Critical Thinking and Clinical Judgment in Nursing

This set of vocabulary flashcards covers the essential definitions, models, and processes of critical thinking, clinical judgment, and the five steps of the nursing process (ADPIE) as outlined in the lecture notes.

Clinical decision-making skills

The skills that separate professional nurses from technical and ancillary staff, requiring them to seek knowledge, act quickly, and make sound clinical decisions.

Clinical Judgment

Defined by Kataoka-Yahiro and Saylor ($1994$) as the outcome of critical thinking that is relevant to nursing problems in a variety of settings.

Knowledge Base

A component of the critical thinking model that includes basic and nursing science, nursing and health care theory, and patient data.

Experience

A component of critical thinking competence derived from personal experience, clinical practice, and skill competence.

Environment

Contextual factors affecting critical thinking including time pressure, setting, task complexity, and interruptions.

Critical Thinking Attitudes

A set of dispositions including confidence, thinking independently, fairness, responsibility and accountability, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility, and self-awareness.

Nursing Process

A decision-making model consisting of five steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation ($ADPIE$).

Reflection / Reflective journaling

A tool used to clarify concepts by thinking back or recalling situations.

Concept mapping

A visual representation of client problems and interventions that illustrates an interrelationship and provides a holistic perspective of health care needs.

Subjective data

Information consisting of the client’s perceived needs, health problems, and responses to problems.

Objective data

Observable and measurable data obtained through physical examination and diagnostic tests.

$$PQRST$$

A mnemonic used during the present illness portion of the nursing health history to assess symptoms.

Medical diagnosis

The identification of a disease condition based on specific evaluation of signs and symptoms.

Nursing diagnosis

A clinical judgment about the client in response to an actual or potential health problem.

Collaborative problem

An actual or potential complication that nurses monitor to detect a change in client status.

$$NANDA$$

North American Nursing Diagnosis Association, founded in $1982$ to standardize nursing diagnostic terminology.

Actual (Problem Focused) Nursing Diagnosis

Describes undesirable human response to existing problems or concerns of a patient.

Risk Nursing Diagnosis

Describes human responses to health conditions or life processes that may develop.

Health Promotion Nursing Diagnosis

Identifies the desire or motivation to improve health status through patient education or other interventions.

Related Factors ($r/t$)

The component of a nursing diagnosis that identifies the cause or contributing factors of a patient's response.

Maslow’s Hierarchy of Needs

A framework used in the planning phase to establish priorities, ranging from physiological needs to self-actualization.

Expected Outcomes ($NOC$)

Nursing Outcomes Classification consisting of goals that are Specific, Measurable, Attainable, Realistic, and Timed ($SMART$).

Nurse-initiated (Independent) Interventions

Actions that a nurse initiates without a physician's order, such as patient education or symptom relief.

Physician-initiated (Dependent) Interventions

Actions that require an order from a physician or another health care provider.

Collaborative (Interdependent) Interventions

Interventions that require the combined knowledge, skill, and expertise of multiple health care professionals.

$$NIC$$

Nursing Interventions Classification; standardized nursing interventions using a common language.

Standing orders

Pre-printed documents containing orders for the conduct of routine therapies, monitoring guidelines, or diagnostic procedures for specific patients with identified clinical problems.

Evaluation

An ongoing process used to determine if outcomes were met and if nursing interventions were successful.