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clinical reasoning
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- 1what is Critical thinkingpurposeful, focused, informed, results-orientated thinking in any situation. Used interchange-ably with clinical reasoning, clinical judgement, problem solving, and decision making.
- 2what is Clinical reasoningis governed by laws, standards, policies and procedures and it can be a challenging and complex process.
- 3critical thinking and clinical reasoning makeclinical judgement
- 4critical thinking when doing an assessmentTo obtain assessment data:
ask relevant questions
validate evidence or data that has been collected
identify present and potential concerns.
Then be sure to analyze the assessment data and determine the nursing diagnoses. To do this, you must interpret the collected data and identify gaps. For example, if laboratory values are missing, call to obtain test results or schedule a test that wasn't performed. - 5critical thinking when planning careDuring the planning stage, critical thinking skills come in handy when considering how the patient is expected to achieve goals. During this stage, consider the consequences of planned interventions. This is also the time to set priorities of care for the patient.
- 6critical thinking when implementingDuring the implementation stage, use critical thinking to involve the patient and other members of the health care team in implementing the care plan.
- 7critical thinking when evaluatingDuring the evaluation stage, use critical thinking to continually reassess, modify, and individualize care. Evaluation enables you to assess the patient's responses and determine whether expected outcomes have been met.
- 8Critical thinking in nursing is:1. Guided by standards, policies, ethics codes and laws
2. Based on nursing process principles, problem solving and the scientific method
3. Focused on safety and quality
Carefully identifies-key problems, issues and risks involved
4. Applies logic, intuition and creativity
Driven by patient, family and community needs
5. Calls for strategies that make the most of human potential - 9CT characteristics
- 10Personality affectsyour processing of information, decision-making and the degree of structure and control in your life.
- 11Extravertedthinking out loud, draws energy from people
- 12Introvertedthinks inside, draws energy from being quiet
- 13Sensingperceives the world by 5 senses, looks for facts
- 14Intuitiveperceives the world overall, looks for meaning
- 15Thinkinguses objective data, seeks just decisions
- 16FeelingUses subjective data, seeks fair decisions
- 17Judgingorders the environment, likes to plan
- 18Perceivingkeeps things flexible and open, likes to be spontaneous
- 19VARK’s learning stylesvisual
auditory
reading/writing
kinaesthetic - 20Stages of knowledge and expertise acquisition-BennerNovice
Advanced beginner
Competent
Proficient
Expert - 21Logical FallaciesA logical fallacy is incorrect argument in logic and rhetoric resulting in a lack of validity, or more generally, a lack of soundness. Essentially it is an error of reasoning.
- 22Appeal to authoritywhere an assertion is deemed true because of the position or authority of the person asserting it
- 23Argumentum ad hominemthe evasion of the actual topic by directing the attack at your opponent.
- 24Argument from silencewhere the conclusion is based on the absence of evidence, rather than the existence of evidence
- 25argument from ignoranceassuming that a claim is true because it has not been or cannot be proven false, or vice versa
- 26Appeal to emotionwhere an argument is made due to the manipulation of emotions, rather than the use of valid reasoning.
- 27Association Fallacy’guilt by association’ linking one idea or practice with something negative in order to infer guilt on another person
- 28False Dilemma/Dichotomysomeone presenting their argument in such a way that gives only two options
- 29Non-sequitur’it does not follow’ a fallacy where someone asserts a conclusion that doesn’t follow from the proposition
- 30Red herringintroducing irrelevant facts or arguments to distract from the question at hand.
- 31Slippery Slopeadopting one policy or action will result or lead to a series of other policy or actions
- 32Straw manrefuting an extreme version (or straw man) of someone’s argument rather than the argument itself. Then tearing down the straw man as part of the argument.
- 33Hasty generalisationmaking assumptions on a group based on a small sample. Eg. Stereotypes
- 34Weak/False analogywhen relying and comparing two things in an argument that aren’t alike=weak analogy.
- 35Appeal to the popularurging the person to accept a position because the majority of people hold to it.
- 36Appeal to traditiontrying to get someone to accept something because it has ‘always been done this way’.
- 37Avoiders in conflictignore issues or pull away or withdraw from conflict. Opportunities missed and things can build up to ‘explode’.
- 38Accommodators in conflictgive up own needs to ‘smooth over’ to make others feel better. Can also lead to ‘exploding’ due to failure of honestly addressing and confronting issues
- 39Forcers in conflictgetting their way even if others have to give up their needs or wants and don’t care if they aren’t liked.
- 40Compromisers in conflicteveryone gives up their wants and needs. Persuade everyone to give up and compromise thus everyone loses something
- 41Collaborative problem solvers in conflictequal concern for issues and relationships. Solutions for win-win. Issues are fairly faced together with seeking of full support of everyone involved.
- 42The ParentNurturing (NP) – caring and concerned, safety, calming
Firm (FP)- sets limits, states values and standards, firm and strong
Critical (CP)- tries to make the person do what the parent wants to them to do, blaming, critical, attacking
Rescuing (RP)- rescues, helpful, tries to take responsibility unnecessarily - 43The AdultThe grown up rational person, talks reasonably and assertively- not controlling or reacting.
Business like, objective, organised, solves problems, listens, makes decisions, reasons
Our ‘ideal self’ - 44The ChildFree child (FC)- unaware, ‘yahoo’, playing, open, vulnerable, imaginative, creative
Adaptive child (AC)-reacts to world around them, changing themselves to fit or rebel
Conforming child (CC)-obeys, conforms, anxious to please
Withdrawn child (WC)-defies, stubborn, argues - 45Communication and transactionsWe communicate using transactions between different ‘ego states’
Complimentary transactions occur when people are at the same level
Problems occur when transactions are ‘crossed’ where the person is at a different level - 46Moral reasoningJudgement based on personal standards of right and wrong
- 47Ethical reasoningProfessional judgement based on standards
- 48Ethical principles1. Autonomy-self determination
2.Beneficence-do good
3.Non-maleficence-do no harm
4. Justice-treat fairly-give what is due or owed
5. Fidelity-keep promises
6. Veracity-be honest and tell the truth
7. Confidentiality-keep info private
8. Accountability-accept responsibility - 498 suggested steps for moral and ethical reasoning1. Identify the ethical issues (facts) based on main stakeholders-most affected by care
2. Clarify your personal values and how they influence your ability in decision making
4. What will be your role?
5. Determine courses of action
6. Determine outcomes (consequences of actions)
7. List courses of action and rate them (greatest balance of benefits over harm)
8. Develop plan with stakeholders
Plan into action and monitor pt and family responses closely (can change plan as required) - 50assessing systematically and choprehensively'Using an organised approach that enhances your ability to discover all
the information needed to fully understand a persons health status (eg.
What are the actual and potential problems? What needs aren’t being
met? What are the persons strengths and resources?)’ - 51Clinical judgement: accuracy and reliability: guidelinesReview data collected-does objective (observed) data support subjective (stated) data?
Analyse if the information is reliable
How does the data compare with similar data (eg. automatic BP cuff vs Manual BP)
How does the information relate to the patients current health status and condition?
Focus your assessment to gain more information as required to confirm accuracy - 52Decision making and clinical judgement: The 5 ‘W’ questions and the 1 ‘H’ questionwho?
what?
where?
when?
why?
How? - 53Critical thinking and problem solving skills Bloom (1956)Bloom (1956) devised a taxonomy of domains for learning
Knowledge and comprehension (levels 1 and 2) relate to theoretical understanding
Application and analysis (levels 3 and 4) is where theory is applied to nursing care
Synthesis and evaluation (levels 5 and 6) show a high degree of integration of theory and practice
- 54Deteriorating patientsMultiple factors necessitate the need for robust systems around care of the deteriorating patient
The patient population is ageing, patients have more co-morbidities than previously
Hospital length of stay is decreasing
Complex surgery is being performed on patients who had previously been considered too high a risk for surgery - 55Care of the acutely unwell patient – when it goes wrongDevelopment of acute illness
Lack of recognition
Inadequate monitoring and interpretation
Physiological deterioration
Organ failure
Multi-organ failure
Cardio-respiratory arrest - 56Deteriorating Patient: CONTRIBUTING FACTORSUncertainty about when to trigger assistance
Delays by medical staff in responding or provision of an inappropriate response
Inconsistent skills of ward medical and nursing staff
A delay or not seeking supervision or advice in a timely manner
Ineffective communication and handover
Patients cared for in units without specific expertise
Changes in vital signs not detected - 57Clinical judgement: Distinguishing normal from abnormal-identifying signs and symptomsAid in identifying problems early
Early warning scoring (EWS) system-all hospitals-plan, escalating levels of action, senior help
Need to know accepted standards (what is normal/abnormal) eg. HR below 60 bpm
Need to recognise the information and data changes if the patients condition worsens - 58Clinical judgement: Making inferences-drawing valid conclusionsForming valid opinions that follow logically based on patient cues (subjective/objective data)
Requires broad knowledge-signs and symptoms, human behaviour in health, age group specific needs, holistic care needs-’pt as a person’. Eg. No eye contact with the nurse may be for cultural reasons and not that the pt is being rude or dismissive when educating them or talking with them. - 59Clinical judgement: Clustering data cues for patterns and relationshipsRelationships and patterns between data
Classifying information-body systems approach- note writing in pt notes -bringing information [puzzle] together eg. CVS:, RESP:, GIT:, etc
Use a framework-clinical pathways, care plans, admission documents, concept mapping - 60Clinical judgement in assessmentRecognising inconsistencies
When information contradicts each other-need to investigate issues and compare data more closely. Eg. When asking if the pt has pain- they deny. Pt. barely moves and is shallow breathing and wife is concerned they are ‘not himself’ may be inconsistent with the subjective data.
Helps to recognise problems early by focusing on ‘facts’ - 61Clinical judgement Sorting the irrelevant from relevantUseful when presented with much information
What information is important and what isn’t related- may require experience and senior help
Focus on the pertinent ‘facts’ for decisions relating to relevancy
Scientific method- classifying or categorizing information - 62Other skills for clinical judgement in assessmentIdentifying patterns
beginning picture of problems,
recognise gaps in data collection
Identifying missing information
recognising gaps in data-
searching for info to fill the gaps
Risk factors: identifying and management
Detecting, and
managing risk factors- eg. Post MI- education, admission info sheet
Diagnosing actual and potential problems - actual and potential problems are correctly named with appropriate evidence from data
Setting priorities
important- could cause life threatening delays
Determining pt outcomes
what results are observed to show expected benefits of care at a certain period of time.
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- batchelor of nursing clinical reasoning Fichas sobre clinical reasoning, creado por AISLING HORAN el 24/08/2015.
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