1. Safety
2. Healthcare quality
3. Leadership
4. Patient education
5. Evidence
Concepts of clinical judgment 6. Professionalism
7. Care coordination
Analytic reasoning Situation is unfamiliar
Intuitive reasoning Able to recognize the situation immedialy. Pattern based
Narrative reasoning Situation to patient experience with illness.
1. Identify signs and symptoms
2. Complete and accurate date
3. Assessing systemically and comprehensively
Noticing 4. Predicting and managing patient complications
5. Identifying assumptions
Interpreting Understanding of the situation
Responding Based on what you interpreted the nurse will determine appropriate actions
Observing patient reaction to the action the nurse chose and deciding if the situation
Reflection in action was fixed
Patient responses to the outcomes. Nursing refelection after the situation was
Reflection on action solved
Novice nurse Uses analytic reasoning. Uses textbook in a systemic analysis of a situation
Uses intuitive reasoing. Recognizes patterns immediatly. Able to look at the big
Expert nurse picture
Assessment Collecting and analyzing data from the patient, family members, health care team
Who does the initial assessment RN
Focused assessment Used to gather information on a specific problem
Head to toe assessment Systemic approach so you dont miss something
Objective data What you can observe or measure. Also known as signs
Subjective data Can not be measured. What the patient is feeling. Also known as symptoms
Interpretation or conclusion about a patients needs, concerns or health problems,
and/or the decision to take action ( or not) use or modify standard approaches, or
Clinical judgment improvise as one deems appropriate to the patients response
Reasoning Leads to clinical judgment
Planning and the coordination of care, patient advocate for providing quality care,
Case management cost effective outcomes for the patient
Analysis and database Lead to the identification of nursing diagnosis
Defining characteristics
Data clustering Helps to identify patterns that assist with the identification of nursing diagnosis
Database Completed health history and physical examination, large store or bank of info
Psychosocial history Psychological and social factors
1st method of data collection Interiew patient, health history. Patient is your primary source
2nd method of data collection Physical examination ( guided by subjective and objective)
1. Safety
2. Healthcare quality
3. Leadership
4. Patient education
5. Evidence
Concepts of clinical judgment 6. Professionalism
7. Care coordination
Analytic reasoning Situation is unfamiliar
Intuitive reasoning Able to recognize the situation immedialy. Pattern based
Narrative reasoning Situation to patient experience with illness.
1. Identify signs and symptoms
2. Complete and accurate date
3. Assessing systemically and comprehensively
Noticing 4. Predicting and managing patient complications
5. Identifying assumptions
Interpreting Understanding of the situation
Responding Based on what you interpreted the nurse will determine appropriate actions
Observing patient reaction to the action the nurse chose and deciding if the situation
Reflection in action was fixed
Patient responses to the outcomes. Nursing refelection after the situation was
Reflection on action solved
Novice nurse Uses analytic reasoning. Uses textbook in a systemic analysis of a situation
Uses intuitive reasoing. Recognizes patterns immediatly. Able to look at the big
Expert nurse picture
Assessment Collecting and analyzing data from the patient, family members, health care team
Who does the initial assessment RN
Focused assessment Used to gather information on a specific problem
Head to toe assessment Systemic approach so you dont miss something
Objective data What you can observe or measure. Also known as signs
Subjective data Can not be measured. What the patient is feeling. Also known as symptoms
Interpretation or conclusion about a patients needs, concerns or health problems,
and/or the decision to take action ( or not) use or modify standard approaches, or
Clinical judgment improvise as one deems appropriate to the patients response
Reasoning Leads to clinical judgment
Planning and the coordination of care, patient advocate for providing quality care,
Case management cost effective outcomes for the patient
Analysis and database Lead to the identification of nursing diagnosis
Defining characteristics
Data clustering Helps to identify patterns that assist with the identification of nursing diagnosis
