Studied by 26 people
Clinical judgement
An interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response.
Clinical decision-making model
The nursing process: Assessment, Diagnosis, Planning, Interventions, Evaluation
Assessment, diagnosis, planning, interventions, evaluation
The nursing process (ADPIE)
Assessment
The systemic and continuous collection, organization, validation, and documentation of data about a client. Continues through all steps of the nursing process and creates a database about the client. Serves as the basis for the individualized plan of nursing care.
Diagnosis
Conclusion that determines what care the patient will receive.
Planning
Begins after identification of a client’s nursing diagnosis and strengths. Nurse sets client-centered goals and expected outcomes, plans nursing interventions, and prioritizes interventions.
Implementation
Initiates or completes planned actions or nursing interventions. This step may include organizing and managing planned care, aiding with ADLs, counselling or teaching the patient and family, providing care, or delegating care to others.
Evaluation
Final step in the nursing process Involves two components: An examination of a condition or situation, and a judgement as to whether change has occurred.
Primary source
Collecting data from the patient.
Secondary source
Collecting data from caregivers, health care providers, and patient’s record
Tertiary source
Data collection outside the specific patient’s frame of reference and are a result of the nurse’s response to care. Can come from textbooks, nurses’ experience, and patterns noticed in other patients with similar presentations and conditions.
Cue
Information that you obtain through the use of your senses
Validation
Comparison of data with another source to determine data accuracy
Inference
Your judgement or interpretation of data
Objective data
Observations or measurements of a patient’s health status, measurement of data is based on an accepted standard, may be considered normal or abnormal finding. Nurses apply critical thinking standards to interpret their findings.
Subjective data
Patient’s verbal descriptions of their health concerns. Are obtained through health history and nurses questions and explanation the atient provides. Only patients provide this.
Cluster data
Organizing data into meaningful and usable clusters, keeping in mind the patient;s response to illness. A set of signs or symptoms grouped together in a logical way.
Medical diagnosis
The identification of a disease condition on the basis of specific evaluation of signs and symptoms
Nursing diagnosis
A clinical judgement about client response too an actual or potential health problem. Focuses on a client’s actual or potential response to a health proble rather tan on the physiological event, complication, or disease.
Collaborative problem
An actual or potential complication that nurses monitor to detect a change in client status
NANDA
Means of translating nursing observations and assessments into standard conclusions in a common nomenclature (language). Provides a precise definition of the client’s needs, gives all members of the health care team a common language to use.
Diagnostic reasoning
A process of using assessment data to create a nursing diagnosis
Defining characteristics
Clinical criteria or assessment findings that help confirm an actual nursing diagnosis
Clinical criteria
Objective or subjective signs and symptoms tat lead to a diagnostic conclusion
Actual nursing diagnosis
Describes human responses to health conditions or life processes
· Risk nursing diagnosis
Describes human responses to health conditions or life processes that may develop
Health promotion nursing diagnosis
Clinical judgement of client’s motivation and desire to increase wellbeing by readiness to enhance specific health behaviours, such as nutrition and exercise.
· Wellness diagnosis
Describes levels of wellness in a client that can be enhanced
Maslow’s Hierarchy of Needs
complex human behaviour can be best explained as a response to the competing demands of various basic needs (physiological, safety, belongingness and love, esteem, self-actualisation needs)
SMART Goals (Specific, Measurable, Achievable, Relevant, Time bound goals)
Change in a client’s status that is expected in response to nursing care. Provides focus or direction. Determines when a specific client-centered goal has been met. Used to evaluate if problem has been addressed.
Short term goal
An objective client behaviors or response expected within hours to a week
Long term goal
An objective client behavior or response expected within weeks or months
Nursing Care Plans
End product of planning phase is a formal or informal plan of care Formal care plans are written guides that organize and direct nursing care of clients. Provde continuity of care, and must be individualized.
Achieved Goal
Goal that is achieved based on evaluative data
Partial Goal
Parts of goal are achieved based on evaluative data
Unmet goal
Goal is not achieved based on evaluative data
Concept mapping
Part of organizing, analyzing, and communicative interrelationships among concepts through a visual representation of components
Predictable client
A client who has needs and a well-defined and established plan of care, has a predictable deteriorating health condition or disease, and has outcomes and changes that are predictable.
Accountability
Answerable for what we do, how well we do it, for what we decide not to know. Client, employers, legislation, working in our scope of practice and knowing the scope of practice of others.
Ethics
The study of good conduct, character, and motives. Concernved with determining what is good or valuable for all people.
Autonomy, beneficence, nonmaleficence, and justice.
Four principles of bioethics
Ethical dilemma
A conflict between two sets of human vales, both of which are judged to be “good,” but neither of which can be fully served. Can cause distress and confusion for patients and caregivers.
Value clarification
The process of appraising personal values, becoming aware of your existing values and how they affect behavior.
Systematic review
Provide a synthesis of quantitative evidence. Includes the available evidence on a topic in the form of randomized controlled trials that are summarized using a systemic methodology. The results of many studies are evaluated and a conclusion is drawn on the effectiveness of a particular treatment.
Quantitative research
Precisely measured and quantified research. Surveys, cross-sectional studies, case control, cohorts, randomized control trial, case studies (numbers).
Qualitative research
Descriptive, phenomenology, grounded theory, ethnography narrative research, art-based, historical research
Research Ethics board
Group that reviews the ethical acceptability of research projects, reflecting on potential risks and benefits; respect for and protection of research participants; and relevance and rigor of the research.
Fitness to Practice
All qualities and capabilities of an individual relevant to their practice as a nurse, including but not limited to freedom from cognitive, physical, psychological, or emotional condition and dependence on alcohol or drugs that impairs their ability to practice nursing
Self-care
An individual’s ability and responsibility to engage in healthy lifestyle behaviors that optimize functioning and human development. Is personal, unique, and intentional.
Cue: Information that you obtain through the use of your senses
Inference: Your judgement or interpretation of cues
What are methods of data collection during the assessment stage of the nursing process?
A clear, concise record
Nurses provide a thorough database inclusive of historical and current information about the patient’s health.
Consider using appropriate terminology
Using standardized forms and communication
Know some important considerations related to data documentation [4]
Diagnostic label,
related factors,
definition,
risk factors
, support of the diagnostic statement
What are the components of a nursing diagnosis? [5]
Actual problem, potential problems, and wellness response
What are the three parts of a diagnostic statement?
Helps nurses anticipate and sequence nursing interventions
Why is it important to establish priorities?
Client’s health values and beliefs,
client’s priorities, resources available,
urgency of health problem,
medical treatment plan
What factors should be considered when establishing priorities?
Client-centered, measurable, realistic and based on the client’s needs and resources, is short-term or long-term.
What factors should be considered when establishing goals?
Mutual goal setting, include client and family, active participation.
What is the role of the client in goal setting?
To mimic the thought process of the RNs
Analyze the relationships in the data
Establish priorities
Build on previous knowledge
Facilitate critical thinking
Guide patient care
Working/live document
Why is concept mapping used in clinical? [7]
1. Assessment (patient research)
2. Organizing the data
Reason for admission (medical dx)
List symptoms
Cluster related symptoms
Assign data cluster to a Gidden’s concept
Formulate a nursing diagnosis for each category
3. Consider related facors
4. Determine key assessment
5. Prioritize
6. Analyze relationships and link nursing diagnosis concepts
7. Develop nursing care plan
Seven steps of process mapping
RNs do not have limitations on the complexity of a client they can care for. However, their scope limits the roles functions, responsibilities, and activities that they are educated, competent, and authorized to perform.
Are there limits on an RNs scope of practice?
Assessment
Complex dressing
Removal of sutures
Admissions
COVID-19 swabs/vaccinations
CVADs
Administer blood and blood products
Explain the shared competencies of RNs and LPNs [7]
Differences are based on the breadth and dept of each education program, and the client, complexity of care, and the environment.
What are the differences between the scope of practice of RNs and LPNs based on? [4]
LPN: Client with predictable outcomes
RN: Unpredictable outcomes
Understand the RN and LPN role in relation to assignment of care.
LPN: Predictable client,
LPN (with RN collaboration): a client who has a change in health condition that has predictable outcomes because the change occurs in patient from time to time, or has anticipated predictable outcomes however, the client’s condition at this point in time, is not as anticipated.
LPN (consult with another HCP, RN/NP/Dr): if assessment findings are not as anticipated, changed or new; client is not achieving intended outcomes; status is becoming variable or less predictable
RN: A client with outcomes and changes that are unpredictable; care needs are not well defined or constantly changing; interventions that may have unpredictable outcomes and risks
Differentiate between the type of client that RNs and LPNs can care for.
Empirical
Aethetic
Personal
Ethical
Identify Carper’s four ways of knowing that is utilized by John’s Model
Empirical knowing
Applying knowledge to practice that arises fom dingings of exploratory, descriptive, or inferential studies that have influenced nursing practice that guides clinical decision-making process
Aesthetic knowing
Using your own comfort level to develop relationship with clients and their families that make the nurse seem more genuine. Related to how the nurse, as a unique individual, chooses to respond in a client situation. Unique reflection of personalit and creativity.
Personal knowing
How we use aesthetic way of knowing. The means of interacting with others, our body movements, our expressions of emotions, the values that influence the way we view our nursing practice, and our interactions with clients, families, and other HCPs.
Ethical knowing
Way of knowing shaped by our values, what one knows to be right or wrong. Comes from professional valued (CNA code of ethics). Integration of personal and professional values
Compassion
Competence
Conscience
Confidence
Commitment
Identify the 5 Cs outlined in Roaches’ Caring Theory
Major: replicability (verified when repeated), Reliability (consistency), Validity (accuracy)
Explain major attributes of evidence [3]
Minor: Publicly available, understandable, useable
Explain minor attributes of evidence [3]
Abstract,
introduction,
literature review or background,
purpose/aim/onjectives,
methods or design,
results or conclusions,
clinical implications.
Identify parts of a research report [7]
Quantitative: measurement of numbers
Qualitative: Description of not numbers.
1. Distinguish between quantitative and qualitative research.
Noticing: Asserts that the factors behind the nurse’s eyes are important
Interpreting: Nurse begins to assemble all the information and makes sense of it
Responding: Nurse usestheir interpretation to respond to the patient issue through one or more nursing interventions
Reflecting: Reflective thinking
How do nurses make clinical judgements? [4]
Holistic view of patient situation
Process orientation (circular): Nurse, patient, and contextual factors continuously influence each other
Reasoning and interpretation (analytic, intuitive, narrative)
What are attributes and criteria for clinical judgement? [3]
Note 
Flashcard (54)