Critical Thinking, Clinical Reasoning, and Communication in Health Assessment

Vocabulary flashcards based on Chapters 1 and 2 of Estes Health Assessment & Physical Examination, covering critical thinking frameworks, the nursing process, NCJMM, documentation formats, and communication techniques.

Components of Critical Thinking

The core cognitive processes consisting of interpretation, analysis, inference, explanation, evaluation, and self-regulation.

Universal Intellectual Standards for Critical Thinking (UIS)

A set of standards used to evaluate thinking quality, consisting of clarity, accuracy, precision, relevance, depth, breadth, logic, significance, and fairness.

Nursing Process

A standard critical thinking framework comprising six steps: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.

Nursing Clinical Judgment Measurement Model (NCJMM)

A clinical reasoning framework comprising six steps: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes.

Assessment (Nursing Process)

The step of the nursing process focused on gathering health history, physical examination findings, and diagnostic and laboratory data.

Diagnosis (Nursing Process)

The step of formulating diagnoses, which include problem-focused, health promotion, and risk diagnoses.

Outcomes Identification

The phase of the nursing process that establishes client goals, specific/measurable outcomes, and a defined time frame.

Planning (Nursing Process)

The step of the nursing process that involves prioritization, intervention selection, and integration of evidence-based practice.

Implementation (Nursing Process)

The phase of the nursing process involving coordination of care, health teaching and health promotion, and execution of the care plan.

Evaluation (Nursing Process)

The final step of the nursing process that determines if goals/outcomes were met and prompts care plan revision if they were not.

Recognize Cues (NCJMM)

The NCJMM step centered on identifying relevant versus irrelevant information, determining key data, and identifying immediate concerns.

Analyze Cues (NCJMM)

The NCJMM step where the nurse determines client conditions consistent with cues, considers supporting/contraindicating evidence, and evaluates why specific cues are of concern.

Prioritize Hypotheses (NCJMM)

The NCJMM step that evaluates which clinical explanations are most or least likely and identifies the most serious possible explanations.

Generate Solutions (NCJMM)

The NCJMM step that defines desirable outcomes, selects interventions to achieve them, and identifies what actions should be avoided.

Take Action (NCJMM)

The NCJMM step focused on choosing the most appropriate intervention or combination of interventions and determining how to accomplish them.

Evaluate Outcomes (NCJMM)

The NCJMM step assessing signs of improving or declining client status and evaluating whether interventions were effective.

SBAR

A standardized verbal communication or hand-off framework representing Situation, Background, Assessment, and Recommendation.

CBE

A written documentation format standing for Charting by Exception.

SOAP

A structured method of written documentation representing Subjective data, Objective data, Analysis of data stated as a nursing diagnosis, and Plan.

PIE

A written documentation format representing Problem/diagnosis, Intervention, and Evaluation.

Client Interview

A goal-directed, holistic, client-centered data collection process that covers all aspects of health and has a wider scope than a traditional medical interview.

Motivational Interviewing

A client-centered approach supporting long-term behavior change by building trust through empathy and client ownership, requiring clients to recognize their need for change and set shared, realistic goals.

Stages of the Interview

The three phases of a client interview: Stage I – Joining stage, Stage II – Working stage, and Stage III – Termination stage.

Effective Communication Techniques

Interview strategies used to gather information, including open-ended questions, closed questions, facilitating, and using silence.

Listening Responses

Interactive communication responses including making observations, restating, reflecting, clarifying, interpreting, sequencing, encouraging comparisons, and summarizing.

Action Responses

Active communication interventions including focusing, exploring, presenting reality, confronting, informing, collaborating, limit setting, and normalizing.

Nontherapeutic Communication Techniques

Communication approaches to avoid, including requesting an explanation, probing, offering false reassurance, giving approval/disapproval, defending, and advising.

Problematic Questioning Techniques

Flawed interaction methods including leading questions, interrupting, neglecting to ask pertinent questions, talkativeness, multiple questions, medical jargon, and authoritativeness.

Telehealth and Telenursing

Care delivery modalities that require strong communication skills to mirror in-person care while supporting and empowering clients.