2019 UNMC PCC 2 Clinical Judgment

Applying critical thinking and clinical judgment to the care of a hospitalized patient:

-Interpretation; be orderly in collection data about patients. Apply reasoning while looking for patterns to emerge. Categorize the date. Gather additional data or clarify any data about which you are uncertain -Analysis; be open-minded as you look at information about a patient. Do not make careless assumptions. Does the data reveal a problem or trend that you believe is true, or are there other options? -Inference; look at the meaning and significance of findings. Are there relationships among findings? Does the data about the patient help you see that a problem exists? -Evaluation;Look at all situation objectively. Use criteria to determine results of nursing actions. Reflect on your own behavior. -Explanation; Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients. -Self-regulation; reflect on your experiences. Be responsible for connection your actions with outcomes. Identify the ways you can improve your own performance. What will make you believe that you have been successful? -Confidence; learn how to introduce yourself to a patient; speak with conviction when you begin a treatment or procedure. Do not lead a patient to think that you are unable to perform care safely. Always be well prepared before performing a nursing activity. Encourage a patient to ask questions. -Thinking independently; read the nursing literature, especially when there are different views on the same subject. Talk with other nurses and share ideas about nursing interventions -Fairness; Listen to both sides in any discussion. If a patient or family members complains about a co-worker, listen to the story and speak with the co-worker as well. If a staff member labels a patient uncooperative, assume the care of that patient with openness and a desire to meet the patient's needs. -Responsibility and Authority; ask for help if you are uncertain about how to perform a nursing sill. Refer to a policy and procedure manual to review steps of a skill. Report any problems immediately. Follow standards of practice in your care. -Risk taking; if your knowledge causes you to question a health care provider's order, do so. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients. -Discipline; Be thorough in whatever you do. Use known scientific and practice-based criteria for activities such as assessment and evaluation. Take time to be thorough and manages your time effectively. -Perseverance; Be cautious of an easy answer. If co-workers give you information about a patient and some fact seems to be missing, clarify the information or talk to the patient directly. If problems of the same type continue to occur on a nursing division, bring co-workers together, look for a pattern, and find a solution. -Creativity; look for different approaches if interventions are not working for a patient. For example, a patient in pain may need a different positioning or distraction technique. When appropriate, involve the patient's family in adapting your approaches to care methods used at home. -Curiosity; always ask why. A clinical sign or symptom often indicates a variety of problems. Explore and learn more about a patient so as to make appropriate clinical judgments -Integrity; recognize when your opinions conflict with those of a patient; review tour position and decide how best to proceed to reach outcomes that will satisfy everyone. Do not compromise nursing standards or honesty in delivering nursing care. -Humility; recognize when you need more information to make a decision. When you are new to a clinical division, ask for an orientation to the area. Ask registered nurses regularly assigned to the area for assistance with approaches to care.

principles of prioritization:

-Life before limb (hypoglycemia before fracture) - Acute before chronic (new onset of delirium before client with Alzheimer's dementia) - Actual before potential problem (Adm diuretic for HF before ROM exercise for client with CVA) - Listen & don't assume (Accept client's report of pain, even if vitals are stable and client is resting) - Recognize trends & report them/ transient findings (Recognize increase in BP during shift after BP meds given) - Identify medical emergencies/complications vs. expected findings (Sudden onset of dyspnea vs. dyspnea during ambulation in client with COPD) - Application of clinical knowledge (Draw blood cultures before adm antibiotic to identify organism) - Make effective use of time by combining activities such as physical assessment with bath - Delegate when necessary

Priority setting frameworks

-Maslow's Hierarchy -Airway, Breathing, Circulation (ABC) framework -Safety/Risk reduction -Assessment/Data Collection First -Survival Potential -Least Restrictive/Least Invasive -Acute vs. Chronic/Urgent vs. Nonurgent/Stable vs. Unstable

When delegating a task to someone, it is important for the nurse too...

-assess the knowledge and skills of the delegate; know which tasks and skills are in the scope of practice and job description for the team members to whom you delegate in your agency -communicate clearly; always provide clear directions by describing a task, desired outcome, and the time period within which the NAP needs to complete the task -listen attentively; does the NAP feel comfortable in asking questions or requesting clarification? listen to what the person has to say. help sort out priorities. -provide feedback; always give feedback regarding performance, regardless of outcome; let them know of a job well done and thank them; if outcome is undesirable, find a private place to discuss what occurred

Attributes and criteria of clinical judgement:

-holistic view of the patient situation; requires a willingness to consider all factors involved in patient care, including certain characteristics of the nurse -process orientation; nurse employs a deep understanding of the individual patient situation and his/her own background, experience, and values; the nurse notices relevant features and intervenes -reasoning and interpretation; analytic, intuitive, and narrative

Team communication elements for effective communication:

-respect others' ideas -share information/stay informed -strive to improve your communication -share expectations of communication -use structured communication techniques -active listening (remember acronym (S.O.L.E.R.) -sharing observation, empathy, hope, humor, feelings -using touch, silence -clarifying -paraphrasing -summarizing -validation

5 rights of delgation

-right task; ones that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have potential minimal risk -right circumstances; consider the appropriate patient setting, available resources, and other relevant factors -right person; delegating the right tasks to the right person to be performed on the right person; making sure the right person is performing the task; making sure the task is being performed on the right person -right direction/communication; give a clear, concise description of a task, including its objective, limits, and expectations; communication needs to be ongoing between RN and NAP during a shift of care -right supervision/evaluation; provide appropriate monitoring, evaluation, intervention as needed, and feedback; NAP need to feel comfortable asking questions and seeking assistance

Concepts for a critical thinker

1. Truth seeking 2. Open-mindedness 3. Analyticity; analyze potentially problematic situations and anticipate possible results or consequences 4. Systematicity; organized, focused, etc. 5. Self-confidence 6. Inquisitiveness; be eager to acquire knowledge and learn 7. Maturity

A nurse and an AP are providing care for four clients who were admitted to the med-surge unit on the previous shift. the nurse should delegate meal assistance for which of the following clients to the AP? A. a client who has a lumbosacral spinal tumor B. a client who has gulliain-barre syndrome C. a client who has amyotrophic lateral sclerosis (ALS) D. a client who has systemic sclerosis

A. a client who has a lumbosacral spinal tumor

Following a tornado, a nurse is determining which of the patients assigned to her care can be discharged to free up beds for incoming injured patients. Which of the following patients should the nurse recommend for discharge? A. a young adult patient with crohn's disease and is 1 day pre-op for an ileostomy B. an adolescent patient who was admitted 24 hours ago for a spontaneous pneumothorax C. a middle-aged patient who is 36 hours post-op from an open laminectomy D. an older adult patient admitted for diabetic ketoacidosis

A. a young adult patient with crohn's disease and is 1 day pre-op for an ileostomy RATIONALE/FRAMEWORK: crohn's disease is a chronic disease and since they are preop their appt. can be rescheduled- no one else is stable. acute vs. chronic, unstable vs. stable

A nurse is caring for an adolescent patient who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. perform a neurovascular assessment (CMS check) B. explain the discharge instructions to the patient and parents C. provide privacy for the patient D. apply an ice pack to the affected leg

A. perform a neurovascular assessment RATIONALE/FRAMEWORK: check for movement, sensation, circulation (Function). nursing process, ABC, maslow's

A nurse has several tasks to delegate to an AP. which of the following tasks should the nurse ask the AP to perform first? A. take an arterial blood gas (ABG) specimen to the lab B. transport a client to the radiology department for an x-ray C. pass fresh water to clients on the unit D. obtain a routine urine sample from a newly-admitted client

A. take an arterial blood gas (ABG) specimen to the lab

The nurse on the cardiac unit has received the shift report from the outgoing nurse. which client should the nurse assess first? A. the client who has just been brought to the unit from the ED with no report of complaints B. the client who received pain meds 30 mins. ago for chest pain that was a level 3 on a 1-10 pain scale C. the client who had a cardiac catherization in the morning and has palpable pedal pulses bilaterally D. the client who has been turning on the call light frequently and stating her care has been neglected

A. the client who has just been brought to the unit from the ED with no report of complaints RATIONALE: this client may or may not be stable. the client may have "no complaints" at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized.

The clinic nurse is returning phone messages from clients. which phone message should the nurse return first? A. the elderly client with pneumonia who reports being dizzy when getting up B. the client with cystic fibrosis who needs a prescription for pancreatic enzymes C. the client with lung cancer on chemo who reports nausea D. the client with pertussis who reports coughing spells so severe that they cause vomiting

A. the elderly client with pneumonia who reports being dizzy when getting up RATIONALE: so that the nurse can determine whether the dizziness when getting up is the result of the med or some other reason. orthostatic hypotension can be life-threatening

A nurse on a med surge unit is assigning tasks to an assistive personnel (AP). which of the following tasks should the nurse delegate to the AP? (select all that apply) A. demonstrate technique to instill eye drops B. ambulate a client who has a cane C. irrigate a wound D. transfer a client to a stretcher E. record urinary output

B. ambulate a client who has a cane, D. transfer a client to a stretcher, E. record urinary output

The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. the nurse notes there is no tidaling in the water-seal compartment. which initial action should be taken by the nurse? A. check the tubing for any dependent loops? B. auscultate the client's posterior breath sounds C. prepare to remove the client's chest tubes D. notify HCP that the lungs have re-expanded

B. auscultate the client's posterior breath sounds RATIONALE: after 3 days, the nurse should assess the lung sounds to determine whether the lungs have re-expanded

The UAP working in a long-term care facility notifies the nurse that the client diagnosed with CHF is on a low-sodium diet is complaining that the food is inedible. which intervention should the nurse implement first? A. have the family bring food for the client B. check to see what the client has eaten in the past 24 hrs C. tell the client that a low-sodium diet is an important part of the diagnosis D. ask the dietician to discuss food preferences with the client

B. check to see what the client has eaten in the past 24 hrs RATIONALE: assessing the client's intake will help the nurse determine the extent of the client's complaints

An elderly patient with dementia keeps getting out the wheelchair without calling for help, continues to set off safety alarms, and has already fallen once this hospital stay. which action should the nurse take next to prevent another fall? A. apply soft wrist restraints while the patient is sitting B. move the patient closer to the nurses' station C. place a soft mat on the floor next to the bed D. administer a dose of benadryl

B. move the patient closer to the nurses' station RATIONALE/FRAMEWORK: moving the patient closer makes for quick response by the nurses, the nurses will be able to keep a closer eye on this patient, be more available, and the nurses will also be able to be more hands on (possible sitter is a good idea as well). least restrictive/least invasive

The primary nurse in the critical care resp. unit is very busy. which nursing task should be the nurse's priority. A. assist the HCP with a sterile dressing change for a client with a left pneumomnectomy B. obtain a tracheostomy tray for a client who is exhibiting air hunger C. transcribe orders for a client with cystic fibrosis who was transferred from the ED D. Assess the client diagnosed with mesothelioma who is upset, angry, and crying

B. obtain a tracheostomy tray for a client who is exhibiting air hunger RATIONALE: the client exhibiting air hungry indicates a sign of resp. distress

A nurse is assessing a patient who returned to their room 4 hours ago having a partial colectomy procedure. which of the following findings should the nurse address first? A. moderately saturated dressing B. report of severe incisional pain C. a distended bladder D. SaO2 of 95%

B. report of severe incisional pain RATIONALE/FRAMEWORK: expect pain, nut not severe incisional pain. expected vs. unexpected, maslow's, urgent vs. non-urgent, actual vs. potential

The nurse is preparing to make rounds after receiving shift report. which client should the nurse assess first? A. the patient diagnosed with end-stage COPD complaining of SOB after ambulating to the bathroom B. the patient diagnosed with a DVT who is requesting an anti-anxiety med C. the patient diagnosed with cystic fibrosis who has a sputum specimen to be taken to the lab D. the patient diagnosed with emphysema who has a temp of 100.8 F, pulse of 118, resp. rate of 26, and BP of 148/64

B. the patient with a DVT who is requesting an anti-anxiety med RATIONALE: patients diagnosed with DVT have a risk of developing a PE. anxiety is a symptom of PE. the nurse must determine if interventions are needed for PE, a life-threatening emergency

How nurses make judgments:

BY -noticing; identify relevant patterns from a broad set of patient data that signals concern either specific or general -interpreting; using the data and a germane theoretical and experiential knowledge base to assemble the information and make sense of it; making sense of the data -responding; using the interpretation to issue through one or more nursing intervention; depending of level of expertise, nurse may or may not be able to judge effectiveness of intervention before implementing -reflecting; the process of thinking and learning from experiences (2 types)

The student nurse can best develop critical thinking skills by performing which of the following? A. attending educational workshops related to strategies for critical thinking B. studying with peers every night for at least 3-5 hours C. actively participating in all clinical experience D. interviewing staff nurses about their nursing experiences

C. actively participating in all clinical experiences

A nurse is planning client care for herself and an AP working with her. which of the following tasks should the nurse plan to perform? A. administration of an enema B. application of anti-embolic stockings C. assessing a client's sacrum for edema D. assisting a client to cough and deep breathe

C. assessing a client's sacrum for edema

The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and the B/P increases to 210/130. Which intervention should the intensive care nurse implement first? A. Notify the client's healthcare provider B. Administer the vasopressor hydralazine C. Discontinue the client's vasoconstrictor,dopamine D. Assess the client's neurological status

C. discontinue the client's vasoconstrictor, dopamine RATIONALE: the nurse should first discontinue the med that is causing the increased BP prior to doing anything else

The client on the psychiatric unit is yelling at other clients, throwing furniture, and threatening staff members. the charge nurse determines the client is at imminent risk for harming the staff/clients. which intervention should the charge nurse implement first? A. place the client in a posey vest in his bed B. give an IM injection of Haldol to calm the client C. place the client in a seclusion until he has calmed down D. put the client in a therapeutic hold

C. place the client in a seclusion until he has calmed down RATIONALE: this is the safest/least restrictive of the interventions

A nurse is planning care at the beginning of a shift. which of the following tasks could a nurse assign to AP? A. removing a client's nasogastric tube B. inserting indwelling urinary catheter C. provding a client's postmortem care D. assisting the client to select a low-residue diet

C. providing a client's postmortem care

A patient has been receiving intermittent enteral tube feedings and reports diarrhea after each feeding. Which of the following actions should the nurse take to prevent subsequent diarrhea after feedings? A. chill formula prior to administration B. verify tube placement C. reduce the rate of the feedings D. place the patient supine during feedings

C. reduce the rate of feedings RATIONALE/FRAMEWORK: the slower the rate of the feeding the more time the intestines have to absorb nutrients and water which help with reducing the amount of diarrhea. least invasive, safety risk reduction, nursing process

A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). which of the following should the nurse assign to the LPN? A. complete an admission assessment for a client who has COPD B. measure I&O for a client who has an indwelling urinary catheter C. reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty D. develop a plan of care for a client who has cholecystitis

C. reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty

A nurse is assessing a patient who is 12 hours postpartum after a cesarean birth with spinal anesthesia. which of the following findings requires immediate intervention? A. BP 100/70 B. headache of "6" C. resp. rate of 10 D. urinary output 30mL/hr

C. resp. rate of 10 RATIONALE/FRAMEWORK: resp. rate of 10 is abnormal. ABC, urgent vs. non-urgent, expected finding vs. potential complications

A nurse is caring for a patient who just returned from the PACU with an infusion and a NG tube in place after an abdominal surgery. Which is the priority assessment? A. patient coping ability B. bowel sounds C. surgical dressing D. NG tube patency

C. surgical dressing RATIONALE/FRAMEWORK: absent bowel sounds and little output from the NG tube are expected findings after an abdominal surgery, and while they should be assessed, they are not the first action a nurse should take. the surgical dressing is a concern because of the risk for complications such as bleeding or post-op infection. complications before expected findings, risk reduction, nursing process

The nurse is caring for children in a psychiatric unit. which client requires immediate intervention by the nurse? A. the 10-year-old diagnosed with oppositional defiant disorder who refuses to follow the directions of the mental health worker B. the 5-year-old child diagnosed with pervasive developmental disorder who refuses to talk to the nurse and will not make eye contact C. the 7-year-old diagnosed with conduct disorder who is throwing furniture against the wall in the day room D. the 8-year-old mentally retarded child who is sitting on the playground eating dirt and sand

C. the 7-year-old diagnosed with conduct disorder who is throwing furniture against the wall in the day room RATIONALE: the child with conduct disorder is aggressive to people and animals, bullies and threatens others, destroys property, and sets fires. throwing furniture can endanger the child and other clients.

The charge nurse on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse? A. the client diagnosed with mitral valve stenosis B. the client diagnosed with asymptomatic sinus bradycardia C. the client diagnosed with fulminant pulmonary edema D. the client diagnosed with acute AFIB

C. the client diagnosed with fulminant pulmonary edema RATIONALE: a client with fulminant pulmonary edema is experiencing an acute, life-threatening problem.

The clinical manager assigned the psychiatric nurse a client diagnosed with major depression who attempted suicide and is being discharged tomorrow. which discharge instruction by the psychiatric nurse would warrant intervention by the clinical manager? A. the nurse provides the client with phone numbers to call if needing assistance B. the nurse makes the client a follow-up appointment in the psychiatric clinic C. the nurse gives the client a prescription for a 1-month supply of anti-depressants D. the nurse tells the client not to take any OTC meds

C. the nurse gives the client a prescription for a 1 month supply of anti-depressants RATIONALE: the client should be given a 7 day supply because the safety of the client is the priority. as anti-depressants become more effective, the client is at a higher risk for suicide, therefore the nurse should ensure that the client cannot take an overdose of medication.

A nurse is assessing a patient who is 48 hours post-op following an abdominal surgery. which of the following findings should the nurse report to the provider? A. BP 112/66 B. straw-colored urine from an indwelling urinary catheter C. yellow-green drainage on the surgical incision D. resp. rate of 18

C. yellow-green drainage on the surgical incision RATIONALE/FRAMEWORK: the colors of the drainage are abnormal and should be reported; yellow-green drainage could indicate infection. expected vs. unexpected findings, urgent vs. non-urgent, nursing process

The nurse is just starting the day shift. which one of the following clients would the nurse need to see first? A. 20-year old with history of chest pain and drug abuse B. 62-year old with obesity and a BP of 150/96 C. 40-year-old with chronic liver failure and edema D. 80-year old with dehydration and heart rate of 110

D. 80-year-old with dehydration and heart rate 110

A nurse is assessing four patients; which of the four should the nurse assess first? A. a patient with COPD that has a resp. rate of 23 B. a patient with gastric cancer that reports nausea and vomiting C. a patient who has rheumatoid arthritis and has joint swelling D. a patient who has a chest tube and has asymmetrical chest wall movement

D. a patient who has a chest tube and has asymmetrical chest wall movement FRAMEWORK: acute vs. chronic, stable vs. unstable

After receiving change-of-shift report, a nurse is organizing the day. which patient should the nurse plan to see first? A. a patient awaiting transport to their scheduled abdominal x-ray B. a patient who has new orders for discharge to home C. a patient who received PO pain med 30 minutes ago D. a patient who told a CNA he is SOB

D. a patient who told a CNA he is SOB. RATIONALE/FRAMEWORK: this is the only option which would cause potential harm if not addressed right away. ABC's, urgent vs. non-urgent

The clinic nurse is scheduling a chest x-ray for a female client who may have pneumonia. which question is most important for the nurse to ask the client? A. have you ever had a chest x-ray before? B. can you hold your breath for a minute? C. do you smoke or have you ever smoked cigarettes? D. is there any chance you may be pregnant?

D. is there any chance you may be pregnant? RATIONALE: X-rays can harm the fetus

A nurse on a med surge unit is planning to delegate tasks to an adult volunteer. which of the following tasks should the charge nurse avoid assigning to the volunteer? A. delivering meal trays to clients in their rooms B. assisting a client who has difficulty seeing the foods on the tray while eating C. delivering a routine urine specimen to the lab D. observing a post-op client who is confused

D. observing a post-op client who is confused

Which client should the telemetry nurse assess first after receiving the a.m. shift report? A. the client diagnosed with DVT who has an edematous right calf B. the client diagnosed with mitral valve stenosis who has heart palpitations C. the client diagnosed with arterial occlusive disease who has intermittent claudication D. the client diagnosed with CHF who has pink frothy sputum

D. the client diagnosed with CHF who has pink frothy sputum RATIONALE: the nurse would not expect the client with CHF to have pink frothy sputum because this is a sign of pulmonary edema.

The student nurse desires to apply the components of critical thinking model for nursing judgement. which of the following will support this desire to make the best clinical decisions possible? A. instilling personal values and beliefs with client decision-making B. asking the charge nurse to determine the priority setting framework C. making clinical judgement based on intuition D. utilizing the nursing process

D. utilizing the nursing process

Communication:

a process of interaction between people in which symbols are used to create, exchange, and interpret messages about ideas, emotion, and mind states

Critical judgment:

an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response

Level 3 (commitment) of critical thinking

anticipate when to make choices without assistance from others and accept accountability for decisions made

Level 2 (complex) of critical thinking

begin to separate from experts; begin to analyze the clinical situation and examine choices more independently

Reflection ON action

considering the situation, response, outcomes after patient care has occurred; LOOKING BACK ON WHAT HAS BEEN DONE ALREADY

scope ranges for communication:

effective communication --> no communication

Prioritization:

establishing priorities in nursing practice that the nurse made these decisions based on evidence obtained

Level 1 (basic) of critical thinking:

learner trusts that the experts have the right answers for every problem; thinking is concrete and based on a set of rules or principles

reflection IN action

nurse's understanding of patient responses to action while care is occurring; REAL TIME REFLECTION

Therapeutic communication:

specific responses that encourage the expression of feelings and ideas and convey acceptance and respect

Critical thinking:

the ability to think in a systematic and logical manner with openness to a question and reflect on the reasoning process

Delegation:

transferring responsibility for the performance of an activity or task while retaining accountability for the outcome