CLINICAL JUDGEMENT PROCESS/SAFETY

me and my b-domo and the alchemist

assessment

the collection, organization, validation, and documentation of data about a patients health status. includes health history, physical assessment, and a medical chart review. information could be subjective (patient) or objective (nurse) data.

analysis

the synthesis of subjective information to determine the patient problem. can be written in a PES statement. does not count as the medical diagnosis.

PES statement

patient problem related to cause of problem as evidenced by proof of the problem. justifies the intervention you choose to take and improves continuity of care for other members of the team.

planning

composing a plan of care that includes individualized goals/interventions that are planned to achieve the best possible outcome for the patient. involves using SMART goals.

SMART goals

goals that are specific, measurable, achievable, realistic, and timely. can be short term or long term, but should address the patients problem identified during analysis.

implementation

actions should accomplish your goal. use clinical judgement and thinking to create interventions that can affect change and move the patient closer to optimal health.

evaluation

determining if the interventions implemented were successful and impactful. nurse determines if the POC needs to be modified, as patient care requires constant assessment and adjustment to best meet client needs.

delegation

assigning a nursing task or procedure to another person who has the training appropriate for that task or procedure. RNs cannot delegate tasks that would require RN judgement or decision making to a PN or AP.

national patient safety goals

designed to focus on client safety, safe and effective delivery of healthcare, and recommendations to avoid adverse outcomes. involves correctly IDing patients, improved staff communication, using meds safely, using alarms safely, preventing HAIs, reducing the risk of suicide, and preventing adverse events in surgery.

identify clients correctly

use 2 identifiers; ensure meds, procedures, treatment, and care are intended for that specific patient. can be via asking client’s name, DOB, hospital ID #, and phone number when in the pharmacy.

improve staff communication

report critical results (out of range results) promptly. involves documentation of communication and building rapport with the healthcare team. never communicate sensitive information via voicemail.

use meds safely

involves labeling all medications (meds without labels should be discarded, don’t make assumptions on what a medication is), using extreme caution with anticoagulants (monitor patient and inform them of risks, interactions, and possible adverse effects), and medication reconciliation (comparing home meds to newly prescribed meds to identify any possible interactions).

use alarms safely

audible alert devices can warn healthcare workers that a potentially serious event may be occurring, but false alarms can lead to alarm fatigue. this leads to healthcare workers subconsciously tuning out alarms and increases the risk for negative patient outcomes.

prevent HAIs

prevention of nosocomial infections; these infections are associated with high mortality rates, increased stay times, and increased costs of care. hand hygiene is #1 barrier.

reducing suicide risk

clients 12 or older with a primary admitting diagnosis for behavior health must be screened for suicidal ideation. involves round-the-clock surveillance, possibly harmful items being removed from the room, and bedside sitters.

preventing adverse effects in surgery

involves a mandated time out before every surgery to confirm procedure specifics. also involves using two client identifiers to establish clients identity, asking client if they know what procedure is being done and on which side, and marking the surgical site if possible.

standards of compliance

goals that have been routinely adopted by healthcare professionals and are now retired from the national patient safety goals.

near miss

a potential event or circumstance that could have caused harm, but was caught and avoided. still must be reported.

client safety event

an unexpected event or circumstance that was not caught and had the potential to cause harm to the client, but did not.

adverse event

a situation or circumstance that caused unexpected harm to the client.

sentinel event

a critical, unexpected adverse event that caused severe physical or psychological harm to a client, including death, dismemberment, permanent injury, and severe or temporary injury.

RACE

acronym for fire safety involving rescue (assist in removing those in immediate danger), alarm (sounding facilities emergency fire alarm), contain (containing the fire by closing doors and windows), and extinguish (put out fire if it is small)

PASS

acronym for extinguishing fires involving pull (pulling the pin), aim (aim the nose of the extinguisher at the base of the fire), squeeze (squeeze hand around handle to release contents), and sweep (sweep the base of the fire by spraying from side to side).

physical restraints

manually holding or immobilizing the client using physical strength

mechanical restraints

use of materials (straps, fabric, leather) that can be fastened around the wrists or ankles of client. use quick release tie as opposed to knot in case restraint needs to be quickly removed

chemical restraints

administration of meds (benzodiazepines, antipsychotics, and neuro-muscular blocking agents) to reduce client movement and control client behavior

barrier restraint

using barriers to limit movement such as a concave mattress and lapboards attached to chairs. another example is all 4 side rails on a bed being raised (do NOT do this unless you are trying to restrain a patient).

seclusion (the hole)

environmental restraint involving putting the client alone in a securely locked room without their consent (?).

complications from restraints

pressure ulcers, pneumonia, constipation, incontinence, strangulation, lack of circulation, and death.