Lesson 1 The Nursing Process and Clinical Judgment

Clinical Judgment Concepts

Critical thinking, clinical reasoning, clinical judgment, situational awareness

Tanner's Model - Noticing

Initial grasp and perceptions of situation; impacted by context, nurse's practical experience, knowledge of expected vs unexpected data, ethical perspectives, nurse-patient relationship

Tanner's Model - Interpreting

Attributing meaning to data through multiple reasoning patterns

Tanner's Model - Responding

Deciding on action (or inaction) and monitoring outcomes

Tanner's Model - Reflecting

In-action and on-action reflection

Six Clinical Judgment Functions

Recognize cues (What matters most?), Analyze cues (What does it mean?), Prioritize hypotheses (Where do I start?), Generate solutions (What can I do?), Take action (What will I do?), Evaluate outcomes (Did it help?)

Nursing Process Steps

Assessment, Diagnosing/Identifying actual or potential problems, Planning (identifying interventions with rationales), Evaluation

Assessment Components

Gather all information, identify cues and make inferences, validate data, cluster related data, identify patterns, report/record data

Clinical Reasoning Definition

Analysis, synthesize, reflect, draw conclusions

Steps of Data Interpretation

Recognize significant data, compare data to standards, recognize patterns/clusters, identify strengths and problems, identify potential complications, reach conclusions, partner with patient and family

Recognizing Significant Data

Compare data to standards; recognize patterns or clusters; identify strengths and current or potential problems; identify potential complications

Assessment Conclusion - No Problem

No RN response needed; reinforce patient's health habits and patterns; initiate health promotion activities to prevent disease; wellness diagnosis

Assessment Conclusion - Possible Problem

Collect more data to confirm or disprove suspected problem

Assessment Conclusion - Actual/Potential Problem

Document; begin planning, implementing and evaluating care; consult with healthcare professionals; educate patient if they deny issue

Diagnosing/Analyzing Health Problem

Identify how pts responds to actual or potential health and life processes; identify contributing factors/etiologies; identify resources/strengths

Health Problem Definition

Condition that needs intervention to prevent/resolve illness or to promote coping and wellness

Nursing Diagnosis Definition

Clinical judgment about individual, family or community responses to actual or potential health problems or life processes; provides basis for nursing interventions

Problem-Focused Nursing Diagnosis

Clinical judgment concerning undesirable human response to health condition for individual, family or group

Risk Nursing Diagnosis

Clinical judgment concerning vulnerability of pt for developing undesirable human response to health condition

Health Promotion Nursing Diagnosis

Clinical judgment concerning motivation and desire to increase well-being and actualize human health potential

Problem Statement vs Medical Diagnosis

Problem statement focuses on unhealthy responses to health/illness, may change day to day; medical diagnosis identifies disease, remains same while disease present

Nursing Diagnosis Components

Problem (identifies what is unhealthy), Etiology (factors maintaining unhealthy state), Signs and symptoms (subjective and objective data)

Etiology Factors

Physiologic, psychological, sociologic, spiritual and environmental factors related to problem

Diagnostic Statement Guidelines

State as actual or potential problem; patient problem precedes etiology; identify at-risk populations or associated conditions; include signs/symptoms; write legally advisable terms; nonjudgmental language; state what is unhealthy or what patient wants to change; avoid medical diagnosis

Validating Nursing Diagnoses Questions

Is database sufficient/accurate/supported by research? Does synthesis demonstrate pattern? Are data characteristic of health problem? Is statement based on scientific knowledge? Is confidence >50% other practitioners would formulate same statement?

Common Diagnosis Errors

Premature diagnoses (incomplete database), erroneous diagnoses (inaccurate database/faulty analysis), routine diagnoses (failure to tailor to unique needs), errors of omission

Clinical Judgment Development Tips

Be familiar with health problems, read professional literature, use reference guides; trust clinical experience but ask for help; respect intuition but use repeated observation; recognize personal bias and keep open mind

Nursing Diagnosis Example

56-year-old mother of 7, 5'4", 167 lbs, "whenever I sneeze, I dribble urine" = stress incontinence of urine due to decreased muscle tone related to advanced age, obesity and gravid uterus