Clinical Judgement and Nursing Process

Clinical Judgement & Nursing Application

This unit focuses on clinical judgement within the nursing application.

What is Clinical Judgement?

Clinical judgement is a systematic decision-making approach used by nurses to organize and provide patient care. It involves using critical thinking skills to assess patient conditions, identify potential problems, and implement appropriate interventions. The nursing process is foundational to this.

Key Aspects of Clinical Judgement:

• Holistic View: Consider the whole patient, including physical, psychological, emotional, and social factors.

• Contextual Awareness: Recognize the specific situation, including the environment and available resources.

• Sound Reasoning: Use logical reasoning and evidence-based practice to make informed decisions.

• Reflection: Evaluate the outcomes of interventions and adjust the plan of care as needed.

Steps in Clinical Judgement:

1. Recognize cues: Identify relevant information from patient assessments, history, and observations.

2. Analyze cues: Interpret the data and determine its significance to the patient’s condition.

3. Prioritize hypotheses: Formulate potential diagnoses or problems and rank them based on urgency and risk.

4. Generate solutions: Develop a range of possible interventions to address the prioritized problems.

5. Take action: Implement the chosen interventions in a timely and effective manner.

6. Evaluate outcomes: Assess the patient’s response to the interventions and modify the plan as needed.

Clinical Judgement Measurement Model (NCSBN, 2019)

This model provides a framework for evaluating clinical judgement skills and includes the following components:

• Assessment: Recognize signs and symptoms; Distinguish between normal and abnormal. Includes collecting data, reviewing history, and conducting physical exams.

• Analysis: Connect pathophysiology with client presentation; Use findings/observations to determine client needs; Prioritize client needs based on likelihood and risk. This involves interpreting data and identifying patterns.

• Planning: Develop possible care options that align with client needs; Identify things to address and things to avoid. Setting goals and desired outcomes is crucial.

• Implementation: Identify and perform appropriate clinical actions; Determine if a potential action is indicated, nonessential, or contraindicated. Actions may include requesting an order, administering treatment/medication, performing a skill, documenting, and/or communicating. This phase requires critical thinking and adaptability.

• Evaluation: Evaluate outcomes and determine the effectiveness of actions. Identify findings that indicate improvement or worsening of a condition. This step informs future actions and adjustments to the plan.

The Nursing Process

The nursing process is a universal, evidence-based approach to care. It's often represented by the acronyms ADPIE or ADOPIE.

• Assessment: Collection of subjective and objective data.

• Diagnosis (Nursing): Identification of patient problems based on assessment data.

• (Outcomes Identification)\": Formulation of goals and outcomes.

• Planning: Development of nursing interventions.

• Implementation: Performance of nursing interventions.

• Evaluation: Assessment of the effectiveness of interventions.

Concept Maps

A concept map is a non-linear, visual tool used to represent the relationships between different ideas and concepts. It is a graphical representation of knowledge that helps organize information and understand how different concepts connect to one another. Concept maps are useful for:

• Identifying relationships

• Improving critical thinking

• Enhancing understanding of complex topics

Nursing Diagnoses

The second step of the nursing process involves using clinical judgement to analyze cues collected during the assessment phase. This determines the highest priority needs.

Three Types of Nursing Diagnoses:

1. Problem-Focused (actual problem): 3-part statement

2. Risk (potential problem): 2-part statement

3. Health promotion: 1- or 2-part statement

Problem-Focused Diagnoses

Follows PES format: problem, etiology, signs and symptoms.

3-part statement:

Diagnostic label + Related to statement + Defining characteristics

Examples:

• Impaired Gas Exchange: Inadequate oxygen and carbon dioxide exchange in the alveoli.

• Social Isolation: Feelings of aloneness or being unwanted by others.

• Imbalanced Nutrition: Insufficient or excessive intake of nutrients.

• Impaired Mobility: Limitation in physical movement.

Risk for Diagnoses

Used when there are risk factors but NO evidence of an actual problem.

2-part statement:

Diagnostic label + Related to statement

Note: There is no third part for a risk diagnosis because signs and symptoms (clinical manifestations) do not exist as evidence.

Examples:

• Risk for Impaired Skin Integrity: Vulnerable to damage of the epidermal and/or dermal layers.

• Risk for Falls: Increased susceptibility to falling.

• Risk for Infection: Increased risk of being invaded by pathogenic organisms.

Health Promotion Diagnoses

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

Examples:

• Readiness for enhanced coping: Desire to improve management of stress or challenges.

• Readiness for enhanced self- care: Desire to improve performance of activities of daily living.

Planning Care

This step occurs after the nursing diagnosis is selected. Goals and outcomes for the patient are set.

• Goals: general statements describing a desired change

• Outcomes: measurable changes needed to reach a goal

Goals should be SMART:

• Specific: Clearly defined and focused.

• Measurable: Able to be quantified and assessed.

• Achievable: Realistic and attainable.

• Relevant: Pertinent to the patient's needs and values.

• Time-bound: With a specific timeframe for achievement.

Once goals of care are established, the nurse can select evidence-based nursing interventions to help the patient reach their expected outcomes and goals.

Types of Interventions & Factors to Consider

• Nurse-Initiated: Actions performed by a nurse without needing a provider’s order.

• Healthcare-Provider-Initiated: Actions requiring a provider’s order.

• Collaborative Interventions: Actions performed in conjunction with other healthcare professionals.

When planning interventions, the nurse considers the following:

• Expected outcome

• Nursing diagnosis statement

• Evidence to support use of the intervention

• Logistics (interventions planned by other health team members, feasibility of intervention)

• Acceptability to the patient

• Abilities of the nurse providing the care

Implementation

Begins once the plan of care is developed (goals & outcomes selected, interventions planned).

• Includes ALL therapeutic actions (interventions)

• All interventions should be evidence-based

• Direct care vs. indirect care

Evaluation

Determines if the plan of care has been met. Have the identified alterations in health been resolved?

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

Examples of evaluation:

• Reassessing patient pain after administering pain medication

• Rechecking vital signs and watching the trend

Sometimes, the plan of care may not have been met and outcomes/goals not reached. What will the nurse do in this case?

Revising the Plan of Care

• What does it mean to revise a plan of care? It means reassessing the patient's condition, reviewing the existing plan, and making necessary adjustments.

• When will the nurse revise the plan? When the patient's condition changes, goals are not met, or new information becomes available.

• Who is involved in this process? The nurse, the patient, and other members of the healthcare team.

Your Role in Planning Care as a Nursing Student

• Utilize the nursing process

• Create concept maps

• Using a nursing diagnosis handbook

Let's Practice!

Case Study 1

Place in order the list of actions the nurse will complete for a 75- year-old client who presented to the ED with c/o confusion, fatigue, low urine output, dark urine, burning and pain with urination, and intermittent sweating:

• Obtain ordered blood and urine cultures

• Administer prescribed antibiotics

• Complete head to toe assessment

• Introduce self and verify patient identity

• Assess current level of comfort, LOC, VS

Answer to Case Study 1:

1. Introduce self and verify patient identity

2. Assess current level of comfort, LOC, VS (focused assess)

3. Complete head to toe assessment

4. Obtain ordered blood and urine cultures

5. Administer prescribed antibiotics

Case Study 2

What evidence is present in the nurses’ notes below that indicate that a NANDA diagnostic label of “Acute Pain” would be applicable? These are also called the cues/clues, signs/symptoms, and Defining Characteristics.

Sally (preferred name) is a 75-year-old woman who appears unwell and restless, admitted with symptoms of urinary tract infection. She has intermittent chills (rigors), lower back right (flank) pain (+4/10 x 2 days), urinary frequency, and hematuria. Vital signs include the following: T: 101.2 °F, HR: 99 bpm, BP: 100/60, RR: 18, and O2: 99\% on room air. On exam, her mucous membranes are dry, suprapubic tenderness is present (+3/10 x 5 days) that increases with light palpation (+5/10), severe right flank pain increases with percussion of the R CVA (+10/10). Patient has 20g PIV in the R basilic vein with 0.9\% NS running at 100mL/hr. Dressing is clean, dry, and intact (CDI); skin around dressing with no evidence of infiltration, swelling, or redness (erythema.) Urine culture came back + for E-coli bacteremia. Signed: R Smith BSN RN

Case Study 3

Select the data that contribute to the ‘related to’ statement or the Etiology of the nursing diagnosis of Acute Pain.

Sally (preferred name) is a 75-year-old woman who appears unwell and restless, admitted with symptoms of urinary tract infection. She has intermittent chills (rigors), lower back right (flank) pain (+4/10 x 2 days), urinary frequency, and hematuria. Vital signs include the following: T: 101.2 °F, HR: 99 bpm, BP: 100/60, RR: 18, and O2: 99\% on room air. On exam, her mucous membranes are dry, suprapubic tenderness is present (+3/10 x 5 days) that increases with light palpation (+5/10), severe right flank pain increases with percussion of the R CVA (+10/10). Patient has 20g PIV in the R basilic vein with 0.9\% NS running at 100mL/hr. Dressing is clean, dry, and intact (CDI); skin around dressing with no evidence of infiltration, swelling, or redness (erythema.) Urine culture came back + for E-coli bacteremia. Signed: R. Smith, BSN, RN

Case Study 4

The nurse is reviewing the plan of care for a patient. Which of the following interventions are considered indirect care?

• Administering medications

• Documenting the shift assessment

• Hand hygiene

• Client education

• Consulting physical therapy

• Calling the homecare agency for report