Clinical Judgement and Nursing Process

Vocabulary flashcards based on lecture notes about clinical judgement and the nursing process.

Clinical Judgement

A systematic decision-making approach nurses use to organize and provide patient care.

Nursing Process

Foundational to what nurses do; includes steps like recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes.

Assessment (Clinical Judgement)

Involves recognizing signs and symptoms and distinguishing between normal and abnormal findings.

Analysis (Clinical Judgement)

Involves identifying the history of and connections between pathophysiology and client presentation.

Implementation (Clinical Judgement)

Identifying and performing appropriate clinical actions, considering whether potential actions are indicated, nonessential, or contraindicated.

Planning (Clinical Judgement)

Developing possible care options that align with client needs, including things to address and things to avoid.

Evaluation (Clinical Judgement)

Evaluating outcomes and determining the effectiveness of actions by assessing findings that indicate improvement or worsening of a condition.

Nursing Process (ADPIE/ADOPIE)

A universal approach to evidence-based care, including Assessment, Diagnosis (Nursing), (Outcomes Identification)*, Planning, Implementation, and Evaluation.

Concept Map

A non-linear, visual tool used to represent the relationships between different ideas and concepts.

Nursing Diagnoses

The second step of the nursing process where the nurse utilizes clinical judgement to analyze cues collected during the assessment phase to determine the highest priority needs.

Problem-Focused Diagnosis

An actual problem; a 3-part statement following the PES format (problem, etiology, signs and symptoms).

Risk Diagnosis

A potential problem; a 2-part statement including a diagnostic label and related to statement.

Health Promotion Diagnosis

Generally written in 1- to 2-parts when a patient demonstrates enhanced wellness and well-being.

Goals (in Planning Care)

General statements describing a desired change for the patient.

Outcomes (in Planning Care)

Measurable changes needed to reach a goal; should be SMART (Specific, Measurable, Achievable, Relevant, Time-bound).

Nurse-Initiated Interventions

Interventions the nurse can independently perform without an order.

Healthcare-Provider-Initiated Interventions

Interventions requiring an order from physician or other healthcare provider.

Collaborative Interventions

Interventions carried out in collaboration with other healthcare team members.

Implementation (in Nursing)

The step that begins once the plan of care is developed, including ALL therapeutic actions (interventions).

Evaluation (in Nursing)

Determines if the plan of care has been met and if identified health alterations have been resolved.

Revising the Plan of Care

Modifying the plan when outcomes/goals are not reached.

Assessment

Recognizing signs and symptoms in a client scenario.

Analysis

Distinguishing the most important information in a client scenario.

Etiology

Related to statement in the nursing diagnosis

Defining Characteristics

Signs and symptoms.

SMART Goals

Specific, Measurable, Achievable, Relevant, Time-bound

Direct Care

Interventions performed through interaction with the patient.

Indirect Care

Interventions performed away from the patient but on behalf of the patient.

Evidence Based Care

Nursing care that is supported by research.

Nursing Diagnosis

Clinical judgement about individual, family or community responses to actual and potential health problems

Prioritizing Client Needs

Considering likelihood, risk, etc.

Potential Action

Can be indicated, nonessential, or contraindicated

Nursing interventions

Actions such as Request an order, administer a treatment or medication, perform (skill), document, and/or communicate

Nursing Diagnosis Handbook

Resource tool to aid in planning care

Cue Recognition

Important information in a client scenario

Data Comparison

Compare data from initial assessment to the expected outcome(s) recorded

Impaired Gas Exchange

Problem-Focused Diagnosis Example

Social Isolation

Problem-Focused Diagnosis Example

Imbalanced Nutrition

Problem-Focused Diagnosis Example

Impaired Mobility

Problem-Focused Diagnosis Example

Risk for Falls

Risk for Diagnoses Example

Risk for Impaired Skin Integrity

Risk for Diagnoses Example

Risk for Infection

Risk for Diagnoses Example

Readiness for enhanced coping

Health Promotion Diagnoses Example

Readiness for enhanced self- care

Health Promotion Diagnoses Example

E-coli bacteremia

Etiology of acute pain

Hematuria

Blood in urine from infection

Subjective Data

Patient verbal description of health problems

Objective Data

Observations or measurements of a patient's health status

RR

Respiratory Rate

HR

Heart Rate

BP

Blood Pressure