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Chapter 1: Professional Nursing PracticeNursing Pe

Clinical Judgement Model:

  • Recognize Cues - gather data about patient condition (both objective & subjective)

  • Analyze Cues - organize the recognized cues to identify meaningful patterns and understand the clinical situation

  • Prioritize Hypothesis - evaluate & rank different possible explanations for patient’s symptoms to determine what is the most likely diagnosis

  • Generate solutions - come up with appropriate interventions and actions for each prioritized hypothesis

  • Take Action - implement chosen interventions made in generate solutions (highest priorities first using Maslow’s hierarchy of needs)

  • Evaluate outcomes - assess patient response to see if anything needs to be changed in care plan

Maslow’s Hierarchy of Needs (bottom to pyramid to top)

  • physiologic needs (basic needs) - air, food, water, shelter, clothing, sleep, health, and reproduction

  • Safety & security - personal security (from infections, substances, fall risks) , financial security, emotional stability, a sense of order & structure

  • Belonging & Affection - social needs, connection with others, friendship, intimacy, sense of acceptance and being part of a group, family and social connections

  • Esteem & Self Respect - self respect and respect of others, recognition of status, having confidence, feeling competent

  • Self actualization - self fulfillment, desire to know & understand, aesthetic needs (to feel/be pretty)

Advance Directives: a legal document where a patient specifies future medical treatment preferences, especially in the event that they cannot make decisions for themselves

  • ex: living will

  • Ex: health care power of attorney

Nursing Process (ADPIE)

  • Assessment - collection of patient data through interview, observation, and examination to determine a patient’s health status or potential health problems (collect subjective & objective data)

  • Diagnosis

    • nursing diagnosis - clinical judgement (informed decision made by health professions based on knowledge, critical thinking, and patient assessment) about individual, family, or community responses to actual or potential health problems/life processes that can be managed by nursing interventions

    • Collaborative problems - certain physiologic complications that nurses monitor to detect onset or changes in status. Nurse manages these problems using physician and nurse prescribed interventions to minimize complications

  • Planning - develop goals and weigh outcomes by making a plan of care to help the patient resolve diagnosed problem

  • Implementation - putting the planned steps into action

  • Evaluation - determining if care plan needs to be modified, working, or needs to be stopped entirely