Effective clinical reasoning begins with a comprehensive or focused assessment based on the patient's needs. The comprehensive health history includes biographic data, chief complaint, history of present illness (often explored through OLD HART or CHARTS), past medical and family history, psychosocial history, and review of systems. The primary survey uses the ABCDE framework—Airway with cervical spine control, Breathing, Circulation with hemorrhage control, Disability (neurologic status), and Exposure with environmental control—while the secondary survey involves a head-to-toe assessment and full AMPLE history. The Glasgow Coma Scale quantifies neurologic status across eye opening, verbal response, and motor response, with a total of 8 or less indicating severe brain injury.
Therapeutic communication is central to building rapport and gathering accurate information. Restatement repeats the patient's words to clarify meaning, while reflection focuses on underlying feelings. Clarification asks the patient to elaborate on vague statements. Open-ended questions and general leads such as "Tell me more" encourage elaboration. Purposeful silence and offering self, including sitting with the patient, demonstrate presence and acceptance without premature reassurance. Cultural competency is supported by the LEARN model: Listen, Explain, Acknowledge, Recommend, and Negotiate.
Communication among team members is standardized through SBAR: Situation, Background, Assessment, and Recommendation. A clear Situation statement identifies the nurse, patient, location, and immediate problem, followed by relevant history, current clinical findings, and what is needed. Advocacy for safety is supported by the two-challenge rule, which encourages the nurse to voice concerns about an unsafe order twice before escalating up the chain of command.
Prioritization frameworks guide clinical decision-making. Maslow's hierarchy directs attention to physiologic needs first, including airway, breathing, circulation, nutrition, and elimination, then safety, love and belonging, esteem, and self-actualization. The ABC priority overrides Maslow when there is an acute airway, breathing, or circulation threat; a patient with stridor or cyanosis is seen before one requesting assistance with comfort. Delegation follows the Five Rights of Delegation: right task, right circumstance, right person with verified competency, right direction and communication, and right supervision and evaluation. The registered nurse retains accountability and may not delegate nursing judgment, assessment, teaching, evaluation, or IV push medications. Unlicensed assistive personnel may provide hygiene, toileting, ambulation, intake and output measurement, and vital signs for stable patients, while LPNs typically may not administer IV push medications, blood products, or chemotherapy, depending on state regulation.