226 quiz 1 - clinical judgement + nursing process

critical thinking

gather + evaluate info (think + stop before making decision)

critical thinking uses

observe, reflect, experience, reason, communicate

situational awareness

(60s assess) be present in moment, look for safety risks (abc, proper IV, etc.)

when to do 60s assess

before shift begins w nurse on (prior) shift, before receiving report

clinical judgement

process all avail. info + decide course of action (sign/symptom + factors, ex. pt on bp meds but BP is 98/68, hold off on giving more)

nursing process

systematic method of using info + clinical judgement to create care plan

nursing process steps

(communicate w other nurses to know what is best for pt) systematic (sequence), dynamic (good overlap of all steps), interpersonal (human beings), outcome orientated, universal

ADPIE - nursing process

assess, diagnose plan, implement, evaluate

comprehensive health assesment

(rare for bedside nurses) complete, head to toe (review of body systems), all history + health problems/patterns

comprehensive assessment used for

dr.'s yearly visit, long term/home care

initial (admission) assessment

after pt admitted (after ER), head to toe for baseline to ID problem (focused within initial)

focused assessment

focus on one specific problem (why they are in hospital), brief assessment (during initial)

quick priority assessment

done by triage nurse, to determine how much of a priority (urgent will be seen ASAP, non urgent wait hrs)

emergency assessment

(via ambulance into ER) for life threatening problem (physiologic/psychologic), ABCs

time lapsed assessment

scheduled to compare current status to baseline (to see any progression), for pt in nursing home/long term (home) care

OLDCART

onset, location, duration, characteristics, aggravating factors, relief (or worsen), treatment

ICE (symptoms)

impact on ADL (daily activity), coping strategy, emotional response

cues

subjective/objective data (ex. pt not responding when on left side)

inferences

judgement made from cue (ex. pt hearing may be impaired on left side)

validating assessment data

keeps data free from error, bias, misinterpretation

how to validate assessment data

ID cues, make inference, validate (both)

clustering data

organize + identify patterns (analyze hypothesis + focus on assessment for more info)

nursing diagnosis (ADPIE)

(clinical judgement) how pt responds to meds (treatment)/diagnosis/hospitilization + any external factors (basis for finding interventions for good outcome)

problem-focused diagnosis

(problem present) clinical judgement of unwanted human response to health condition/life process (in pt, group, family, community) (ex. inadequate nutrition caused by low protein lvl)

risk diagnosis

preventing anything unwanted to occur ((in pt, group, family, community) (ex. central line/urinary cath. can cause infection, "risk for...")

health promotion

no problem/risk, want to better health (ready to enhance health)

nurse diagnosis formulation

(individualized to each pt) problem, etiology (what can be formulated to be the cause, ex. pain from soft tissue swell), evidence (2-3 signs/symptoms to back it up, ex. tender to touch, pain score)

nursing diagnosis - problem

(from data cluster + patterns) pt response to meds, diagnosis, environment

nursing diagnosis - etiology

most likely the cause of pt problem/response (what intervention is based on)

nursing diagnosis

(actual problem, not abt risks) signs/symptoms that helped make clinical judgement (of nursing diagnosis/problem statement)

establishing priorities - maslow's hierarchy

physiologic (priority, air, food water), safety, love + belonging (no isolation/depression), self esteem, self actualization (problem solving, creativity, etc.)

establishing priorities

patient preference (include pt in goal development), anticipate future problems, critical thinking + judgement

writing goals for measuring outcomes

subject, verb, condition (specific), performance criteria (measure what ur looking at), target time

common errors when writing outcomes

express pt as nurse intervention (should always start w pt/family), verbs cannot be observe/measure (pt should be able to verbalize back), more than one pt goal ("and"), being vague

SMART (for goals)

specific, measurable (pain score), attainable (is specific med good for pt), realistic (medically possible), timed (within...)