Frauman A C, Skelly A H
Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia 30322, USA.
Clin Excell Nurse Pract. 1999 Jul;3(4):238-44.
The nursing process, long considered the basic intellectual tool for nursing, has continued to evolve through use by advanced practice nurses (APNs). Traditionally, the nursing process has been comprehensive in guiding the assessment and intervention phases but has left unspecified the cognitive processes involved in clinical decision making. In an effort to compensate for that weakness, nurses in advanced practice have typically integrated medical diagnostic reasoning into the nursing process. The work of Benner and colleagues (1984, 1996) in explicating the unique reasoning process used by APNs has helped further our understanding of clinical decision making in advanced practice. The evolved nursing process, as described in this article, includes the array of clinical decisions that must be made during a patient encounter, including assessment decisions, diagnosis, choice of interventions, and identification of outcomes. This article reviews the nursing and medical literature related to both clinical decision making and diagnostic reasoning, and applies that literature to the evolution of the nursing process.
长期以来,护理程序一直被视为护理的基本智力工具,并通过高级实践护士(APN)的使用不断发展。传统上,护理程序在指导评估和干预阶段时较为全面,但未明确临床决策中涉及的认知过程。为了弥补这一缺陷,高级实践护士通常将医学诊断推理融入护理程序中。本纳及其同事(1984年、1996年)在阐述高级实践护士所使用的独特推理过程方面所做的工作,有助于我们进一步理解高级实践中的临床决策。本文所描述的演变后的护理程序,包括在患者就诊期间必须做出的一系列临床决策,包括评估决策、诊断、干预措施的选择以及结果的确定。本文回顾了与临床决策和诊断推理相关的护理和医学文献,并将这些文献应用于护理程序的演变。