A 68 y/o patient is admitted to the medical unit with a diabetic ulcer on his right toe and is ordered wet to dry dressings with half strength betadine. Dressing changes are scheduled TID 10:00, 14:00, and 20:00. You come onto the unit and accept care to the patient. Using Tanner’s (2006), Clinical judgement model the nurse will care for this patient.
As a nurse on the medical-surgical unit you have expert experience with patients who have diabetic foot ulcers. The noticing component of Tanner’s, (2006), model is not just assessment but particularly focuses on nurse’s expectations and initial grasps. As a nurse on the medical/surgical unit who has many patients with diabetic foot ulcers will recognize the pain level that the patient is in and administer PRN pain medications prior to changing the dressing for effective pain control. The nurse will be able to assess when the dressing should be changed PRN and make appropriate assessments on the diabetic foot ulcer when changing the dressing. When changing the dressing the nurse notices that there is unusual redness and heat coming from the wound – an experienced nurse can notice the signs of infection and take a sample for bacteria growth while reporting the abnormal findings to the physician. With a change in the clinical situation the nurse was able to react in a way that will provide effective patient care to avoid further complications.
In this situation, the nurse grasped an intuitive that the diabetic foot ulcer could be infected. The analytic component of Tanner’s, (2006), model would be the collection of a CBC and wound culture to determine whether or not the patient has a true infection. The tests that were collected will confirm the nurse’s hypothesis to reach an interpretation that supports an infection. Interventions will be applied and antibiotics will be discussed with the MD. These analytic and intuitive components that the nurse has shown represent clinical reasoning and responding (Tanner, 2006).
There are two components to reflection according to Tanner’s model: Reflection-in-action and Reflection-on-action (Tanner, 2006). Reflection-in-action is when the nurse is able to evaluate the patients response to the interventions applied (Tanner, 2006). The patient was given antibiotics for their infection that they have developed from their diabetic foot ulcer. In the meantime the nurse will be assessing the patients response to the antibiotic, fever will be monitored, and pain level is continually assessed. The nurse will document and assess the wound at each dressing change noting any positive or negative changes found at the wound site. Reflection-on-action is when the nurse can gain knowledge from the experience (Tanner, 2006). The nurse will reflect on how to properly change diabetic foot ulcers without breaking the sterile field to avoid future infections whether or not this was the cause. The nurse will be able to recognize wound infections quickly and efficiently and apply appropriate interventions in the future. As a result of nursing actions the patient has recovered from his diabetic foot ulcer infection and avoided life threatening complications such as sepsis or even septic shock leading to mortality.
How does this clinical judgement model reflect on e-health or informatics?
According to the Registered Nurses Association of Ontario [RNAO] ,(2012), Tanner (2006) stated:
“As we increasingly move toward an environment of instant and infinite information, it becomes less important for students to know, memorize, or recall information, and more important for them to be able to find, sort, analyze, share, discuss, critique, and create information. They need to move from being simply knowledgeable to being knowledge-able” (p.76).
Informatics can be used by nurse’s in the following ways:
- Compare previous documented assessments
- Evaluate patient response
- Review MD and nursing notes
- Review laboratory findings
E-health resources can be used to reflect on up to date information in regards to dressing changes to promote wound healing. Continuing education can be applied by Best Practice Guidelines for use of appropriate tools for reference (RNAO, 2012). Evidence informed practice is used by nurses for accurate decisions and judgments on decision making (RNAO, 2012). Knowing how to find these resources through internet research is the key to finding and using these evidence based literature. (RNAO, 2012)
Registered Nurses Association of Ontario. (2012). Best practice guideline: Nurse educator ehealth resource. Retrieved from https://rnao.ca/sites/rnao-ca/files/Nurse_Educator_eHealth_Resource_-_2012_2.pdf
Tanner, C. (2006). Thinking like a nurse: a research-based model of clinical judgment in nursing. The Journal of Nursing Education, 45(6), 204-11.
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16780008