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Clinical Decision-Making in Nursing (pdf)

   

Added on  2021-04-19

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0Running Head: CLINICAL DECISION MAKING IN NURSINGAdvanced clinical decisionmaking in nursingAuthor’s name:

1CLINICAL DECISION MAKING IN NURSINGContentsBackground......................................................................................................................................1Clinical decision making..............................................................................................................1Clinical reasoning............................................................................................................................2Strengths and weaknesses of the clinical decision making process................................................4Strengths.......................................................................................................................................4Weaknesses..................................................................................................................................4Reflective practice in clinical decision making in nursing..............................................................5Changes that should be made in clinical decision making..............................................................6Bibliography....................................................................................................................................7

2CLINICAL DECISION MAKING IN NURSINGBackground Clinical decision making In nursing, clinical decision making is a collaborative and integrative process that involves the collaboration of different departments in order to come up with a perfect plan of care for the client [ CITATION Sta17 \l 1033 ]. The nurse cannot rely on their assessment data only but they need the help of laboratory technicians, doctors and other specialist in the medical field to adequately diagnose a client in order for them, to come up with a plan of care for the patient that is appropriate and effective to the condition being dealt with[ CITATION Mor17 \l 1033 ]. Clinical reasoning Clinical decision making involves clinical reasoning which is involve acquiring cues from the patient and using ones knowledge and critical reasoning to come up with an appropriate diagnosis and plan of care. In clinical reasoning the nurse will ask the patients questions pertaining to their demographic data, past medical history, presenting medical history and chief complaint at the time of the health assessment [ CITATION Man17 \l 1033 ]. All of these factors determine the plan of care accorded to a patient, because they help isolate what has been done and what has not been done, also this process helps isolate if the chief complaint is a new condition or an existing condition. These data also helps identify if the condition has a genetic link or not. A nurse should have effective clinical reasoning skills for them to be able to offer quality care to their clients and pinpoint conditions that require emergency attention just from thehistory of the patient and the presenting signs and symptoms [ CITATION Lev15 \l 1033 ]. Proper clinical reasoning is needed for proper clinical decision making. Poor clinical reasoning results into poor clinical decision making[ CITATION LoB14 \l 1033 ].

3CLINICAL DECISION MAKING IN NURSING Clinical reasoning cycle case study1.Consider the patient situationIn morning handover report, we have A.H, female, she's 90 years old. Conscious, oriented to person, place, time and situation. She was admitted to the emergency room with complains of unusual body pain and weakness since 1 week. She was transferred to medical ward to complete her treatment. When I did the initial assessment; I asked her about her complaint, and the patient said "I feel very weak and I have pain in all part of my body". Her vital signs were stable. There is no surgical history. Her medical histories are hypertension (HTN), chronic kidney disease (CKD) and epilepsy. She is on anti-epileptic drugs and atenolol for hypertension. She's semi-bedridden, she need assistance to walk. Socially, she lives with her housemaid in home. The patient interacts with others easily. Her husband passed away a long ago. Her sons take care of her and visit her regularly. 2.Collect cues and information2 (a). Review current informationIn the morning report, they said that the patient have a low appetite and her veins is difficult to find, according to dietician, administer 60 gram protein with low salt and low potassium. When Icommunicated with the patient she said "I don’t like this food" so the dietician change her diet tobe modified diet. Her vital signs 2 (b). Gather new information

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