Week 3 - Clinical Reasoning & Judgment in Nursing Flashcards by Annie Ge

What is the processes by which nurses make judgments, including generating alternatives, weighing them against evidence, choosing the most appropriate?

Clinical reasoning

The process by which nurses make judgement about patient’s care

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What are the 3 main types of knowledge in clinical reasoning?

Recognizing patterns
- You’ve seen this before
- Theoretical knowledge
- Learned in school

Intuition
- Gut instinct

Tacit knowledge
- Hidden knowledge

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What is an 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 develop new ones as deemed appropriate by the patient’s response?

Clinical judgement

The outcome & the course of action

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What are the 4 stages in the Tanner’s model of clinical judgement?

Noticing
Interpreting
Responding
Reflecting

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Whats the process using Tanner’s Model?

Context background relationship
- if this happened before
- do you know how to fix it
- Need to gather more info
Noticing
a). Expectations
- how many times this has happened
- do you have background knowledge in this field

b). Initial grasp

Interpreting (trying to figure out the problem using the info g
- reasoning patterns
- analytic
- intuitive
- narrative

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Examples of clinical judgment in nursing

Deciding which assessments to perform for a patient after surgery

How to teach a patient newly diagnosed with a condition about their illness and how best to manage it

Deciding which type of pain medication to give a patient and when

Selecting appropriate communication techniques when someone is upset or angry

Deciding which patient needs care first, when you are responsible for multiple patients at once

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Tanner’s model of clinical judgement

What is the data and info gathering phase?

Noticing

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Tanner’s model of clinical judgement

What does effective noticing involves in nursing?

Focused observation
Recognizing deviations from expected patterns
Information seeking

Noticing things when communication
Noticing is also based on the context

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Tanner’s model of clinical judgement

What does the phase, noticing involve?

A perceptual grasp of the situation at hand

Involves the nurse having an expectation of the situation from the specific patient’s pattern of responses, textbook knowledge (comparing the patient’s condition to what’s learned in school), and clinical knowledge from similar patients

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Tanner’s model of clinical judgement

What is the setting priorities and making a plan phase?

Interpreting

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Tanner’s model of clinical judgement

What does the interpreting phase include?

Developing a sufficient understanding of the situation

Involves using one or more reasoning patterns to interpret the meaning of the data and determine an appropriate course of action

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Tanner’s model of clinical judgement

What does effective interpreting involve?

Making sense of and prioritizing data
- Prioritizing first
- What’s the most important? Which patient is the most important? Who to attend to first?
- Then develop a plan

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Tanner’s model of clinical judgement

What are the types of reasoning patterns used in interpreting?

Analytic patterns: hypothetico-deductive reasoning, weighing alternatives.
- Often used by beginning nurses
- Hypothetico-deductive: if you do this then this is likely to happen
- Learned in school, textbooks etc

Intuition: depends on experience with similar situations, often involves pattern recognition
- Rely more on experience

Narrative thinking: by understanding the illness experience and the meaning attached to it can care be provided.
- Rely more on experience
- Patient’s story
- Adds context which help you to notice when something’s off, help you pick the right intervention, etc)
- Knowing the meaning help you to make priorities and how to communication with that patient

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Tanner’s model of clinical judgement

What is the doing (putting plan to action) phase?

Responding

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Tanner’s model of clinical judgement

What does the responding phase do?

Deciding on a course of appropriate action for the situation

sometimes it might be doing nothing
- not b/c you dk how to or that you’re too lazy but b/c what you’re already doing is working so you don’t need more

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Tanner’s model of clinical judgement

What does effective responding involves?

Clear communication

Having a calm, confident manner

Having well planned interventions, while also maintaining flexibility

Being skillful

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Tanner’s model of clinical judgement

What is the thinking of your action phase?

Reflecting

thinking about what you’re doing and if it has achieved the intended outcome

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Tanner’s model of clinical judgement

What does the reflecting phase include?

Attending to the patients’ responses to the nursing action while in the process of acting.

Involves both reflection-on-action and reflection–in-action.
- Assessing a patient’s responses while providing care
- After completing care to evaluate your work and its effectiveness

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Tanner’s model of clinical judgement

What does effective reflecting involve?

Evaluation and self-analysis

Commitment to improvement

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Tanner’s model of clinical judgement

What are the types of knowledge?

Abstract, generalizable, applicable in many situations and derived from science and theory
- Textbook knowledge

Knowledge from experience that is often tacit, and aids in instant recognition of clinical states
- Tacit - unseen
- Gut feeling

Highly localized and individualized, and comes from knowing the patient
- Narrative of the patient

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Tanner’s model of clinical judgement

What are the 2 types of knowing the patient?

Knowing their pattern of responses (typical responses) and knowing the patient as a person

Often tacit
Comes with working closely with others
Knowing the patient is aided through use of formal assessments

What are the 4 basic steps in Tanner’s clinical judgement model? Simplified

Noticing - Gather the info, do their assessments
Interpreting - Decide what’s most important
Responding - Do the action
Reflection - Reflect

What influences clinical judgement?

What nurses bring to the situation at hand than by objective data
Influenced by context of care and culture of the nursing unit
Requires knowing the patient and engaging with their concerns
Nurses use a variety of reasoning patterns
Reflection on practice often triggered by a breakdown in judgment and is needed for improvement in reasoning

What is the nursing process?

A problem-solving approach to identifying and treating client health issues

It is dynamic, interactive and not linear

What's the goal of the nursing process?

To identify, diagnose, and treat actual and potential health issues and challenges from a holistic client perspective

What are the 5 steps in the nursing process?

Assessment, Diagnosis, Planning, Implementation, Evaluation ADPIE

Nursing process What is the assessment step?

Collection of pertinent data about client health status or situation - Both subjective (what the patient tells you) and objective (what you observed) E.g. head to toe, agency guidelines or policies

Nursing process What is the plan step?

Creation of a formal plan that outlines strategies and alternatives to attain expected outcomes

Nursing process What is the implementation step?

Carrying out the plan - Coordinating care, providing health teaching or health promotion activities, consulting with other care providers, providing medication/treatments/therapies within RN scope

Nursing process What is the evaluation step?

Evaluation of client responses to the interventions, whether they were effective, and if goals/outcomes were achieved - Evaluate throughout the whole nursing process

Nursing process What is the diagnosis step?

Analyze assessment data to determine key issues and make clinical judgments Identification of client outcomes or goals

How is the Tanner's model of clinical judgement similar to the Nursing process?

What is a nursing diagnosis?

Nursing diagnosis determines health problems in the domain of nursing - Something the nurses can do or fix - A clinical judgment about a client’s responses to actual and potential health problems of life processes

What is a medical diagnosis?

Identifies a disease condition

What can nursing diagnoses provide?

Provide the basis for selecting appropriate nursing interventions - There are standard approaches for most conditions

What does nursing diagnoses involve?

Involves organizing or clustering data, identifying client needs, and formulating an actual nursing diagnosis - Diagnoses can be actual, risks, health promotion, enhancing wellness

Examples of nursing diagnoses

Imbalanced body temperature Reduced breathing pattern Impaired gas exchange Altered tissue perfusion Caregiver role strain Potential for falls Acute pain

What are the types of resources used in nursing diagnoses?

- experience - nursing standards (CNA, CNO) - bring certain qualities to assessment - knowledge

How should a nursing diagnosis be formatted (the basic)?

the diagnosis…related to…as evidence by…

Where to see approved nursing diagnosis labels?

NANDA

Why is planning care important for nurses?

Setting priorities Setting goals Expected outcomes (client-centered goals)

What are client-centered goals?

Client-centered goals are those that are specific, measurable, and reflect the highest level of wellness and independence for the client

How should priorities be set?

1. Safety 2. ABCs (airway, breathing, circulation) 3. Comfort/pain (if pain is related to ABCs, it's more serious) - Conditions that, if left untreated, would harm the client or others are highest priority

How to set client-centered goals?

One at a time - Be observable, time limited, set neutrally with patient, realistic SMART goals - Specific - Measurable - Attainable - Realistic - Time-limited

How does knowing the outcomes help nurses?

Outcomes help to provide indicators for measuring the success of nursing interventions e.g. pain remains less than 3/10 during activity

_____ and ______ should be client focused, singular, observable, measurable, time-limited, set mutually, and realistic

GOALS and OUTCOMES should be client focused, singular, observable, measurable, time-limited, set mutually, and realistic

Difference between nurse initiated treatment and collaborate treatment

Nurse initiated treatment is something within the nursing scope Collaborate treatment is something a physician has ordered that a nurse would carry out

What are the 3 main importance of clinical reasoning in nursing practice?

- Nursing practice is complex, with competing factors, values, and demands - Good clinical judgments require an ability to consider multiple factors, interpret and respond with appropriate action - Provides a vision for excellent nursing care, that values the nurse-patient connection and knowing the patient

What is a clinical judgment about a client’s responses to actual or potential health problems of life process?

Nursing diagnosis

What type of interpreting is this: The nurse is concerned about a patient because she has a "bad gut feeling"?

Intuitive interpreting