Clinical Judgment and Critical Thinking in Nursing

Vocabulary flashcards covering key terms from the lecture notes on clinical judgment, critical thinking, and the nursing process.

Clinical Judgment

Observed outcome of critical thinking and decision making about a patient’s needs or health problems that leads to taking or avoiding action, using or modifying standard approaches, or creating new approaches based on the patient’s response.

Clinical Decision Making

Process that separates professional nurses from technicians or assistive personnel; involves carefully examining data, forming inferences, and selecting appropriate interventions based on the patient’s condition.

Critical Thinking

Ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process; essential for nurses to make effective judgments.

Recognize Cues

Identify important data that signal a patient’s health status or problems.

Analyze Cues

Examine cues to interpret meaning, identify patterns, and determine implications.

Prioritize Hypotheses

Rank likely explanations about a patient’s problems to guide investigation and action.

Generate Solutions

Develop potential interventions or actions to address identified problems.

Evaluate Outcomes

Assess the results of interventions to determine if goals were met and adjust the plan as needed.

Reflection

Deliberate examination of the reasoning process to improve future clinical decisions.

Nursing Process

Framework for applying critical thinking in nursing to improve patient care outcomes.

ADPIE

Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation.

Assessment (Nursing Process)

Process of collecting patient information and data to identify problems.

Diagnosis (Nursing)

Identification of patient problems based on analysis of data.

Outcomes Identification

Defining measurable patient outcomes and criteria for success.

Planning

Developing interventions and strategies to achieve identified outcomes.

Implementation

Performing nursing actions and delivering care according to the plan.

Evaluation

Determining patient progress toward outcomes and modifying the care plan as needed.

Focused Assessment

A targeted assessment for a specific problem or change.

Head-to-Toe Assessment

Comprehensive initial assessment covering all body systems.

Present Illness (PQRST)

Details of the current health issue using Provokes, Quality, Radiation, Severity, and Timing.

Biographical Information

Factual demographic data about the patient.

Chief Concern

Primary reason the patient is seeking care.

Past Health History

History of the patient’s previous illnesses and health events.

Family History

Health history of the patient’s relatives.

Psychosocial History

Social, emotional, and environmental factors affecting health.

Spiritual Health

Beliefs and practices that influence health and care decisions.

Review of Systems (ROS)

Systematic questioning to identify symptoms across body systems.

Data Sources

Sources of information: patient, family/caregivers, health care team, medical records, diagnostic tests, handoffs.

Subjective Data

Information the patient reports about experiences, feelings, and perceptions.

Objective Data

Data that are observable or measurable (vital signs, labs, physical findings).

Documentation

Recording information objectively, concisely, and without bias.

Interview Techniques

Methods for obtaining information, including open-ended questions and attention to nonverbal cues.

Open-ended Questions

Questions that encourage detailed, expansive responses.

Nonverbal Cues

Observed behaviors such as demeanor, body language, posture, and environment.

4 Cs of Communication

Courtesy, Comfort, Connection, Confirmation guiding patient interactions.

Interview Phases

Orientation, Working, and Termination phases of an interview.

Orientation Phase

Phase to establish rapport and explain the purpose of the interview.

Working Phase

Phase to ask questions, collect health history, concerns, and context.

Termination Phase

Phase to summarize, confirm understanding, and address questions.

Environment and Judgment

Time pressure, interruptions, and patient load can affect clinical judgment.

Interprofessional Teamwork

Collaboration with care partners and the health care team to improve outcomes.

PGBST Approach

System appraisal framework: Provokes, Quality, Radiation, Severity, Timing.

Competence

Ability to apply the nursing process and perform required skills.

Knowledge Base

Educational background, knowledge, and experience informing practice.

Attitudes

Professional dispositions influencing practice, including confidence, independent thinking, fairness, responsibility, risk-taking, discipline, perseverance, creativity, curiosity, integrity, and humility.