NUR 200 Tanner\'s Model - Noticing through Reflecting-updated 2020 PDF

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Nursing 200: Critical Thinking for the Registered Nurse Tanner’s Model of Clinical Judgment

Step 1 - Noticing Thinking Skill 1. Identifying Signs and Symptoms

2. Gathering Complete and Accurate Data

3. Assessing

What it Means Indicates when a

Examples 1. Collect Subjective/Objective Data

situation is normal, abnormal or has

Ex: T: 100ºF, BP: 80/50, skin tear, headache, c/o

changed. Getting an

burning on urination, bilat pitting edema, syncope,

initial grasp of a patient’s

nausea, etc

situation Data collected from all

1. Patient interview: (subjective and objective data)

available sources is used 2. Medical Records: Health Hx/Dx as the basis for

3. Medication Record/Hx

identifying issues,

4. Spouse/caregiver

problems, and concerns. 5. Lab values, diagnostic reports, etc Use a systematic method 1. Head-to-Toe assessment

Systematically and

of assessment so no

2. Pain assessment (numeric scale/FACES)

Comprehensively

information is missed

3. Focused assessment (neuro, resp., etc)

4. Body systems data collection (review of systems) 4. Predicting (and

Looking at the “big

“Potential for…”

Managing) Potential

picture” to prepare for

1. Dehydration: pt NPO

Complications

potential future

2. Infection: pt has a wound/incision

complications

3. Decreased Skin integrity r/t Immobility

Look at possibilities for

4. Pain can cause poor gas exchange and lead to

complications

pneumonia 5. Hypovolemia: r/t blood loss

5. Identifying Assumptions

Arriving at a conclusion

6. DVT: due to immobility 1. Injury from a fall-could be other cause

without supporting

2. Pt crying so they must be depressed (could have just

evidence

lost someone close to them) 3. Medication non-compliance due to no transportation 4. BP is low due to pt’s inactivity 5. Pt with dementia-is forgetfulness 6. All elderly are Incontinent related to age

Step 2 - Interpreting

Nursing 200: Critical Thinking for the Registered Nurse Tanner’s Model of Clinical Judgment Thinking Skill 1. Clustering Related Information

2. Recognizing Inconsistencies

3. Checking Accuracy and Reliability

What it Means

Examples

Grouping together

1. Physical: LOC, CNS, GI issues, vision

information with a

2. Medication: therapeutic/adverse. Affect

common theme to

3. Medical Hx: Current Dx

determine issues,

4. Psychosocial: Widow, work hx, support

problems or concerns. Data does not match

5. Diagnostic tests: MRI, CT, 12 lead EKG, etc 1. Movement sufficient when states has severe pain but

may indicate additional

Grimacing: states no pain

problems

2. c/o nausea but requesting pizza to eat

Actions based on

3. laughing excessively but states is sad 1. Recheck VS if finds abnormal readings

inaccurate or unreliable

2. Reassess pain level measurement by using numeric

information could cause

4. Distinguishing

scale or Wong-Baker

patient harm

3. Redo lab associated with patient s/sx

Recognizing information

4. Verifying HCP orders Relevant

Relevant from

that is pertinent to a

Irrelevant

particular problem

irregular pulse; medical hx-DM, HgA1C results, HTN,

Depends on situation at

incr. BP

hand



Unsteady gait r/t fall; raised temp r/t infection; a-fib r/t

Irrelevant 

Hobbies (gardening, ceramics) hysterectomy 25 yrs

Determine importance

ago, works at IHOP Determining “clinical noise,” myriad of information that

Importance of

or significance of

changes throughout a day.

Information

patient information to

*recent, sudden or significant change-unexpected

current situation

pregnancy, fired from job, new living situation, going on

5. Determining the

vacation. 6. Comparing and Contrasting

Allows for recognition of

1. Differences in patients with same dx.

subtle differences

2. Patient response to an intervention: Large BM after

between situations

Dulcolax sup given 3. O2Sat after O2 applied

Plan nursing

4. Vital signs on admission and 12 hours after 1. Dementia patient: plan nursing action/interventions

Managing Potential

interventions to

2. Quadriplegic patient: plan nsg actions/interventions

Complications

decrease the risk of

3. Mastectomy Surgery: teaching, wound care

7. (Predicting and)

Nursing 200: Critical Thinking for the Registered Nurse Tanner’s Model of Clinical Judgment predicted future

8. Judging How Much

management, etc.

complications

4. New medication: teaching about…

Nursing judgment

5. Foley DC’d: encourage fluids, cranberry juice 1. May need more shacks provided to diabetic with

Ambiguity is

based on acceptable

hypoglycemia (55) then another diabetic with

Acceptable

normal ranges may vary

hypoglycemia (60).

depending on a patient

2. Determine best method for pain relief: PO, IM, IV

situation. How much

push

“Wiggle” room allowed? Situational thinking Decisions made within

1. Meeting competencies-standards of care

Professional

legal, ethical, and

2. Using ANA Code of Ethics

Guidelines

professional guidelines

3. License requirements for renewal

9. Using Legal, Ethical &

4. Professional behaviors within laws 5. Following scope of practice (Nursing Practice Act)

Step 3 - Responding 1. Setting Priorities

Carrying out nursing skills

High, Med, Low Priority

and effective

1.

communication when

2. Early ambulation after surgery

providing patient care.

3. Teaching: medications, incisional care, s/s of infection to report, pain control

Simple to complex

2. Delegating

Monitor VS, ABCs, critical labs

*Prioritizing most urgent

4. Apply SCDs, C&DB exercises, etc.

needs first- Maslows

5. DM pt: teach dietary compliance

Transferring authority to

6. HTN pt: teach about meds, activity, monitor BP Decide most appropriate person to perform task (LPN to

perform duties to others

monitor IV site; UAP to obtain VS, wt. on new admission)

Delegating tasks to team (LPN, UAP)

Step 4 – Reflecting 1.

Evaluating Data

Evaluating patient outcomes to

1. Patient teaching effective when the patient

determine effectiveness of

repeats correct instruction for taking Ibuprofen

interventions

with food

Nursing 200: Critical Thinking for the Registered Nurse Tanner’s Model of Clinical Judgment Reflection-in-action: “real-time,” “reading” the patient. How responds to nursing interventions. Making

2. Effective teaching when you observed patient performing accu-check correctly 3. Patient uses and voices understanding of use of walker to prevent falls

adjustments by assessment.

4. Pt teaching: pt demonstrated proper use of IS

Intervening/correcting pt. actions

5. Pt. demonstrates proper splinting site when

Self-awareness of actions and

coughing, sneezing, or with movement Looking back on a situation and lessons learned

Correcting

seek improving thinking/process

from the experience.

Thinking

of actions. Review own actions



Debriefing

after care has been completed.



Journaling

Gains incite and lessons learned



Story telling

2. Evaluating and

Reflection-on-action: after care

Connects ones actions with pt outcomes (RN

is completed

responsibility) Provides nurse with incites from what occurred from nursing actions...