Recording-2025-02-10T15:26:56.319Z

Clinical Decision-Making in Nursing

  • Clinical judgment is essential for developing a care plan based on patient assessment and needs.

Case Overview

  • Patient: Penny, a 79-year-old female

  • Admission History: Recently admitted with a history of stroke, left-sided peripheral neuropathy, and weakness.

  • Nurse: Yuko, working in a long-term care facility.

Steps of Clinical Judgment Measurement Model

1. Recognizing and Analyzing Cues

  • **Nurse Yuko’s Initial Assessment:

    • Skin: Dry, flaky skin noted on lower extremities.

    • Oral Health: Dry, cracked lips, yellow-brown film on teeth.

    • Nails: Thick, discolored toenails observed.

    • Pressure Injury: Found on the left heel.

  • Patient Interaction:

    • Penny explains struggles with ADLs post-stroke, including feeding, grooming, and mobility.

    • Patient reports numbness and weakness in left leg, leading to pressure injury.

2. Analyzing Cues

  • Electronic Health Record (EHR) Review:

    • Can walk short distances but primarily uses a wheelchair.

    • Occupational therapist’s notes indicate moderate assistance required for ADLs.

    • Moderate muscle strength in right hand, poor in left hand.

3. Prioritizing Hypotheses

  • Identified Hypothesis: Self-care deficit based on assessment of Penny's abilities and limitations.

4. Generating Solutions

  • Expected Outcome: Post-intervention, Penny will participate in bathing once per day and oral care twice per day.

5. Taking Action

  • Implementation Steps:

    • Gather supplies for personal hygiene care.

    • Collaborate with Unlicensed Assistive Personnel (UAP) to assist Penny.

    • Encourage Penny to engage in her care:

      • Clean own face and chest with a washcloth (using right hand).

      • UAP provides assistance with back and legs.

      • Apply moisturizer and dress the left heel.

  • Oral Care Support:

    • Nurse Yuko encourages Penny to brush her teeth.

    • Patient expresses discomfort using her non-dominant hand but is encouraged for independence.

6. Evaluating Outcomes

  • Post-Care Evaluation Characteristics:

    • Penny’s skin appears clean, soft, and hydrated.

    • Dressing on left heel remains dry and intact.

    • Lips are warm and moist, and teeth are clean.

Recap of Care Plan Success

  • Nurse Yuko recognized and analyzed cues related to Penny's self-care deficit effectively.

  • Established a set of prioritized hypotheses and generated actionable solutions.

  • Implemented measures for hygiene and skin integrity successfully, as confirmed by evaluation of outcomes.

  • Patient was able to participate actively in care, indicating success in the care plan.