Lecture 1

• Parts of data collection

  subjective and objective data
• subjective data

  History: What the patient wants to tell you about themselves and is saying
• objective data

  Physical examination: what the health care provider observes (through physical test or watching body language, posture, etc.)
• Clinical reasoning models

  diagnostic reasoning, nursing process, critical thinking (ways to look at whole picture)
• Diagnostic reasoning?

  Steps:

  1. attending to cues (what we see but was not said)
  2. formulating hypothesis (based on cues and subjective)
  3. gathering information
  4. evaluating hypothesis and data (give resolutions and wait to see what happens, if nothing, restart and try again)
• Nursing prosess

  Steps:

  1. assessment
  2. diagnosis
  3. outcome identification
  4. planning
  5. implementation
  6. evaluation

  *ask more questions to make sure everything has been touched on
• Critical thinking

  *which problem is more emergent

  Is it important/emergent enough for us to ignore other problems and only focus on this one?
• Identifying assumptions

  where info can be taken for grated or has no evidence (can influence how we approach situations)
• Identifying an organized and comprehensive approach

  "how can I approach my assumptions to see if it is right, should I ignore it, should I ask, What should I focus on?"
• Validation

  Correct assumption or ignore it, get info from outside source to check
• Distinguishing normal from abnormal

  what vital levels are normal for this patient? (heart rate, BP?)
• Making inferences

  make sense of the data you have collected and try to find reasoning behind it
• Clustering related cues

  put data that can influence/cause problem together, patterns
• Socioenvironmental model

  not asking = missing important information

  *always ask then sort through what you have to see if anything is important
• What does the patient want?

  Setting priorities, identifying patient-centred expected outcomes, determining specific interventions, evaluating and revising thinking, finding a comprehensive plan
• What is actually significant?

  distinguishing relevant and irrelevant; recognizing inconsistencies; identifying patterns; identifying missing information; promoting health; diagnosing actual and potential (risk) problems
• distinguishing relevant from irrelevant


  what is important and can help improve the health and what can't. What is useful informtation?
• Recognizing inconsistences


  what does not match physical signs? What can be further booked into
• Identifying missing information

  helps fill in whole picture and find what is missing pieces of informtion
• promoting health

  identify and work with patient to manage risks, how to avoid them and how to deal with them if they happen
• diagnosing actual and potential (risks) problems

  what can come from this problem and how we we overcome them
• Setting priorities

  what do we want to correct first? More emergent problems than others (ABCs or cardiac arrest comes first, anything else after)
• Identifying patient centered expected outcomes

  what results will show improvement in problem after treatment can happen
• Determining specific interventions

  interventions to prevent, manage, resolve health problems
• evaluating and revising thinking

  see real outcomes and evaluate. See if the interventions worked or not, what needs to change
• determining comprehensive plans

  keep plan up-to-date and change/alter when needed
• Guidelines for clinical practice

  Steps:

  • work to build trust
  • engage through listening
  • convey respect for differences
  • pay attention to social and economic contexts
  • be knowledgeable about social and economic policies that influence provision of healthcare (provincial and nationally)
• How to follow guidelines for clinical practice

  steps:

  • ensure privacy
  • refuse interruptions
  • attention to physical environment
  • dressings
  • taking notes
  • electronic clinical documentations
  • audio recording
• Ensure privacy

  close the door, blinds to make barrier with outside world
• refuse interruptions

  no phones, no people knocking on door, just you and the patient
• attention to physical environment

  is it too cold/hot? to loud? too bright, dark? Do we look engaged?
• Dressings

  are we dressed appropriately for weather? are they?
• Taking notes

  give not to look back on of conversation, but do not solely focus on writing
• Electronic clinical documentations


  "Permeant" record of conversations to look back on
• Audio recording

  nee consent before
• Challenges of note taking

  impedes eye contact, shifts attention away from patient, interrupts patient's narrative flow, impedes observation of nonverbal behaviour, can be threatening during talks about sensitive issues
• impedes eye contact

  need to look down to write
• shifts attention away from patient

  focused on writing
• Interrupts patient's narrative flow

  distracts patient
• Impedes observation of nonverbal behaviour

  can no longer look at patient so cannot watch what they are doing with they body