6.1 Critical Thinking in Assessment

Nurses must develop critical thinking skills to gather and analyze patient data. These skills lay the foundation for clinical judgment, which underlies the nursing process.
Clinical judgment allows nurses to synthesize their knowledge, experience, and intuition with the available data to make informed, evidence-based decisions about patient care.
As nurses develop their critical thinking and clinical judgment skills, they will become more adept at evaluating their own process and recognizing areas in need of improvement.
One of the key models used in nursing today is the Clinical Judgment Measurement Model (CJMM), which guides nurses as they develop critical thinking and clinical judgment skills.

6.2 Effective Communication in the Nurse-Patient Relationship

It is the nurse’s responsibility to establish and maintain a trusting therapeutic relationship with each patient in their care.
The nurse-patient relationship is unique and complex, and the nurse will draw on their critical thinking and communication skills to develop and maintain it.
The nurse must establish professional boundaries, striking a balance between being empathetic and avoiding becoming too personal.
Both verbal and nonverbal communication are part of interactions with patients as well as colleagues.
In the clinical setting, the nurse must be aware of the resources and tools available to them to facilitate communication with patients based on needs, as well as strategies to enhance communication with other providers about patient care.
The nurse must understand how different models of communication are used and adjust their communication according to the situation.

The comprehensive health history is a higher-level and more comprehensive view of a patient’s overall health.
The focused health history centers on the chief complaint that prompted the patient to seek care at the present time.
When obtaining a complete/comprehensive health history, the nurse will systematically follow a structured format to ensure that all components have been covered.
The chief complaint, history of present illness, past health history, family history, review of systems, current medications, and sociocultural factors all come together to help the care team form a diagnosis and plan for treatment.

A complete physical examination provides a top-level, thorough view of a patient’s health. It is more comprehensive and inclusive than other assessments and provides an overall view of the patient’s health.
At each step in the assessment and examination process, the nurse must accurately document their findings so that the information can be efficiently and effectively communicated to the care team.
The bedside comprehensive physical examination includes the following nursing assessments: general survey, HEENT, cardiac, respiratory, abdominal (gastrointestinal), peripheral vascular, neuro-muscular, skin, genitourinary, and activity.
When a patient seeks care for a specific problem, the nurse will start with a focused assessment in which they will gather more information on the chief complaint.
While the safety and surroundings assessment pertains to the patient’s safety in the facility, the nurse must also assess the patient’s home safety. The details of the assessment can also be important for the safety of the nurse and other staff.