Concepts Clinical Judgment Terminology

analysis

the analysis of assessment data to identify health problems/ risks and a client’s needs for health intervention. The nurse identifies patterns or trends, compares the data with expected standards or reference ranges and draws conclusions to direct nursing care.

assessment

the application of nursing knowledge to the collection, organization, validation, and documentation of data about a client’s health status. The nurse thinks critically to perform a comprehensive assessment of subjective and objective information

critical thinking

thought process that is systematic and logical in reviewing information and data, that is open to reflection, inquiry, and exploration in order to make informed decisions

delegation

assigning a nursing task or procedure to another person who has the training appropriate for that task or procedure

evaluation

the evaluation of a client’s response to nursing interventions and to reach a nrusing judgment regarding the extent to which the client has met the goals and outcomes. During this step the nurse will also assess client/staff understanding of instruction, the effectiveness of interventions, and identify the need for further intervention or the need to alter the plan

implementation

the application of nursing knowledge to implement interventions to assist a client to promote, maintain, or restore their health. The nurse uses problem-solving skills, clinical judgment, and critical thinking when using interpersonal and technical skills to provide client care. During this step the nurse will also delegate and supervise care and document the care and the client’s response

interprofessional health care team

a group including members from different disciplines who work collaboratively with the client to make decisions and set goals

nursing process

a framework that guides nurses in delivering client-focused care that takes the entire person into consideration. A five step sequential process that guides nurses in assessing and prioritizing care for clients. The five steps are assessment, analysis, planning, implementation, and evaluation

objective data

data that can be observed by the nurse through the senses

plan of care

a plan including the client problem (analysis), plans and goals, implementation, and responses; it is used by the interprofessional health care team

planning

the planning step of the nursing process involves the nurse’s ability to make decisions and problem solve. the nurse uses a client’s assessment data to develop measurable client goals/outcomes and identify nursing interventions. the nurse uses evidence based practice to set client goals, establish priorities of care, and identify nursing interventions to assist the client achieve their goals

subjective data

data that is based upon the client’s feelings, perception, and assumptions