Intro to health exam 1.docx - Clinical Judgement Clinical judgement an interpretation of conclusion about a pts needs concerns or health problems and\/or

Intro to health exam 1.docx - Clinical Judgement Clinical...

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Clinical Judgement Clinical judgement : an interpretation of conclusion about a pts 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 pts response The nursing process: ADPIE Assessment Diagnosis Outcome identification Planning Implementation Evaluation Assessment is the first step and everything is based on the information gathered during assessment. Needs to be accurate, organized and complete. Collect data from multiple sources: Review of clinical record Interview Health history Physical examination Functional assessment Cultural and spiritual assessment Consultation Review of the literature Subjective data: what the pt says about themselves during history taking. Ex: “my head hurts” Objective data : observed when inspecting, percussing, palpating, and auscultating the pt during physical examination
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Clinical judgement involves: Noticing Interpreting Responding Reflecting Noticing is where a nurse notices things about a pt. The nurse is looking for patterns that are consistent with previous experiences and uses that to guide care Interpreting is the process of assembling information to make sense of it. Novice nurses use analytic reasoning while expert nurses use analytic (facts, information) , intuitive (within you), and narrative (look at big picture) Responding is the implementation of actions and interventions based on the pts needs. Reflecting is the process of thinking and learning from experiences. Reflection-on-action happens in real time while care is happening Reflection-in-action happens after pt care occurs Critical thinking skills include interpretation, analysis, evaluation, inference, and explanation Basic critical thinking : not enough experience. Rely on facts, information. Complex critical thinking : separate from experts. Know how to individualize with pt First level priority problems are emergent, life threatening and immediate (ABC) Second level priority problems require prompt intervention to prevent further deterioration. Ex: acute pain, mental status change, abnormal labs, risk to safety.
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