RN Process - Clinical Judgement

• Critical Thinking:

  • Definition: Ability to analyze information objectively and form reasoned judgments.

  • Involves:

  • Actively questioning assumptions.

  • Evaluating evidence.

  • Considering different perspectives.

  • Goal: To arrive at well-supported conclusions.

• Clinical Judgment:

  • Definition: Ability to make decisions and solve problems by making sense of information in a healthcare environment.

  • Involves using nursing knowledge to:

  • Assess situations.

  • Identify priority problems.

  • Generate the best possible solutions for safe patient care.

  • Factors: Understanding medical and nursing implications of a patient’s situation when making decisions about patient care.

  • Utilized in: Identifying changes in a patient’s status and considering patient and caregiver concerns.

  • Citation: (Ignatavicius, 2025)

History of the NCSBN Clinical Judgment Measurement Model

• Overview:

  • More than 50 years of nurses utilizing a 5 Step Nursing Process.

  • Purpose: Systematic problem-solving tool and evidence-based interventions to provide safe, client-centered care.

  • The 5 Steps:

  • Assessment

  • Diagnosis (amended to be Analysis/Clinical Reasoning in 2010)

  • Planning

  • Implementation

  • Evaluation

• Research (2006):

  • Conducted by Christine A. Tanner, PhD, RN, published in Journal of Nursing Education.

  • Conclusion: Nurses rely on clinical judgment skills more than the Nursing Process.

  • Identified Four Clinical Judgment Skills:

  • Noticing

  • Interpreting

  • Responding

  • Reflecting

Six Cognitive Thinking Skills of Layer 3 of the NCSBN Clinical Judgment Measurement Model

1. Recognize Cues:

   • Definition: Assessment data that provides information to inform decisions.

2. Analyze Cues:

   • Task: Consider the cues in light of the client’s condition or history.

3. Prioritize Hypotheses:

   • Task: Consider all possibilities of what is happening to the client and assess urgency and difficulty.

4. Generate Solutions:

   • Task: Identify expected client outcomes and the interventions (actions) which will achieve desirable outcomes.

   • Consider: Interventions that are contraindicated.

5. Take Actions:

   • Task: Decide the actions that address the highest priorities of care and their implementation order.

   • Action: Perform the identified actions.

6. Evaluate Outcomes:

   • Definition: Evaluate client outcomes and compare to expected outcomes to determine improvement or decline.

Summary of Learning – Test Our Knowledge

• Why Update and Improve the Nursing Process?

  • To better align nursing education with the expectations of newly licensed nurses amidst complex client care decisions.

• Definitions Review:

  • Critical Thinking: Ability to analyze information objectively and form reasoned judgments.

  • Clinical Judgment: Ability to make decisions and solve problems in a healthcare environment.

Recognition and Analysis of Cues

1. Recognizing Cues:

   • Definition: Assessing the client to identify relevant signs and symptoms related to their condition.

2. Analyzing Cues:

   • Definition: Determining the significance of the cues and their relationship to each other.

3. Prioritize Hypotheses:

   • Definition: Determining which hypotheses are most likely to require immediate attention.

4. Generate Solutions:

   • Definition: Development of potential courses of action to address client’s condition.

5. Take Action:

   • Definition: Implementation of chosen course of action.

6. Evaluate Outcomes:

   • Definition: Assessing effectiveness of implemented actions and making adjustments as needed.

Defining the Nursing Process

• Definition: A systematic problem-solving process guiding all nursing actions.

• Importance:

  • Framework for nursing care that encompasses evaluation and adjustments.

• Application:

  • Differences from other test questions; applicable to various patient care scenarios.

Nursing Process Steps

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

Flexible Use of the Nursing Process

• Cycle Nature:

  • The nursing process is not linear; steps can occur simultaneously.

  • Example: Assessing lung sounds while evaluating treatment effectiveness.

Critical Thinking vs. Nursing Process

• Differences:

  • Critical thinking is a broader skill encompassing reasoned thinking, openness, reflection, and truth-seeking.

• Skills Required:

  • Higher-order cognitive skills leading to logical and appropriate actions may not always require critical thinking.

Essential Nursing Components

1. Knowing

2. Being with

3. Caring

4. Doing for

5. Enabling

6. Maintaining Belief

Concept of Caring in Nursing

• Significance: Caring is the hallmark of the nursing profession encompassing concern for patients and related projects.

• Goal: Maintaining patient comfort in uncomfortable situations.

• Nursing Theories: Several theories are grounded in the concept of caring.

Assessment Phase

• Phase Definition: First phase of the Nursing Process focusing on data gathering to assist patient care.

• Data Sources:

  • Patient, Family, Assessment.

  • Continuous assessment throughout the nursing process is essential.

Professional Standards Related to Assessment

1. American Nurses Association (ANA):

   • Assessments include collecting pertinent data relative to the healthcare consumer's health or the situation.

2. National Council of State Boards of Nursing (NCSBN):

   • State boards of Nursing governance.

3. The Joint Commission (TJC):

   • Sets standards for national patient safety and quality care.

Application of Assessment Through the Nursing Process

• Diagnosis: Utilizing assessed data to find a diagnosis of patient problems and strengths.

• Planning: Establishing interventions and expected outcomes based on gathered data.

• Implementation: Executing the chosen interventions while assessing client responses.

• Evaluation: Analyzing how effective the interventions were and the client's feelings about them.

Types of Data Collected in Assessments

1. Subjective Data:

   • Patient-reported information.

2. Objective Data:

   • Measurable data using numbers.

Data Classification

• Primary Data:

  • Subjective and objective data obtained directly from the patient/client.

• Secondary Data:

  • Data obtained from sources other than the patient, such as medical records or family reports.

Methods of Physical Assessment

1. Patient/Family Interviewing

2. Observation

   • CROP (Client Room Observation of People)

3. Assessment Skills

Assessment Types

1. Focused Assessment:

   • Addresses patient problem areas and reassesses improvement.

2. Comprehensive Assessment:

   • Includes subjective and objective data, encompassing a review of medical records.

3. Initial Assessment:

   • Conducted at admission covering physical assessment, observation, and interview.

4. Ongoing Assessment:

   • Done during shifts to monitor patient status.

Special Needs Assessments

• Focus on specific aspects that require detailed information relating to:

1. Nutritional needs

2. Pain management

3. Cultural considerations

4. Psychosocial factors

5. Wellness status

6. Family dynamics

7. Community resources

8. Functional ability assessments for discharge planning

   • Reference: Pg. 46 for further details on these assessments.

Patient Communication Techniques

1. Pay attention: To non-verbal cues.

2. Listen: To spoken information.

3. Take your time: Ensure clarity and understanding.

4. Assess: Understand the patient’s situation.

5. Address: Directly addressing patients by their name.

Types of Questions to Use

1. Open-Ended Questions:

   • Allow comprehensive responses.

   • Example: "Tell me about your home situation?"

2. Closed Questions:

   • Simple yes or no responses.

   • Example: "Do you live alone?"

Information to Gather During Assessment

• Biographical Data

• Chief Complaint

• Patient’s Health History

• Family Health History

• Social History

• Medication History

• Alternative Treatment History

• Patient Self-assessment: Perceptions about their health.

Data Validation Techniques

• When to Validate Data:

  • Patient statements don’t match data.

  • Data falls outside normal ranges.

  • Difficulty obtaining data, particularly out-of-range data.

Organizing Collected Data

• Formats:

  • Computerized notes.

  • Written notes.

  • Nursing models.

  • Non-nursing models.

  • Reference: Table 3-4 on Page 49.

Documentation Standards

• Use available tools effectively.

• Ensure documentation is timely and accurate.

• Employ direct quotes from patients; avoid inserting personal feelings.

Diagnosis Phase

• Definition: Second step of the Nursing Process tying together information through critical thinking.

• Objective: Often includes input from patient and family.

Diagnosis Definitions

• NANDA (North American Nursing Diagnosis Association International):

• Diagnosis: Clinical judgment about individual, family, or community responses to health problems or life processes.

  • Provides basis for selection of nursing interventions to achieve expected outcomes.

Medical vs. Nursing Diagnosis

1. Medical Diagnosis:

   • Describes disease or injury; stays consistent over time; informs specific treatments.

   • Nurses cannot provide medical diagnoses.

2. Nursing Diagnosis:

   • Made independently by nurses addressing patient needs; changes with patient condition.

   • Nurses can treat nursing diagnoses without a doctor’s order.

Collaborative Problems

• Definition: Physiological complications monitored by nurses for changes in patient status.

• Treatment: Involves medical orders or nursing interventions.

• Example:

  • Patient short of breath due to COPD exacerbation; treatment includes nebulizer per doctor’s order, position adjustments, and patient education by the nurse.

Nursing Diagnosis Categories

1. Problem Focused: Direct patient issues.

2. Risk Focused: Potential issues due to certain conditions.

3. Health Promotion: Reflects the client’s desire to improve health.

4. Syndrome: Indicates a cluster of related issues.

Diagnostic Reasoning Process

• Definition: Encompasses analyzing and interpreting data gathered during patient assessments.

• Steps:

  • Analyze and interpret data.

  • Prioritize identified problems.

  • Draw conclusions on health status.

  • Write diagnostic statements.

  • Verify conclusions with patients.

Analyzing and Interpreting Data

• Tasks:

  • Identify significant data or cues.

  • Draw conclusions relating to client health.

  • Establish what is normal versus abnormal.

  • Group related cues into clusters suggesting health problems.

  • Identify any data gaps or inconsistencies.

Drawing Conclusions About Health Status

• Tasks include:

  • Making inferences.

  • Identifying problem etiologies, which are inferences rather than direct observations.

Verify Problems with Patients

• Engage patients in conversations to confirm understanding of identified problems.

Prioritizing Problems

• Method: Order problems based on their importance using nursing judgment.

• Framework: Understand possible future consequences and document priorities.

NANDA-I Taxonomy Terminology

• Diagnostic Label: A word or phrase naming the diagnosis.

  • Example: "Risk for infection due to suppressed immune system."

• Definition: Describes the meaning of the diagnostic label.

• Defining Characteristics: Cues enabling identification of a diagnosis.

  • Example: Presence of underlying diseases, specific treatments, nutritional status.

Related Factors (Etiology)

• Definition: Cues or conditions linked to the identified problem.

  • Example: "Risk for infection related to impaired skin integrity."

• Risk Factors: May include environmental, physiological, or psychological characteristics.

  • Examples: Alterations in skin integrity, malnutrition, obesity, chronic illness, immunosuppression.

Diagnostic Statement Components

1. Problem: Describes client health status and identifies needed changes.

2. Etiology: Factors contributing to the problem influencing the plan and interventions.

3. Connecting Phrase: Commonly “related to.”

Formatting Diagnostic Statements

• One-Part Statement: Describe client health status specifically.

  • Example: "Chronic Pain Syndrome."

• Two-Part Statement: Problem related to Etiology.

  • Example: "Risk for Deficient Fluid Volume r/t excessive vomiting."

• Three-Part Statement: Problem, Etiology, Symptoms.

  • Example: "Constipation r/t inadequate intake of fluids and fiber-rich foods AMB painful, hard stool and bowel movement every 5 days."