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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
Concepts of clinical judgment - 1. Safety
2. Healthcare quality
, 3. Leadership
4. Patient education
5. Evidence
6. Professionalism
7. Care coordination
objective data (noticing) - information that is seen, heard, felt, or smelled by an
observer; signs
Analytic reasoning - Situation is unfamiliar
subjective data (noticing) - things a person tells you about that you cannot observe
through your senses; symptoms
Intuitive reasoning - Able to recognize the situation immedialy. Pattern based
factors that influence "Noticing" - -intrapersonal characteristics of the nurse
-theoretical and experiential knowledge of the nurse
-knowing the patient
-context or environment of care
Narrative reasoning - Situation to patient experience with illness.
Interpreting (tanners) - comparing and contrast data, clustering related information,
recognizing inconsistencies, checking accuracy, distinguishing relevant from irrelevant,
determine importance of info, judge how much ambiguity is acceptable (ie b/p dt condition),
determine legal ethical professional guidelines, (predicting and) *managing potential
complications
Noticing - 1. Identify signs and symptoms
2. Complete and accurate date
3. Assessing systemically and comprehensively
4. Predicting and managing patient complications
5. Identifying assumptions
analytic reasoning (interpreting) - based on theoretical knowledge. nurse makes a
hypothesis or best guess about the pt care situation and then tests. typically students and
novice nurses