Week1: Clinical Reasoning Discussion

Week1: Clinical Reasoning Discussion
Week1: Clinical Reasoning Discussion
Week1: Clinical Reasoning Discussion
Week 1: Clinical Reasoning and the Physical Assessment Using course materials, textbooks, and the SOAP Note Format document provided in the Course Resources area of the course, choose a friend, colleague, or family member and perform a complete history on your “patient” that presents for a history and physical examination. This is the kind of history you might obtain from a new patient, or during an annual well-visit exam. You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of fatigue, fever, and muscles aches. You should include a complete ROS and all the other components of a complete patient history. This week you will only need to document thesubjective portion of the SOAP note (not objective). Document your findings in a systematic manner and identify some of the key components of the history that may tip you off to primary care interventions that this patient may require. Share these findings in this discussion. Please note the first post is due by Tuesday, 11:59 p.m. MT.Nurses with effective clinical reasoning skills have a positive impact on patient outcomes.
Conversely, those with poor clinical reasoning skills often fail to detect impending patient
deterioration resulting in a “failure-to-rescue” (Aiken, Clarke, Cheung, Sloane, & Silber,
2003). This is significant when viewed against the background of increasing numbers of
adverse patient outcomes and escalating healthcare complaints (NSW Health, 2006).
According to the NSW Health Incident Management in the NSW Public Health System
2007 (2008) the top three reasons for adverse patient outcomes are: failure to properly
diagnose, failure to institute appropriate treatment, and inappropriate management of
complications. Each of these is related to poor clinical reasoning skills. The Quality in
Australian Healthcare Study (Wilson et al, 1995) found that “cognitive failure” was a factor
in 57% of adverse clinical events and this involved a number of features including failure to
synthesise and act on clinical information. Education must begin at the undergraduate level
to promote recognition and management of the deteriorating patient, the use of escalation
systems and effective communication (Bright, Walker, and Bion, 2004).
Contemporary learning and teaching approaches do not always facilitate the development
of a requisite level of clinical reasoning skills. While universities are committed to the
education of nurses who are adequately prepared to work in complex and challenging
clinical environments, health services frequently complain that graduates are not „work
ready?. A recent report from NSW Health Patient Safety and Clinical Quality Programme
(2006) described critical patient incidents that often involved poor clinical reasoning by
graduate nurses. This report parallels the results of the Performance Based Development
System, a tool employed to assess nurses? clinical reasoning, which showed that 70 per

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