Health Assessment And Clinical Reasoning Notes PDF

**Notes for Health Assessment and Clinical Reasoning** ====================================================== - The License exam or NCLEX RN -- is the registered nurse licensure exam; will change format identified as "next gen." ----------------------------------------------------------------...

**Notes for Health Assessment and Clinical Reasoning** ====================================================== - The License exam or NCLEX RN -- is the registered nurse licensure exam; will change format identified as "next gen." -------------------------------------------------------------------------------------------------------------------- - It is a CAT exam; *computerized adaptive test* - thus not all of you will see the same items; adaptive to test taker! --------------------------------------------------------------------------------------------------------------------- - Total of 5 hour exam; --------------------- - Implementation of the new exam set for April 2023. More clinical reasoning, critical thinking and clinical judgment questions. ------------------------------------------------------------------------------------------------------------------------------ - Nursing Faculty in N1175 Foundations are committed to teach clinical reasoning, critical thinking in order to help students develop clinical judgment. - Clinical reasoning strategies will be found in the class, lab and clinical. - In the lab, students will be pressed to think about the skills they are performing and to be safe with their actions - Students are encouraged to use the NCSBN Clinical Judgment Model in all case scenarios they see and learn to apply this in clinical practice. - Recognize and Analyze Cues - Hypothesis questions -- what could be happening? - Priority Solutions - Take Action (priority actions) - Evaluate Outcomes - Students are encouraged to review the Next GEN future exam questions and videos about the new exam at The overall goal of the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - One of the main QSEN competencies is Patient Centered Care the person is unique with own values beliefs hopes and history ------------------------------------------------------------------------------------------------------------------------- all team members are considered caregivers unique individual with needs, values etc ----------------------------------------------------------------------------------- ### - ### Nurses committed to patient centered care have blended competencies ### There are four blended competencies (cognitive, technical, interpersonal, ethical/legal); Nurses should be willing to use them creatively and critically with patients to promote or restore health, prevent disease or illness, and facilitate coping with altered functioning. ### Cognitive Competencies = - ### Critical thinking affected by your own values and experiences - ### We must be independent thinkers using knowledge to guide our actions!!!! - ### Status quo or social media can't affect or control our thinking. Remember EBP ### Technical Competencies = - ### Those that may have experience as CNAs, GNAs, techs -- may need to be careful and learn competent RN actions - ### Nursing school will teach skills and procedures. RNs [develop] the expertise and start as novices. Clinical settings provide exposure to observe and learn actions by health care. You may see right and wrong skills during your clinical practicum. Do the right thing! ### Interpersonal Competencies = - ### How you look affects your patient relationship; BE AWARE of what your looks, speech and touch communicate to patients and those around you. That is why we have uniform attire policy -- most agencies do!! ### Ethical Legal Competencies = - ### Communication is caring! Always use to inform your patient and or their family! - ### Be responsible and respectful with all your actions. - ### There are ethical and legal implications with competent with knowledge, skills and actions. ### ### As identified in the literature, clinical reasoning and critical thinking work leads to clinical judgment. ### Clinical reasoning and critical thinking learning activities are embedded in this course and within the Course Point products. ### As per ebook: clinical reasoning is the process for analyzing a situation and is built on a foundation of knowledge. ### ### Critical thinking is part of the process of clinical reasoning. ### - ### Reflective practice \*student writing of their reflections are included in each chapter ### - ### Reflection leads to improvement of practice and has been part of nursing education for years! ### Through reflective practice, nurses become aware of their action, knowledge and actions or inactions with patient centered care; - ### Students complete reflective practice as part of clinical assignments. ### ### Students are encouraged to review the NCSBN website which discusses the license exam "Next Gen" that will be implemented in 2023 ### See [www.ncsbn.org](http://www.ncsbn.org) Health Assessment ----------------- Cultural influences affect beliefs and values. Environmental preparation is key to physical assessment health history Use of correct equipment and adequate lighting is key. Halogen or overhead lighting preferred if room a bit dark. Also know variations in finding based on individual = certain patients have darker pigmentation which will require knowledge of adequate assessment. Assessment of hard palate and oral mucous membranes may be reliable indicator for assessing jaundice This requires clinical judgment! Know the population you are caring for. Southern MD patient population versus big city areas. The brief general assessment found in the chapter = provides guideline for situational assessment that will be learned later in this course Health history is a collection of patient data collected by the nurse using therapeutic communication/relationship and interview skills. May include subjective and objective data Subjective info: don't paraphrase -- use quotes; record exact patient words It is important to get the patient's own words in why they are seeking health care. This is considered by some agencies as the "chief complaint." The health history and physical assessment are parts of the initial database that gets completed with admission to an agency. See Docucare for examples. Focused assessment = assessing a specific problem or assessing a specific body system. For example for those with pneumonia, you will want to focus on completing a full pulmonary assessment that will include vital signs and any oxygen needs (nasal cannula, face mask etc)/ Nurses need to use equipment that are accurate, clean and in working order = scales need to be calibrated and balanced to read 0.0 A neurological system assessment may include: visual acuity chart appropriate to age, penlight, sharp object, cottonball and tongue depressor. General survey used as first component of physical exam; first moment of your interaction = observe gait, affect of patient and overall cues. Body mass index and waist circumference may be checked. BMI Defined = ratio of weight to height. Can be used to check nutritional status -- obesity or malnutrition Used for tracking diabetes, cancers, heart disease. There are age related variations for older adults: hair loss, age spots, dry skin Decreased skin turgor normal finding in older adults (thus not indicative or hallmark of dehydration). Many integrate neurologic, neuromuscular, and peripheral vascular -- in their assessment. That is the assessment of these 3 systems is done together. Certain physical assessment procedures are now under the scope of the Advanced Practice Nurse Physical assessment findings determine the cause of the diagnosis, which enables nurses to individualize a plan of care. While managing patient problems, you will use physical assessment skills to assess the status of your patient's health. Nurses can revise the care plan to ensure that the patient's problems are addressed. During the evaluation phase, nurses can revise, amend, or discontinue nursing interventions as patients achieve their outcomes and/or goals. To inspect, carefully look, listen, and smell to distinguish normal from abnormal findings. Recognize normal and abnormal. Inspection is the simplest of the five assessment skills. Always tell the patient what you are doing. Place the patient in a comfortable position, and encourage the patient to relax. Palpate sensitive areas last. APRNs have integral roles in physical assessment and certain skills are reserved for their expertise. RNs need to know their role versus APRNs Interpersonal Competencies = ### Nursing Process The nursing process and clinical reasoning are linked together. The nursing process achieves scientifically based, holistic, individualized care; the opportunity to work collaboratively with nurses; and continuity of care. Use of the nursing process and clinical reasoning are what makes nurses safe! Helps us in handling 10 to more patient assignments! Prevention of errors and the promotion of best care! ### ### Concept mapping strategy to affect Clinical Reasoning Concept mapping is an instructional strategy that requires learners to identify, graphically display, and link key concepts, and that they are a proven means to promote critical thinking and self-directed learning.