Module 1B: Cliical Reasoning Flashcards
clinical reasoning
decision-making, “past experiences”
critical thinking
foundation of clinical reasoning, analyzing data and generating solutions within data, systemic approach
the nursing process
assessment, diagnosis, planning, implementation, evaluation (ADPIE)
assessment
systemically collect data (subjective + objective)
priority assessment (ABCDE)
airway, breathing, circulation, disability/discomfort, equipment/environment
medical diagnosis
identifying a disease, condition, injury from its s/s
nursing diagnosis
problem and its definition, etiology, defining characteristics
collaborative problems
health issues that require nurses to work with other HCPs
actual problems
supported by evidence (data)
potential problems
have data to suggest risk, the problem does not currently exist
planning
development of goals and outcomes to guide implementation, assign priorities to interventions, keep a current and flexible plan, involve pt and their families and other members of the healthcare team in the plan
intervention
putting plan into action, all interventions relate to a desired goal/outcome, needs to be pt specific, ethical and appropriate for pts age and culture, standardization of interventions
evaluation
determine its response to interventions, gauge if outcomes have been met, document, and start the process again, multiple processes at different stages
bandura social learning theory
learn from one another by observation, imitation and modelling
communication frameworks
SBAR, IDRAW