Chapter 1: Clinical Judgement

ADPIE

Assessment, diagnosis, planning, implementation, and evaluation: nursing process

Clinical Judgement Model

Recognize cues, analyze cues, prioritze hypotheses, generate solutions, take action, and evaluate

Culture of Safety

Workplace environment where safety practices are prioritized and supported

Registered Nurse

Cannot diagnose

Licensed Practical Nurse

Cannot do IV push, do first/advanced assessment, or educate patient

Unlicensed Assistant Personal

Can do basic care (vitals, ambulation, blood glucose)

Charge RN

Controls assignments and patient movement on floor

Primary Prevention

Reduce incidence of disease/injury before it occurs

Secondary Prevention

Screen, identify, and treat early to limit progression

Tertiary Prevention

Reduce complications and support function after disease/disability occurs

Nurse Practice Acts

Rules that regulate nursing within each state/territory, defines scope, title, licensure conditions and standards, sets legal boundaries

Board of Nursing

Group that enforces state rules/regulations, approves nursing education requirements, and protects public through licensure oversight

Delegation

Tasks can be delegated but clinical reasoning and judgement cannot, when you delegate make sure to clarify scope, policy, client stability, and supervision needs

Clinical Reasoning

Mental process used to analyze a clinical situation and decide what to do

Clinical Judgement

Observable outcome of reasoning over time, shaped by knowledge, experience, evidence, and priorites

Five Rights of Delegation

Right task, right circumstance, right person, right direction/communication, right supervision/evaluation,

U-EAT

If a patient is unstable, evaluate, assess, and teach

Primary Data

Patient interview

Secondary Data

Info from anything other than the patient

Quality Improvement

Moving from problem to measurable change, involves model for improvement, PDSA, lean, and six sigma

Model for Improvement

Clarify aim, measurement, and charges worth testing for QI

PDSA

Plan, do, study, and act in small cycles for QI

Lean

Remove steps that do not add value for QI

Six Sigma

Reduce variation and prevent errors in QI

Nursing Informatics

Integration of nursing science, information science, and computer science

Documentation

Legal record of assessment, interventions, and patient responses, should be factual, accurate, organized, complete, current, and professional

SMART Outcomes

Outcomes should be specific, measurable, attainable, relevant, and timed

Independent Interventions

Nurse-initiated actions within nursing scope (repositioning, education, safety/comfort measures)

Dependent Interventions

Provider prescribed actions carried out by the nurse (medication administration and treatments)

Interprofessional Interventions

Actions requiring collaboration with other disciplines (consults, referrals, discharge, nutrition therapy, and case management)

Maslow’s Hierarchy of Needs

Physiological needs → safety and security → love and belonging → self-esteem → self actualization

Research

Systematic inquiry that makes new knowledge

PICOT

Patient, intervention, comparison, outcome, time

Spirit of Inquiry

Ask PICOT, search, appraise, integrate, and evaluate

SOAP

Method for documentation: subjective, objective, assessment, pain

Charting by Exception

Only writing detailed notes on deviations when baseline is already charted