Clinical Reasoning Cycle - Levett-Jones et al. Flashcards
Deliberate and systematic collection of data to determine a client’s current and past health and functional status and to determine the client’s present and past coping patterns.
Assessment
Describe or list facts, content, objects or people (part of assessment).
Patient Story (patient situation)
Review, gather, recall (part of assessment).
Collect cues / information
Determines health problems within the domain of nursing.
Nursing diagnosis
Clinical judgements about individual, family, or community responses to actual and potential health problems or life processes that are within the domain of nursing.
Nursing diagnosis
Interpret, discriminate, relate infer, match, and predict (part of nursing diagnosis).
Process information
Synthesize facts and inferences to make a definitive diagnosis of the patient’s problem (part of nursing diagnosis).
Identify problems / issues
Category of nursing behaviour in which a nurse sets client-centred goals, outlines expected outcomes, proposes nursing interventions, and prioritizes and selects interventions that will resolve the client’s problems and achieve the goals and outcomes.
Planning
Describe what you want to happen, the desired outcome, and a time frame (part of planning).
Establish goals
Initiates or completes planned actions or nursing interventions.
Implementation
Select a course of action between different alternates available (part of implementation).
Take action
Involves two components: (1) an examination of a condition or situation and (2) a judgement as to whether change has occurred.
Evaluation
Evaluate the effectiveness of and action outcomes: “has the situation improved
now?” (part of evaluation).
Evaluate outcomes
Contemplate what you have learned from the process and what you would
have done differently (part of evaluation).
Reflect on process and new learning
Clinical Reasoning Cycle