week 2: seminar - clinical judgement, assessments, and safety

what is the clinical judgment measurement model?

• recognize cues → analyze cues → prioritize hypothesis → generate solutions → take action → evaluate outcomes

what is the nursing process?

• assessment → analysis → planning → implementation → evaluation

assessment

• subjective

• objective data

• i.e. health history

analysis

• data analysis

• identify priority concerns

• problem identification

• what is normal vs abnormal

• unstable vital signs and ABC

planning

• priorities of care

• identifying outcomes (what are we hoping to do?)

• determine interventions

• what am I going to do about this?

implementation

• carry out interventions

  • nurse vs physician initiated?

evaluation

• outcomes met?

• better/no changes/worse?

• reassess vital signs

• able to identify?

Kevin is a 67-year-old male. He visits the nursing station complaining of a cough and “tight feeling in his chest” for the last 2 weeks.

Sort the tasks according to which can be independent vs. require an order:

1. Administer bronchodilator inhaler medications to the patient

2. Reassess vital signs & focused respiratory assessment

3. Reposition the patient

4. Draw bloodwork (CBC)

5. Send the patient for a chest x-ray (CXR)

1. order

2. independent

3. independent

4. order

5. order

Kevin’s bloodwork is normal, and his chest x-ray indicates he is having a flare of his asthma. The physician orders 2 more puffs of the bronchodilator Salbutamol, and 2 puffs of Flovent (a longer-term corticosteroid inhaler). You are ordered to “reassess Kevin in an hour; if he has improved, then he is discharged to go home”.

QUESTION: What/how will you reassess with Kevin?

• vital signs → esp. respiratory

• general survey

• focus assessment

• subjective complaints

What findings would indicate Kevin is improved and ready to go home? What about findings that might show he is getting worse?

• signs of improvement

  • SP02 increases

  • no more tight chest feeling

  • lowered RR

• signs of decompensation (getting worse)

  • further decreased SPO2

  • increased RR

  • posture still in tripod

  • clipped sentences

  • cyanosis or pallord

general survey

what

why

when

how

• a critical observation

• patient safety

  • are there any signs of immediate concern?

• every time we interact with the patient\

• observations

H2T

what

why

when

how

• gain through understanding o our patients current condition

• baseline understanding

  • what do I need to prioritize with my patient

• at start of a shift

  • after major event (i.e. fall, surgery)

• top of head and work your way down using IPPA

  • standardized H2T tool

system/focused assessment

what

why

when

how

• in depth focus on specific system

• to assess/reassess areas of concern

• change in condition, after an intervention

• IPPA

  • advanced or more in depth assessment techniques

if you get an abnormal vital sign what should you do?

• first & foremost how does your patient look/respond?

  • unresponsive/not breathing/severe distress → HELP

• verify & validate → is the number correct?

  • was the technique/equipment used properly?

  • can you repeat it on another limb? manually?

  • what is their baseline normally?

• assess for other clinical manifestations

• report and critically think about the cause

• document honestly

common errors

1. wrong patient errors

2. wrong dose errors

3. wrong medication errors

4. wrong time errors/missed dose

5. failure to follow checks/verification

6. documentation errors

7. procedural errors

8. safety events (non-medical)

9. academic/professional integrity

wrong patient errors

• medication given to wrong patient (multiple incidents, including full morning meds, furosemide, hydromorphone, etc.)

• almost gave insulin pen/patch/meds to the wrong patient (caught on final check) → near miss

• wrong IV fluid hung for pediatric patient

wrong dose orders

• Overdose (e.g., 4x HM dose, double lasix miscalculation, wrong titration dose, wrong ciprofloxacin/cefotaxime/vancomycin/indapamide/K citrate/Keppra preparations).

• Underdose (e.g., gave half of ampicillin, pulled half tramadol dose, wrong tacrolimus dose, metoprolol not split correctly).

wrong medication errors

• Gave Resource instead of Nova Renal.

• Confused nicotine patch with nitro patch.

• Prepared wrong RL solution (contained KCl).

• Pulled levothyroxine without order

wrong time errors/missed doses

• Medications given very late or very early (e.g., 1400 meds at 0800, dalteparin at wrong times, insulin at wrong meals, B12 not split, multiple insulin doses missed, Tylenol and PRNs late).

• Forgot to give scheduled medications (e.g., metformin, gliclazide, gabapentin, vancomycin, thiamine, misty spray, Septra)

failure to follow checks/verification

• Missed second nurse check for high-alert meds (insulin, hydromorphone, opioids).

• Failed to complete 3rd check for furosemide, hydromorphone, and potassium chloride.

• Did not double-check IV fluid compatibility.

• Signed MAR inaccurately or not at all. •Gave meds without CEF present when required.

documentation errors

• Failed to sign MAR (or signed late/incorrectly).

• Failed to record insulin doses, PRNs, or discontinued meds properly.

• Confusion with MAR transcription/handwritten notes

procedural errors

• Near misses with IV pushes (wrong rate, wrong route, missed compatibility).

• Did not follow NG tube skill competency but gave meds anyway.

• Incorrect pill splitting/crushing.

• Did not label or prepare tube feed meds correctly.

• Missed accuchecks before insulin.

safety events (non-medication)

• Needlestick injuries (heparin, dalteparin, IV start).

• Postpartum fall due to residual epidural effects.

• Omitted patient care task (brief change).

academic/professional integrity

• AI used in prep guides despite being told not to (x2).

• Shared prep guides with partner despite instruction not to (x2).

• pitting edema

• cyanosis

• clubbing

• tripod position

• jaundice

• pallor

• jugular vein distension