EXAM 2
6 Cognitive skills for clinical judgement
Recognize Cues: Assessment sub/obj data
Analyze Cues: Pt problems: Abnormal stuff /Concept: Good thing
Prioritize hypotheses: Planning
Generate solutions: Planning/interventions
Take Action: interventions
Evaluate outcomes: Did pt meet the goal?
Environmental factors that influence clinical judgement skills
Task complexity (Make sure you do ur task correctly)
Time pressure (Good time management) (Keep timed notes)
Interruptions ( Doctor calls, Pt codes, Xray calls)
Specialty area and autonomy (extra training depending speciality you work)
1. Define the nursing process.
The nursing process is a systematic, patient-centered approach used by nurses to assess, diagnose, plan, implement, and evaluate care to promote optimal health outcomes.
2. Describe the steps of the nursing process based on the clinical judgement model.
The steps include:
Assessment: Collecting and analyzing patient data (cues).
Diagnosis: Identifying patient problems based on data.
Planning: Setting measurable goals and developing interventions.
Implementation: Carrying out the planned interventions.
Evaluation: Assessing the effectiveness of interventions and patient outcomes.
3. Describe the relationship between identifying and analyzing cues and goal attainment.
Identifying and analyzing cues allows nurses to recognize patient needs accurately, which informs goal setting. Accurate cues lead to appropriate goals that guide effective interventions, increasing the likelihood of goal attainment.
4. Discuss the importance of planning throughout patient care.
Planning ensures care is organized, individualized, and goal-directed. It helps prioritize interventions, allocate resources effectively, and provides a roadmap to achieve desired patient outcomes.
5. Explain the significance of prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes in the clinical judgement model.
Prioritizing hypotheses helps focus on the most urgent patient problems. Generating solutions enables tailored interventions. Taking action implements the best interventions, while evaluating outcomes ensures the care was effective or needs adjustment for continuous improvement.
6. Describe the relationship between care plan modification and quality improvement.
Modifying care plans based on ongoing evaluation promotes quality improvement by ensuring care remains relevant, effective, and responsive to patient changes, thereby enhancing overall patient safety and outcomes.
7. List the five rights of delegation.
The five rights of delegation are:
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision/Evaluation
1. Describe the scope and categories of professional communication.
Professional communication in healthcare encompasses verbal, nonverbal, written, and electronic interactions between healthcare providers, patients, and families. It includes categories such as therapeutic communication, interpersonal communication, and documentation aimed at delivering safe, effective patient care.
2. Define the phases of professional relationships.
The phases of professional relationships typically include:
Orientation: Establishing trust and setting expectations.
Working: Collaborating on patient care and building rapport.
Termination: Concluding the relationship appropriately once goals are met or care ends.
3. Identify ways that technology and electronic documentation impact health care.
Technology and electronic documentation improve accuracy, accessibility, and efficiency of patient records, enhance communication among healthcare teams, reduce errors, and support evidence-based decision-making.
4. Discuss the uses of technology in health care.
Technology is used for electronic health records (EHR), telemedicine, patient monitoring, diagnostic tools, medication management, and data analytics to improve patient outcomes and streamline care delivery.
5. Explain the importance of using standardized terminologies in electronic health records.
Standardized terminologies ensure consistent, clear communication across healthcare providers and systems, facilitating accurate documentation, interoperability, data analysis, and improved patient safety.
6. Describe SBAR used in healthcare facilities.
SBAR (Situation, Background, Assessment, Recommendation) is a communication tool used to provide concise and structured information during handoffs or urgent communications to enhance clarity and patient safety.
7. Define and describe the concept of sensory perception.
Sensory perception is the process by which the body detects, interprets, and responds to sensory stimuli (such as sight, hearing, touch, taste, and smell) to interact effectively with the environment.
8. Notice risk factors for impaired sensory perception.
Risk factors include aging, chronic illnesses (e.g., diabetes), neurological disorders, medication side effects, trauma, and environmental factors like noise or lighting.
9. Recognize when an individual has impaired sensory perception.
Signs include difficulty seeing or hearing, changes in balance or coordination, withdrawal from social interactions, confusion, or delayed responses to sensory stimuli.
10. Provide appropriate nursing and collaborative interventions to optimize sensory perception.
Interventions include assessing sensory function regularly, promoting safety (e.g., fall prevention), providing assistive devices (glasses, hearing aids), enhancing environmental stimuli, educating patients and families, and collaborating with specialists such as audiologists or ophthalmologists.