1. Complete assess- A review and physical examination of all body systems, for stable
patients only
ment
2. 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.
3. Database Completed health history and physical examination, large store or bank
of info
4. 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
5. Psychosocial
his- tory Psychological and social factors
6. evidence-
based practice clinical decision making that integrates the best available research with
7. 1st method clinical expertise and patient characteristics and preferences
of data
collection Interiew patient, health history. Patient is your primary source
8. Tanner's Model Noticing
Interpretin
g
Respondin
g
Reflectin
g
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, Critical Thinking nur 200 Hondros, 200 Exam 1
9. 2nd method
of data Physical examination ( guided by subjective and objective)
collection
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, Critical Thinking nur 200 Hondros, 200 Exam 1
10. noticing
(tanners model) identify s/s, gather complete and accurate data, assessing
systematically and comprehensively, *predicting (and managing)
potential complications, identify- ing assumptions
11. Concepts of clini-
cal judgment
1. Safety
2. Healthcare quality
3. Leadership
4. Patient education
5. Evidence
12. objective 6. Professionalism
data
(noticing) 7. Care coordination
13. Analytic information that is seen, heard, felt, or smelled by an observer; signs
reason- ing
14. subjective
data Situation is unfamiliar
(noticing)
15. Intuitive things a person tells you about that you cannot observe through your
reason- ing
senses; symptoms
16. factors that
influ- ence Able to recognize the situation immedialy. Pattern based
"Noticing"
-intrapersonal characteristics of the nurse
-theoretical and experiential knowledge of the nurse
-knowing the patient
-context or environment of care
17. Narrative reason- Situation to patient experience with illness.
ing
18.
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