Components of Clinical Reasoning in Nursing

Sources of Data

• Client records, including demographic profiles, medical records, and laboratory records
• Healthcare professionals, such as nurses, social workers, primary care providers, and physiotherapists
• Literature, which provides additional information on standards, cultural and social health practices, spiritual beliefs, and assessment data

Data Collection Methods

• Observing, which occurs whenever the nurse is in contact with the client or support persons
• Interviewing, used mainly when taking the nursing health history, and includes focused interviews to collect specific information
• Examining, a major method used in physical assessment, which involves observing, inspecting, auscultating, palpating, and percussing

Interviewing

• A planned communication with a purpose, used to collect information related to the client's problem
• Anchored on the belief that well-reasoned thinking will lead to trustworthy conclusions
• Curiosity, setting priorities, and developing rationales are essential components of clinical reasoning

Clinical Reasoning

• Developing rationales, which explains priority setting and nursing interventions
• Acts as a check for potential errors, justifies nursing actions, and contributes to client safety
• Learning how to act, which involves understanding relevant medical and nursing information and translating it into a plan of care
• Clinical reasoning in transition, which involves recognizing changes in the client's condition over time

Nursing Process

• Collecting, organizing, validating, and documenting client data to establish a database about the client's response to health concerns or illnesses
• Diagnosing, which involves analyzing and synthesizing data to identify client strengths and health problems
• Planning, which involves developing an individualized care plan that specifies client goals and related nursing interventions
• Implementing, which involves carrying out planned nursing interventions to assist the client in meeting desired goals
• Evaluating, which involves measuring the degree to which goals have been achieved and identifying factors that positively or negatively influence goal achievement

Phases of the Nursing Process

• Assessing, which involves collecting, organizing, validating, and documenting client data
• Diagnosing, which involves analyzing and synthesizing data to identify client strengths and health problems
• Planning, which involves developing an individualized care plan that specifies client goals and related nursing interventions
• Implementing, which involves carrying out planned nursing interventions to assist the client in meeting desired goals
• Evaluating, which involves measuring the degree to which goals have been achieved and identifying factors that positively or negatively influence goal achievement

Types of Assessment

• Initial assessment, which is performed within a specified time after admission to a healthcare agency
• Problem-focused assessment, which is an ongoing process integrated with nursing care
• Emergency assessment, which is done during any physiological or psychological crisis of the client
• Time-lapsed assessment, which is done several months after initial assessment

Nurse's Role in Health Assessment

• The goal of medical practice is to diagnose and treat disease, whereas the nurse's role is to identify client strengths and health problems

Planning the Interview

• Setting, including time, place, seating arrangement, and distance
• Language, including open-ended and closed questions
• Avoiding leading questions, as they can create problems if the client gives inaccurate answers

Stages of an Interview

• Opening, which involves establishing rapport and orientation
• Body, which involves the client communicating what they think, feel, know, and perceive in response to questions from the nurse
• Closing, which involves offering to answer questions, concluding, providing a summary, and thanking the client

Examining

• Physical examination or physical assessment, which involves systematic data collection using observation to detect health problems
• Techniques used in examination include inspection, auscultation, palpation, and percussion