Nursing 250: Exam 2, Clinical Judgment ad Prioritizing Care

1. Noticing
2. Interpreting
3. Responding
4. Reflecting

What are the four steps of the Clinical Judgement Process?

Nursing Process

The _____________ ____________ is key to helping nurses make clinical judgements that are appropriate for clients

Assessment- assess the objective and subjective data that pertains to the client

What is the FIRST step of the nursing process for RN... describe it?

Analysis- determine the client problems

What is the SECOND step of the nursing process.for RN.. describe it?

Planning- create a plan to address client problems

What is the THIRD step of the nursing process for RN... describe it?

Implementation- take action to provide care as outlined in planning

What is the FOURTH step of the nursing process for RN... describe it?

Evaluation- evaluate the effectiveness of the interventions provided and document the client's response

What is the FIFTH step of the nursing process for RN ... describe it?

Data Collection- collect subjective and objective data about the client and report changes to the RN

What is the first step of the nursing process for a Licensed Practical Nurse (LPN)... describe it?

Planning- create a plan to address client problems under supervision and guidance of the RN

What is the SECOND step of the nursing process for a Licensed Practical Nurse (LPN)... describe it?

Implementation- collaborate with the RN to take action as outlined in planning

What is the THIRD step of the nursing process for a Licensed Practical Nurse (LPN)... describe it?

Evaluation- evaluate the effectiveness of the interventions provided, within the LPN scope of practice, and under the supervision of the RN

What is the FOURTH step of the nursing process for a Licensed Practical Nurse (LPN)... describe it?

assess, diagnosis, planning, implementation, evaluation

What are the Nursing Care Plan steps?

Critical Thinking

the skill of learning to analyze and interpret data to solve a problem to achieve a desired outcome
- includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity

Clinical Reasoning

mental process used when analyzing the elements of a clinical situation and using analysis to make a decision
- requires the nurse to assess and comply data, select and discard various pieces of information based on relevance, and make decisions regarding client care based on nursing knowledge
-cannot be delegated

Clinical Judgment

is the visible or observed outcome of critical thinking and decision making that considers nursing knowledge, client situation, and prioritization of client problems and concerns, while utilizing evidence based practice
-cannot be delegated

Evidence Based Practice

nursing care provided that is supported by sound scientific rationale

priority Setting

is an essential skill for all nurses, as the nurse's ability to intervene on the highest risk problems first can decrease avoidable client outcomes

- defined as the delivery of nursing care based on the importance of client needs

- involved the organization of client care whereby the most critical intervention or action is completed first

Maslow's Hierarchy of Needs

(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization


1) Illustrated as a pyramid with fivelevels ranging from basic needs atthe base of the pyramid,psychological needs in the middleof the pyramid, and self-fulfillmentat the peak of the pyramid.2) Physiological needs must typicallybe met before individuals attempt tofulfill higher levels in the pyramid.3) Individuals may move back andforth through the levels at differenttimes in their life.

A - airway
B - breathing
C - circulation
D - disability
E - exposure

What is the A.B.C.D.E. method that can be used in establishing priorities for an individual or group of clients and is appropriate in any clinical crisis stand for?

Critical- emergent, life-threatening situation

What does the "C" in the C.U.R.E of Hierarchy mean?

Urgent- situations in which the client could suffer harm of discomfort if there is a delay in addressing the clients needs

What does the "U" in the C.U.R.E of Hierarchy mean?

Routine- routine tasks associated with client care

What does the "R" in the C.U.R.E of Hierarchy mean?

Extras- tasks that are not essential to client care but promote comfort

What does the "E" in the C.U.R.E of Hierarchy mean?

Triage

assigns priority to what is being ranked based upon a quick initial, focuses assessment followed by the assignment of an acuity level indicative of the amount of time a client can safely wait for screening and treatment

Prioritization

involves ranking potential nursing actions in order of importance

5-level triage system

designates level 1 as the most urgent category with clients experiencing a life-threatening illness and level 5 as the least urgent category with clients being stable and suffering from nonemergency ailments

Emergency Severity Index (ESI) and the Canadian Triage Acuity Scale (CTAS)

The most common 5-level triage system used in the United States is the ___________ _____________ ____________ and the ___________ ________ ___________ ________ which categories clients into those who need to be seen emergently versus urgently.

Resource Allocation

is the process of assigning a portion or amount of service

Priority Setting

involves the allocation of resources, as users must decide how resources will be distributed in caring for their clients