Critical Thinking and Clinical Judgment in Nursing (1-30)

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

Critical Thinking

The disciplined, systematic, logical process of questioning and reflecting to reach sound clinical decisions.

Clinical Judgment

The conclusion about a patient’s needs or health problems from critical thinking that guides actions.

Nursing Process

A six-step framework used to apply critical thinking in practice: Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation.

Assessment

Collection and analysis of patient data to determine health status.

Diagnosis (Nursing Dx)

Clinical judgment about a patient’s responses to health issues; used to plan care.

Outcome Identification

Determining measurable goals for patient outcomes.

Planning

Developing strategies and interventions to meet outcomes; can be independent, dependent, or interdependent.

Implementation

Carrying out planned interventions and actions.

Evaluation

Comparing actual outcomes with expected outcomes and revising care as needed.

Recognize Cues

Filtering information from signs, symptoms, and history to identify relevant data.

Analyze Cues

Linking cues to clinical presentation to define probable needs or problems.

Prioritize Hypotheses

Ranking potential explanations by urgency, risk, and impact.

Generate Solutions

Identifying outcomes and nursing actions; collaborating to plan care.

Take Actions

Implementing prioritized interventions; monitoring, documenting, and educating.

Maslow's Hierarchy of Needs

A framework ordering needs from physiological to self-actualization to guide prioritization.

Intellectual Standards

Criteria for thinking (clear, precise, accurate, relevant, logical, deep, broad, complete, etc.).

Critical Thinking Attitudes

Qualities like confidence, fairness, independence, responsibility, risk-taking, discipline, perseverance, creativity, curiosity, integrity, and humility.

Competence

Combination of knowledge, experience, and ability to perform nursing duties.

Knowledge Base

The information and understanding that support thinking and practice.

Experience

Practical involvement that informs judgment, including intuition.

Environment

Situational factors affecting thinking (time pressure, task complexity, interruptions).

Standards

Professional and intellectual guidelines and rules used to judge thinking.

SBAR

Situation-Background-Assessment-Recommendation, a communication framework for handoffs.

Handoff

Transfer of essential information between caregivers to ensure continuity of care.

Independent Interventions

Nurse-initiated actions that do not require an order.

Dependent Interventions

Actions requiring an order from a physician or authority.

Interdependent Interventions

Actions requiring collaboration among multiple health professionals.

Concept Mapping

A visual diagram that shows relationships among cues, data, and plans.

Data Clustering

Grouping collected data into patterns or trends.

Defining Characteristics

Attributes that identify a problem or syndrome within data patterns.

Diagnostic Reasoning

Using cues and knowledge to understand clinical problems and decide on care.

Subjective vs Objective Data

Subjective: patient-reported data; Objective: observable or measurable data.

Data Sources

Where data come from (family, healthcare team, medical records, diagnostic data).

NCSBN Clinical Judgment Model

Model outlining recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes.

Problem Statements (PES)

P = Problem, E = Etiology, S = Symptoms/defining characteristics.

Types of Assessments

Patient-centered interview, Comprehensive, Periodic, and Problem-focused assessments.

Patient-Centered Interview

Interview phases: Orientation, Preparing, Working, Termination; emphasis on rapport and communication.

Open-ended Questions

Questions that invite detailed, expansive responses (e.g., What health concerns do you have?).

Direct/Closed-ended Questions

Questions with yes/no or specific brief answers (e.g., Are you allergic to penicillin?).

Back Channeling

Verbal cues like 'I understand. Go on' to encourage the patient to continue.

Probing

Asking for more details to clarify or expand on a response.

Documentation

Clear, concise, organized, thorough, and accurate recording of data and actions.

Basic Critical Thinking

task oriented, concrete thinkers who apply straightforward logic to address specific issues.

Complex Critical Thinking

Start to trust decisions based on deeper analysis and reasoning.

Commitment Critical Thinking

Accountability for decisions made.