Clinical Grasp
The central skill in critical thinking is creating your clinical grasp.
By the end of this article, you will be able to:
By the end of this article, you will be able to:
- Understanding what clinical grasp is.
- Why you care about it.
- Ways to start strengthening your clinical grasp TODAY.
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What is Clinical Grasp?
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Pre-Reqs to the Skill
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3 Tips
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Pro-Tips
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Still unsure?
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Put plainly, wrapping your mind around the clinical picture is called Clinical Grasp. It really is that simple. But in real life, “Getting a Grip” isn’t always so straight forward, and that is why it’s a skill that must be developed.
So why do we care about it? Because it orients you- think of it as your compass. Having clinical grasp means you understand what is happening. And when you understand what is happening, you can initiate interventions and act appropriately. Having clinical grasp will make or break everything you do for that patient. That is why getting a grip is the first priority.
An expert nurse enters a clinical situation with the goal of gaining a good grasp on the situation. Besides it being a safe thing to do, there are three main reasons why gaining clinical grasp before you do anything else is imperative:
So why do we care about it? Because it orients you- think of it as your compass. Having clinical grasp means you understand what is happening. And when you understand what is happening, you can initiate interventions and act appropriately. Having clinical grasp will make or break everything you do for that patient. That is why getting a grip is the first priority.
An expert nurse enters a clinical situation with the goal of gaining a good grasp on the situation. Besides it being a safe thing to do, there are three main reasons why gaining clinical grasp before you do anything else is imperative:
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#1) It gives you an understanding of the patient’s baseline, so that any deviation from that baseline can guide you to have clinical inquiry.
#2)It will help you identify or predict/prevent problems (AKA having clinical forethought) #3) It puts your priorities into place, and makes your actions appropriate. |
Those skills mentioned above in italics are gone into detail in other articles. But what you need to know is that they all require you to have a grasp on what is happening. Your understanding is your foundation.
What parts make up the skill of clinical grasp?
2. Having the right mindset: Openness to being wrong and to change course of action as new things develop
- Having theoretical background- Everything you learned in nursing school
2. Having the right mindset: Openness to being wrong and to change course of action as new things develop
#1) Get your baseline: your story.
Understanding the story of your patient is like reading a recipe for something you are about to bake. You must get familiar with all the ingredients to start understanding how they make up the big picture.
When you get report at the beginning of your shift, that will be the first story you come to understand. Once you have that, personalize the story. That means take that story and go look at your patient. Does what you were told make sense when you look at them in the bed, at the machinery around them, at the vital signs on the monitor?
You may have had some questions or thoughts during report. Take a few minutes, if you can, to dig around the chart to get things straight in your mind.
As you do your first assessment, actively think about everything you observe, and WHY its present (crackles, murmurs, etc). Does that fit into your understanding of the story? Or is that something new?
Getting report and doing your first assessment is very important, because the rest of your shift will be based on your understanding of what is normal for this patient, and what isn’t.
Understanding the story of your patient is like reading a recipe for something you are about to bake. You must get familiar with all the ingredients to start understanding how they make up the big picture.
When you get report at the beginning of your shift, that will be the first story you come to understand. Once you have that, personalize the story. That means take that story and go look at your patient. Does what you were told make sense when you look at them in the bed, at the machinery around them, at the vital signs on the monitor?
You may have had some questions or thoughts during report. Take a few minutes, if you can, to dig around the chart to get things straight in your mind.
As you do your first assessment, actively think about everything you observe, and WHY its present (crackles, murmurs, etc). Does that fit into your understanding of the story? Or is that something new?
Getting report and doing your first assessment is very important, because the rest of your shift will be based on your understanding of what is normal for this patient, and what isn’t.
#2) Be present and apply yourself.
Sometimes we get into a bad habit of coasting through our shift. If you ever find yourself doing that, STOP! Never, ever be on autopilot. We must get away from seeing our job as observers, and start interacting with the clinical picture.
To do that, train yourself to apply your senses (touch, sight, smell, sound, etc). Every detail counts, especially in the ICU. And instead of gathering data for charting purposes, gather it to create an understanding of the picture (both big and small).
Every occurrence or finding can point you in the right direction, if only you recognize it and think about it. And to recognize it, you have to be aware, to be present. Has the urine output dropped? Are your patient’s vital signs trending in the wrong direction? Are the lung sounds changing? These subtle clues can lead to big discoveries- so put yourself in a position to see them.
At the beginning, it might be overwhelming to think about all these things, but keep in mind: critical thinking develops as your experience. Don’t worry about everything else. If you can SEE and understand, the rest will follow.
Sometimes we get into a bad habit of coasting through our shift. If you ever find yourself doing that, STOP! Never, ever be on autopilot. We must get away from seeing our job as observers, and start interacting with the clinical picture.
To do that, train yourself to apply your senses (touch, sight, smell, sound, etc). Every detail counts, especially in the ICU. And instead of gathering data for charting purposes, gather it to create an understanding of the picture (both big and small).
Every occurrence or finding can point you in the right direction, if only you recognize it and think about it. And to recognize it, you have to be aware, to be present. Has the urine output dropped? Are your patient’s vital signs trending in the wrong direction? Are the lung sounds changing? These subtle clues can lead to big discoveries- so put yourself in a position to see them.
At the beginning, it might be overwhelming to think about all these things, but keep in mind: critical thinking develops as your experience. Don’t worry about everything else. If you can SEE and understand, the rest will follow.
#3) Become a detective
Clinical grasp is not static: it is something you have to constantly CREATE in yourself as things evolve. Going hand in hand with being present, train yourself to recognize, and to listen to, when you don’t understand something you are seeing.
The number one red flag that you have lost your clinical grasp is that you will realize something doesn’t make sense, or does not align with your expectations. (“Hmm, his O2 Sats are dropping- he’s never done that before…” or “I expected by now she would be more awake but she is still hard to arouse…”).
This is a great thing to happen, because it will wake you up to look at something closer, to ask questions, to figure out why something has changed or isn’t changing. Don’t ever take for granted that something is transient or a one-time occurrence. There is a reason why that thing happened. And its your job to figure out why.
From the time you get report at the beginning, to when you give it at the end, you should always be asking questions, to be trying to understand WHY, WHAT, and HOW.
Clinical grasp is not static: it is something you have to constantly CREATE in yourself as things evolve. Going hand in hand with being present, train yourself to recognize, and to listen to, when you don’t understand something you are seeing.
The number one red flag that you have lost your clinical grasp is that you will realize something doesn’t make sense, or does not align with your expectations. (“Hmm, his O2 Sats are dropping- he’s never done that before…” or “I expected by now she would be more awake but she is still hard to arouse…”).
This is a great thing to happen, because it will wake you up to look at something closer, to ask questions, to figure out why something has changed or isn’t changing. Don’t ever take for granted that something is transient or a one-time occurrence. There is a reason why that thing happened. And its your job to figure out why.
From the time you get report at the beginning, to when you give it at the end, you should always be asking questions, to be trying to understand WHY, WHAT, and HOW.
Pro-Tip #1-
Think it out
When there is a change in clinical relevance, think it through and reason yourself to an understanding. It may seem silly at first to sit there and tell yourself “Well, of course he is acidotic: he is breathing 9 times a minute” But do it ANYWAY. You may start making connections to other pictures of the puzzle as you talk it through with yourself.
For example, his breathing isn’t up to parr, he is acidotic and now you are seeing a lot more ectopy on the monitor. Why is this happening? Is there a link between these things? Once you get a clinical grasp of what is occurring, you will be able to act. Perhaps his respiratory rate needs to be increased, perhaps his ectopy is from having a low potassium level because of the acidosis, etc… These hypotheses will guide you to act and to address the acidosis and hopefully prevent complications that are occurring (or will occur) as a result.
Think it out
When there is a change in clinical relevance, think it through and reason yourself to an understanding. It may seem silly at first to sit there and tell yourself “Well, of course he is acidotic: he is breathing 9 times a minute” But do it ANYWAY. You may start making connections to other pictures of the puzzle as you talk it through with yourself.
For example, his breathing isn’t up to parr, he is acidotic and now you are seeing a lot more ectopy on the monitor. Why is this happening? Is there a link between these things? Once you get a clinical grasp of what is occurring, you will be able to act. Perhaps his respiratory rate needs to be increased, perhaps his ectopy is from having a low potassium level because of the acidosis, etc… These hypotheses will guide you to act and to address the acidosis and hopefully prevent complications that are occurring (or will occur) as a result.
Pro-Tip #2-
Recognize changing clinical Relevance
It has happened to us all: one minute you think everything is just dandy, the next minute, the whole world just fell apart. Sometimes changes for the worse do not have warnings. But a lot of the times, they do.
Recognizing changing clinical relevance is build on the skill of being present and applying yourself (as mentioned previously). It also has to do with knowing what to expect from your patient (both in specific patient populations AND your particular patient.) Having an expected clinical trajectory AND being an astute observer, you will begin to recognize when something is going well and when it isn’t.
For example: you gave 2 units of PRBCs for your patient with a Hgb of 6.3. You EXPECT that his post-infusion Hgb will be around 8.3. So if it comes back at 5.8- that should be a red flag that there has been a change in clinical relevance: If it comes back that low, he is likely having an active bleed somewhere. Coming to that realization will switch all your priorities around because now you have an actively bleeding patient with a prreetttyyy low hgb.
Recognize changing clinical Relevance
It has happened to us all: one minute you think everything is just dandy, the next minute, the whole world just fell apart. Sometimes changes for the worse do not have warnings. But a lot of the times, they do.
Recognizing changing clinical relevance is build on the skill of being present and applying yourself (as mentioned previously). It also has to do with knowing what to expect from your patient (both in specific patient populations AND your particular patient.) Having an expected clinical trajectory AND being an astute observer, you will begin to recognize when something is going well and when it isn’t.
For example: you gave 2 units of PRBCs for your patient with a Hgb of 6.3. You EXPECT that his post-infusion Hgb will be around 8.3. So if it comes back at 5.8- that should be a red flag that there has been a change in clinical relevance: If it comes back that low, he is likely having an active bleed somewhere. Coming to that realization will switch all your priorities around because now you have an actively bleeding patient with a prreetttyyy low hgb.
Some of you reading this may feel unsure or not entirely confident (or overwhelmed?) about your current abilities to practice this skill.
But I am here to tell you that you have some awesome things already working in your favor:
These skills will be cultivated and refined as your practice them every shift. Be patient with yourself, and always remember: you have nurses all around you, and us at The Thinking Nurse, to help you through it.
But I am here to tell you that you have some awesome things already working in your favor:
- You are human. And yes, that’s a good thing. You are much better than any machine or technology ever made by Philips or whatever. You can think in ways and experience subjective things that machines can’t. Touching your patient’s foot and feeling how cold it is, then using that information to infer meaning within a specific context? A machine can’t do that.
- You are a licensed nurse. That means you went through nursing school and passed the NCLEX. All that wasn’t for nothing. That experience and training gave you the theoretical background that you MUST have in order to get an understanding of your patient. And remember all those people who didn't make it through school or the NCLEX? If you've gotten this far, you can do this.
These skills will be cultivated and refined as your practice them every shift. Be patient with yourself, and always remember: you have nurses all around you, and us at The Thinking Nurse, to help you through it.
30-Second Summary for the busy folks:
- Wrap your mind around the situaish because otherwise you’re blind. This is called having Clinical Grasp.
- You need a background of a knowledge base and an open mind to get this grasp.
- Three ways to get your grip on:
#2) Be present, don’t go on autopilot.
#3) Channel your inner Sherlock Holmes and get answers to every question/confusion you have, especially as things occur.