Management of Care: Nursing Process and Clinical Judgment

Vocabulary flashcards covering core concepts of the nursing process, clinical judgment model, domain levels, nursing interventions, delegation rules, and clinical priorities from the lecture.

Critical Thinking

A thought process using reflection, inquiry, and exploration to review information.

Clinical Reasoning

Interpreting relevant data to determine how it applies in clinical practice.

Clinical Judgment

Complex decision making using knowledge, experience, intuition, and critical thinking to identify priorities, delegation, legal consequences, and next steps.

Nursing Process (Next Gen 2023)

A 5-step scientific, clinical reasoning approach to client care consisting of Assessment, Analysis, Planning, Implementation, and Evaluation.

NCSBN Clinical Judgment Measurement Model (NCJMM)

A framework developed by the NCSBN focused on clinical judgment, featuring six cognitive skills: Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take Action, and Evaluate Outcomes.

Recognize Cues

The NCJMM cognitive skill of identifying relevant versus non-relevant subjective and objective data to decide if patient findings are expected, unusual, or abnormal.

Analyze Cues

The NCJMM cognitive skill of examining relevant data, linking it to the client's clinical situation, comparing it to standards, and determining its meaning.

Prioritize Hypotheses

Organizing and prioritizing client problems or data according to changes, patterns, and trends using standards such as ABCDE, acute vs. chronic, stable vs. unstable, urgent vs. nonurgent, and Maslow's hierarchy.

Collaborative Problems

Potential complications related to a medical diagnosis, treatment, or diagnostic study that nurses monitor and manage using both provider-prescribed and nursing-prescribed interventions.

SMART Goals

Criteria for client outcomes specifying that goals must be Specific, Measurable, Attainable, Relevant, and Time-Based.

Affective Domain

The learning domain that involves attitudes, values, and feelings, which is considered the most difficult to change.

Cognitive Domain

The domain of learning focused on knowledge acquisition and intellectual processing.

Psychomotor Domain

The domain of learning involving physical or motor skills, such as demonstrating the proper use of a call bell.

Physiologic Domain

The outcome domain relating to measurable bodily or physiological functions, such as changes in vital signs.

Independent Nursing Actions

Interventions that a nurse is licensed to initiate autonomously without requiring a provider's order, such as obtaining daily weights.

Dependent Nursing Actions

Nursing interventions carried out based directly on a healthcare provider's explicit orders.

Interdependent Nursing Actions

Nursing actions carried out in collaboration with other members of the multidisciplinary healthcare team.

CWPAT Mnemonic

A guide for steps to complete before performing interventions: Check orders/equipment, Wash hands, Patient identification, Privacy and safety, Assess problem, Tell what you are going to do.

Delegation

Transferring to a competent individual the authority to perform a selected task in a selected situation while retaining accountability for the results.

5 Rights of Delegation

The essential parameters for delegating care safely: Right Task, Right Circumstance, Right Person, Right Communication, and Right Supervision/Evaluation.

Quality Improvement

An internally driven leadership process aimed at continuously improving care quality, patient well-being, and satisfaction.

Graphic Record

The specific documentation sheet best suited for identifying patterns or trends in a post-operative patient's vital signs.

Stage II Pressure Injury

A painful, partial-thickness skin loss condition caused by intense pressure that requires early intervention to prevent worsening.