module 5 & 6: chapters 15, 16, 17

clinical judgement

nursing decisions, conclusions about needs or problems, impacted by the experience and knowledge

reflection

purposefully reviewing situations to discover purpose or meaning, improves ability to problem solve

critical thinking

the ability to think in a systemic and logical manner

in depth about critical thinking

essential in nursing process

involves knowing as much as possible

need to sort information, recognize cues, makes decisions

leads to safe, efficient, skilled care

improves patient outcomes

continuous process

improving critical thinking

reflective journaling

discussing with peers

concept mapping

care plans

care plans

lineal concept map (useful!)

provides structure and helps nurses future

in depth about clinical judgement

pattern recognition

context is important

required for nurses to make decisions

uses knowledge, experience, and critical thinking

influenced more by experience and knowledge than objective data

nursing process (clinical judgement model)

assess

diagnose

plan

implement

evaluate

clinical judgement measurement model

basis for next generation nclex

unfolding case format

the next steps for you

start with nursing process and nursing diagnoses

next generation nclex (NGN)

partial credit

upfolding case study questions

clinical judgement model

recognize cues

analyze cues

prioritize hypothesis

generate solutions

take action

evaluate outcomes

recognize cues (clinical judgement model)

identify relevant data and important information from different sources

analyze cues (clinical judgement model)

organize and link the recognized cues to the patient’s clinical presentation

sort into “like” categories

prioritize hypothesis (clinical judgement model)

evaluate and ran hypotheses according to urgency

generate solutions (clinical judgement model)

using hypotheses identify expected outcomes and define interventions

take action (clinical judgement model)

implement the solutions that address the highest priorities

evaluate outcomes (clinical judgement model)

compare observed outcomes against expected outcomes

assessment (most important)

method of collection

data validation and interpretation

person-centered

ongoing

recognizing cues

focus- avoid task oreintation

patter or trends- sort and document data

compare- baseline or standard data

relevance- what is relevant? Important? urgent?

analyze cues

1) interpret assessment data

2) cluster data

3) develop hypotheses (nursing diagnoses)

a patient is admitted to the hopsital with shortness of breath. as the nurse assess this patient, the nurse is using the process of

data collection

diagnosis

analysis and interpretation of data

identification of client needs

technical definition of nursing diagnosis

clinical judgement about individual, family, or community responses to actual or potential health problems/life processes

they provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

nursing diagnosis (from the scope of the nurse)

focus (area of attention)

judgement (clinical opinion)

client (whom diagnosis refers)

action (process applied/performed by client)

means (method of accomplishing intervention)

location (orientation of diagnosis or intervention)

time (duration/instance of an occurrence)

types of diagnoses

current/problem focused (tertiary)

risk (secondary)

health promotion (primary)

when an error is likely to happen

data collection

clustering

analysis and interpretation of data diagnostic statement

MET/rapid response

patient may code blue

code blue

heart stops, breathing stops

MEWS score

score for vitals (normal=0) (outsite=1…etc)

smart outcomes

S pecific

M easurable

A chievable

R ealistic

T imely

goals

broad guidelines

short and long term

evidence base practice guides nurses’ clinical judgements in…

making effective, timely, and appropriate clinical decisions

what might you achieve when you become more adept at gathering patient-centered data, identifying patient problems, and planning appropriate nursing interventions

competence

risk taking can sometimes have

positive outcomes

what might you do to evaluate whether clinical judgements were accurate and whether correct decisions were made

participate in a self-evaluation, reflection, and reflective journaling

what is the goal in patient assessment

gather all necessary information

what should the nurse prioritize to create a good patient-centered relationship

effective communication

which phase of the patient interview is when the nurse is gathering accurate, relevant, and complete information about a patient condition

working

it is okay to use ___ when trying to seek information about a problem

close ended questions

a registered nurse is not allowed to

made a medical diagnosis

what separates professional nurses from assistive personnel

clinical decision making

why should a nurse cluster data during an assessment

to combine related factors and identify patterms

a patient is admitted to the hospital with shortness of breath, as the nurse assessing this patient, the nurse is using the process of

data collection

what should be included in a nursing diagnosis

the diagnosis

related factors

assessment findings

how should outcomes be regarding a nursing diagnosis

specific

measurable

realistic

what type of intervention would be classified as dependent

prescription for oxygen administration

the nursing diagnosis: readiness for enhanced communication is an example of what?

wellness nursing diagnosis

what nursing intervention is written correctly

elevate head of bed 30 degrees before meals

(has to be SPECIFIC)

six components of critical thinking

critical thinking competence

knowledge

experience

environment

attitudes

standards

outcomes

follow the SMART guideline

example of goals and outcomes with pain

goal- decreased pain

outcome- patient will be below 5 on pain scale before discharge

independent actions

nurse initiated and carried out individually (patient compliancy)

dependent action

prescribed by provider (meds, diet order)

collaborative action

cooperation and input of all members

once you’re done with the action

reassess the patient

review and revisit the existing care plan

steps for evaluation

1) criteria (outcomes tell you what should happen)

2) collection (gather data)

3) determine if standards were met

4) document

5) next steps

The nurse is assessing the urinary history of a middle-aged married woman. The nurse asks her if she gets up at night. She replies, "Yes." What other question should the nurse ask?

how many times do you get up at night

A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of:

assessment

the purpose of an assessment is to

establish a database concerning the client

During data clustering, a nurse:

Organizes cues into patterns that lead to identification of nursing diagnosis

The nurse gathered the following assessment data. Which of these cues form a pattern?

Client is restless.

Respirations are 24/min and irregular.

Client states feeling short of breath.

The nursing diagnosis: readiness for enhanced communication is an example of which of the following?

health promotion nursing diagnosis

what nursing intervention is written correctly

Elevate head of bed 30 degrees before meals.

Which of the following are defining characteristics for the nursing diagnosis of Impaired urinary elimination?

Nocturia

Frequency

Urinary retention

Sensation of bladder fullness

Crystal starts the data collection. What would she want to accomplish during the interview?

Establish a caring, therapeutic relationship with Chuck and his wife.

Determine what Chuck’s goals and expectations are regarding hospitalization.

Gain insight about Chuck’s concerns and worries.

Obtain cues about which parts of the interview may require further investigation.

During the initial interview, Crystal notices that Chuck is grimacing and will not make eye contact with her. She wants to get more information. Which question is most appropriate to help Crystal in her assessment?

how are you feeling now

Which of the following statements are true about nursing diagnosis?

Nursing diagnoses have two parts, which include the diagnostic label and the related factor.

Errors in nursing diagnosing can occur from inadequate assessment.

Nursing diagnoses are focused on the scope of nursing practice.

Crystal establishes the following nursing diagnoses for Mr. Rhodes. Which one of these nursing diagnoses is best reflective of her assessments?

Imbalanced nutrition: less than body requirements related to decreased ability to ingest food as a result of vomiting

Crystal now has established a nursing diagnosis. This is an example of which of the following types of nursing diagnoses?

Actual nursing diagnosis