Evidence Based Practice and Clinical Judgment

After formulation of the research question or hypothesis, the next step in the research process is to A. Select the population B. Review the literature C. Design the study protocol D. Discussion and/or clinical implications

C. Design the study protocol

This part of the PICOT question identifies what is the usual standard of care or current interventions used now and practice?

Comparison of Interest

EBP step 3

Critically appraise the evidence

A nurse assesses patients and uses assessment findings to identify patient problems and develop an individualized plan of care. The nurse is displaying A. Organizational skills. B. Use of resources. C. Priority setting. D. Clinical decision making.

D. Clinical decision making.

An older client with heart failure is experiencing activity intolerance due to dyspnea on exertion. Which nursing intervention is a priority for the client? A. Complete all nursing care at the end of the shift. B. Delegate care for the client to an aide. C. Complete all nursing care in the morning. D. Pace nursing care throughout the shift.

D. Pace nursing care throughout the shift.

CDM dehydration

Deciding appropriate nursing interventions to resolve dehydration.Normal hydration and minimize electrolyte imbalance.Caution to avoid causing overload that may exacerbate heart failure, compromise circulatory perfusion, and lead to respiratory failure.

CDM Infants

Infants progress from reflexive behavior to simple, repetitive behavior and then to imitative behaviors, learning the concepts of cause-and-effect in a object permanence

EBP step 4

Integrate the evidence with your clinical expertise and patient preferences to make the best clinical decision

PICOT

Population Intervention Comparison Outcome Timeframe

EBP step 2

Search for the best evidence

Interpreting (tanners)

using logical reasoning to gain understanding about a situation and determine appropriate actions

noticing (tanners)

what is happening in patient situation, recognition of or absence of expected significant cues from patients response to illness

Ask a clinical question

A problem or area of interest that could be performed more efficiently, consumes healthcare dollars, or does not make sense. A knowledge focused trigger. Clinical trends. Utilization of PICOT format to state your clinical question

After receiving the morning report, the nurse prioritizes care needed by several clients. What factors should the nurse keep in mind when creating this priority list?Select all that apply. A. Client condition B. Safety C. Time available D. Client preferences E. Time of day

A,B,C,D A. Client condition B. Safety C. Time available D. Client preferences

A nurse asks a client to rate their current level of pain using a scale of 0 to 10 after administering pain medication 30 min ago. Which of the following steps of the nursing process is the nurse performing? A. Evaluation B. Implementation C. Analysis D. Planning

A. Evaluation

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? A. Explore other options for pain relief. B. Discuss the surgical procedure and reason for the pain. C. Explain to the patient that nothing else has been ordered. D. Offer to notify the health care provider after morning rounds are completed.

A. Explore other options for pain relief.

ABCDEs

Airway, Breathing, Circulation, Disability, Exposure

In what order should an RN perform the steps of the nursing process? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Implementation Assessment Evaluation Planning Analysis

Assessment. anaylysis. planning. implmentation. evaluation

A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. What should the nurse do first? A. Notify the physician. B. Complete a thorough cardiopulmonary assessment. C. Administer 10 L of oxygen per face mask. D. Reposition the client to help with breathing.

B. Complete a thorough cardiopulmonary assessment.

A nurse is caring for a client who has been wheezing. The nurse asks an assistive personnel (AP) to use a stethoscope and listen to the client's lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts? A. Delegation of the right circumstance B. Delegation of the wrong task C. Delegation to the right person D. Delegation of the wrong time

B. Delegation of the wrong task

A nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using?A. Evaluation B. Implementation C. Analysis D. Assessment

D. Assessment

Evaluate and share outomes

Did it work? Is it effective? Communicate the results to various groups of nurses or other care providers (facility nursing practice council or research committee)

right time

EARLY recognition of worst possible/most likely complication

EBP step 5

Evaluate outcomes of the practie decisions or changes based on evidence

CUS words

I am Concerned I am Uncomfortable This is a Safety issue

How should the nurse initiate the research process?

Identify a researchable problem.

CDM neurological deficits

Reducing environmental stimuli with the potentially to increase the patients intracranial pressure.Clinical decision to avoid overwhelming the patients sensory perceptions.

EBP step 6

disseminate the outcomes

RIght cues

identify and recognize what clinical data is relevant or most important

Critically appraise evidence

most difficult step in EBP. involves evaluating, determining the value, feasibility, and usefulness of evidence for making practice change

There are many barriers that affect the actual implementation of evidence-based practice (EBP) in a nursing environment. Which statements reflect the most significant concerns of nurses in the community-focused setting?Select all that apply. A.EBP requires compliance by the client. B.EBP requires little support. C.EBP demands change. D.EBP questions long-standing nursing practice. E.Lack of resources

A,D,E A.EBP requires compliance by the client. D.EBP questions long-standing nursing practice. E.Lack of resources

A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make? A. "Critical thinking is the foundation for clinical decision making." B. "Critical thinking takes into consideration nursing, scientific, and technological knowledge in client situations." C. "Critical thinking is the visible or observed outcome while using evidence-based practice." D. "Critical thinking is necessary for the nurse to collect objective client data."

A. "Critical thinking is the foundation for clinical decision making."

CDM adolescents

Able to think abstractly and are able to participate in healthcare decisionsComplex and, when possible, should involve the patients assent to procedure, though the parental consent is still required

A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: A. Evaluative measures. B. Expected outcomes. C. Reassessments. D. Standards of care

B. Expected outcomes.

CDM school age children

Concrete thinkersBenefit from simple, direct explanations; hands-on exploration of equipment and materials; in helping the care provider as appropriate during procedures

The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? A. Provide privacy and check on the patient 30 minutes later. B. Set a box of tissues at the patient's bedside before leaving the room. C. Limit visitors while the patient is upset. D. Ask the patient about the crying.

D. Ask the patient about the crying.

Conflict Resolution Strategies

Ignore the conflict Confront the conflict Postpone the conflict

The standard of care or alternative interventions can be used as comparisons of interest in the PICOT model a. True b. False

a. True

NCSBN Clinical Judgment Measurement Model

recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes

Collect the Best Evidence (what kind)

1. Use scientific literature for evidence i.e. CINAHL, MEDLINE, PUBMed 2. Peer-reviewed = article reviewed by panel experts familiar with topic before it was published

Which of the following statements correctly describes the evaluation process? (Select all that apply.) A. Evaluation is an ongoing process. B. Evaluation usually reveals obvious changes in patients. C. Evaluation involves making clinical decisions. D. Evaluation requires the use of assessment skills. E. Evaluation is only done when a patient's condition changes.

A,C,D A. Evaluation is an ongoing process C. Evaluation involves making clinical decisions. D. Evaluation requires the use of assessment skills.

The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died. On which area(s) should the nurse focus when performing this reflection? Select all that apply. A. Things that could have been done differently B. Gut reactions to the situation C. Things that were done well D. Resources that were used at the time E. Resources that were needed but not available

A,C,D,E A. Things that could have been done differently C. Things that were done well D. Resources that were used at the time E. Resources that were needed but not available

A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.) A. The skin around the wound is tender to touch. B. Fluid intake for 8 hours is 800 mL. C. Patient has a heart rate of 78 beats/min and regular. D. Patient has drainage from surgical wound. E. Body temperature is 38.3° C (101° F). F. Patient states, "I'm worried that I won't be able to return to work when I planned."

A,D,E A. The skin around the wound is tender to touch. D. Patient has drainage from surgical wound. E. Body temperature is 38.3° C (101° F).

The nurse is doing a literature review related to a potential problem that has been identified on the nursing unit. The nurse realizes that nursing research is important in that it is designed to (Select all that apply.) A. Enhance the nurse's chance at promotion. B. Identify new knowledge. C. Improve professional practice. D. Enhance effective use of resources. E. Lead to decreases in budget expenditures

B,C,D B. Identify new knowledge. C. Improve professional practice. D. Enhance effective use of resources.

A client begins to vomit blood. The nurse immediately measures the blood pressure and prepares to insert a nasogastric tube while directing others to notify the physician and prepare to perform iced saline lavage. Which feature(s) of the Tanner Clinical Judgment Model did this nurse demonstrate? Select all that apply. A. Presencing B. Noticing C. Empowerment D. Interpreting E. Responding

B,D,E B. Noticing D. Interpreting E. Responding

The best definition of Evidence Based Practice (EBP) is which of the following A. EBP is a process involving the examination and application of research findings or other reliable evidence that has been integrated with scientific theories B. EBP is a process involving the integration of time honored methods of patient care with scientific theories C. EBP is a process involving the examination and application of medical research findings integrated with historical patient care interventions D. EBP is a process involving the examination and application of research findings or other reliable evidence that has been ordered by the physician

B. EBP is a process involving the integration of time honored methods of patient care with scientific theories

The nurse is aware that using research to fill a gap in knowledge that requires a solution can have what affect on patient care? A. Promote health across the lifespan and increase hospital length of stay B. Improve clinical outcomes and promote health across the lifespan C. Improve clinical outcomes and decrease disease incidence D. Decrease hospital length of stay and decrease disease incidence

B. Improve clinical outcomes and promote health across the lifespan

A nurse researcher finds four useful resources. What is an appropriate next action? A. Decide whether the four resources provide a strong enough base for the topic. B. Review the resources in the articles. C. Talk to the librarian. D. Expand the topic.

B. Review the resources in the articles.

The nurse is assigned two clients. One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO2 of 85. Why does the nurse decide to see the client with pneumonia first? A. The nurse can delegate postoperative teaching to unlicensed assistive personnel (UAP). B. The client with pneumonia needs more care than the client needing postoperative teaching. C. The client with pneumonia may be experiencing respiratory distress. D. The room of the client with pneumonia is closer than that of the client needing postoperative teaching.

C. The client with pneumonia may be experiencing respiratory distress.

Integrate the evidence

How will you incorporate the evidence into practice? Integrate evidence with use of teaching tools, clinical practice guidelines, policies and procedures, and new assessment documentation tools Consider staff support and available resources Conduct a pilot study and attempt to answer your PICOT question

Urgent vs Nonurgent

In the urgent vs nonurgent needs priority-setting framework, urgent needs are usually given priority because they pose more of a threat to the client. (Ex: call light may result in a fall, vs patient itchiness)

Tanner Model of Clinical Judgement

Noticing, Interpreting, Responding, Reflecting

5 rights of clinical reasoning

Right cues, Right patient, Right time, Right action, Right reason

TeamSTEPPS

Team Strategies and Tools to Enhance Performance and Patient Safety

PICOT question example

are _______ (P), who have _______ (I) compare to those without ________ (C) at risk for/of _________over _________ (T)?

Acute vs Chronic

Acute conditions are prioritized over chronic conditions because patients with acute conditions have less opportunity for physical adaptation compared to patients with chronic conditions.

A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? (Select all that apply.) A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice C. Eliminates need to create an individualized care plan for the patient D. Delivers evidence-based interventions for stage II pressure ulcer E. Summarizes the various approaches used for the practice concern or problem

A,B,D A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice D. Delivers evidence-based interventions for stage II pressure ulcer

The nurse is preparing to provide care to a group of clients. On which specific area(s) should the nurse focus in order to prioritize the clients' care needs?Select all that apply. A. Asking if any clients have complex issues B. Noting number of licensed staff assigned for the shift C. Noting time when the attending physicians make rounds D. Identifying clients with specific medication times E. Noting which clients have particular safety needs

A,D,E A. Asking if any clients have complex issues D. Identifying clients with specific medication times E. Noting which clients have particular safety needs

What are MEDLINE and CINAHL?

Among the best-known comprehensive databases that represent the scientific knowledge base of health care.

EBP step 1

Ask a clinical question in PICOT format

After reviewing the literature, the evidence-based practice committee institutes a practice change that bedrails should be left in the down position and hourly nursing rounds should be conducted. The results indicate over a 40% reduction in falls. What is the committee's next step? A. Evaluate the changes in 1 month. B. Implement the changes as a pilot study. C. Wait a month before implementing the changes. D. Communicate to staff the results of this project

D. Communicate to staff the results of this project

During the first step of evidence-based practice (EBP), development of a clinical question: A. Must follow the sequence of PICOT B. Does not allow for identification of key words C. Must contain all of the PICOT elements D. Does not have to follow the sequence of PICOT

D. Does not have to follow the sequence of PICOT A well designed PICOT question does not have to follow the sequence of PICOT. In addition, Intervention (I), comparison (C), and time (T) are not appropriate to be used in every question. The aim is to ask a question that contains as many of the PICOT elements as possible. Proper question formatting allows you to identify keys words to use when conducting your literature search

A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process? A. Evaluation B. Implementation C. Analysis D. Planning

D. Planning

A nurse receives a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? A. The client who needs assistance with activities of daily living B. The client who needs help ambulating to the bathroom C. The client with a pain rating of 3/10 D. The client experiencing shortness of breath

D. The client experiencing shortness of breath

CDM toddlers/preschoolers

Egocentric and engage in magical thinkingNeed explanations in language they can understand, use of dolls and toysSometimes can be given options, such as, "do you want your dressing change before breakfast or after?"

This part of the PICOT question identifies what to implement when utilizing EBP practice? Ex. Treatment, Diagnostic Test, or a Prognostic Factor?

Intervention of Interest

nursing barriers to EBP

Lack of k, nowledgeInformation overload, Lack of role models, Lack of time or money, Resistance to change, Misperceptions, require education

Right action

Once a problem is identified, what nursing interventions must be initiated?

Clinical-decision making involving children

Parents often make decisionsChildren can participate in those decisions in developmentally appropriate ways.Ability to reason and think critically about themselves in their situation develops gradually.

Evidence based practice

Systematic approach to rational decision making that facilitates achievement of best practices

Why should I use PICOT format to state my clinical question?

The questions you ask will eventually lead you to the evidence for an answer. You want to be able to read the BEST four-to-six articles that specifically address your practice question. The more focused a question you ask, the easier it becomes to search for evidence in the scientific literature

unstable vs stable

Unstable patients have experienced an acute change in condition whereas a stable patient has a condition that changes little over time. (Ex: uncontrolled bleeding vs mildly elevated BP with a history of hypertension)

EBP step 0

cultivate a spirit of inquiry

what should a nurse do to ensure effective communication?

document and report

Responding (tanners model)

includes analyzing your situation and choosing the best course of action; includes intuitive knowing from past similar experiences; includes using past similar experiences to make sense of a present clinical situation

Right pt

is your pt high risk for a change in status d/t age or being susceptible to infection?

Critical thinking requires...

lifelong learning and the ability to acquire relevant experiences that can be reflected on continuously to improve nursing judgment.

Right reason

rationale for implementing nursing interventions when a problem is recognized

Aim Statement

specific, measurable, acheivable, results, timebound.

PICOT format

*P* - Identify the population or problem (age, gender, ethnicity, disease/disorder) *I* - Intervention, or range of interventions of interest (exposure to disease, risk behavior, education) *C* - What will you compare the intervention against? (no disease, absence of risk factors, placebo or no intervention) *O* - Outcome of interest (risk of disease, rates of occurrence of adverse outcomes, accuracy of diagnosis) *T* - Time it takes for intervention to achieve the outcome (selected to observe the population or problem/condition)

ADPIE - Nursing Process

Assessment, Analysis, Planning, Implementation, Evaluation

Discussion of clinical implications

• Suggest actions that can be taken as a result of the research findings in the future • Other questions to answer: Will the procedure be effective with patients who have a different diagnosis? • Will age make a difference? What else do we need to know to improve the care of patients? • Also known as the rigor (potential threats to the validity and reliability of the study)

Best evidence includes

agency policy and procedure manuals, quality improvement data, existing clinical practice guidelines, agency experts, staff educators, risk managers, infection control nurses, and peer reviewed articles (specifically within the most recent 5 years from the present date)

A charge nurse is planning to discuss factors that can influence the clinical decision-making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include? (Select all that apply.) A. Appropriate delegation B. Cost of client care C. Available resources D. Awareness of client status E. Support from other staff

C,D,E C. Available resources D. Awareness of client status E. Support from other staff

Which of the following is an appropriate strategy to incorporate in attempting to overcome the barriers which can prevent the adoption of Evidence Based Practice in a healthcare facility? A. Have staff members work independently to make all policy changes B. Use a team approach and proven research when considering policy changes C. Avoid policy changes to maintain consistency in patient care D. Use an autocratic leadership to determine all facility policies

B. Use a team approach and proven research when considering policy changes

A nurse develops the following PICOT question: Do patients who listen to music achieve better control of their anxiety and pain after surgery when compared with patients who receive standard nursing care following surgery? Which information will the nurse use as the "C"? A. After surgery B. Who listen to music C. Who receive standard nursing care D. Achieve better control of their anxiety and pain

C. Who receive standard nursing care Do patients (P) who listen to music (I) achieve better control of their anxiety and pain (O) after surgery (T) when compared with patients who receive standard nursing care following surgery (C)?

Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? A. Drawing on past clinical experiences to formulate standardized care plans B. Relying on recall of information from past lectures and textbooks C. Depending on the charge nurse to determine priorities of care D. Using the nursing process

D. Using the nursing process

A client is admitted to the medical unit with a broken arm. The cast is still wet. What is the first action a nurse will take as the client is wheeled into the room? A. ask the client to put on a hospital gown B. ask the family to leave the room C. ask the family to wrap the cast in a towel D. ask the client about pain and check the fingers for circulation

D. ask the client about pain and check the fingers for circulation

A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) A. Assess condition of skin before making the call B. Rely on the nurse specialist to know the type of surgery the patient likely had C. Explain the patient's response emotionally to the repeated leaking of stool D. Describe the type of bag being used and how long it lasts before leaking E. Order extra colostomy bags currently being used

A,C,D A. Assess condition of skin before making the call C. Explain the patient's response emotionally to the repeated leaking of stool D. Describe the type of bag being used and how long it lasts before leaking

A nurse enters a client's room to check on the client's response to IV pain medication she gave on request 20 minutes earlier. She finds the client on her side lying very still and not wanting to move, and asks the client about her current pain level. Which aspect(s) of the nursing process does this action represent? Select all that apply. A. Assessment B. Diagnosis C. Planning D. Implementation E. Evaluation

A,D,E A. Assessment D. Implementation E. Evaluation

The nurse researcher is aware that PICOT is a research strategy mnemonic for which of the following components? A. Patient population or patient condition of interest, Intervention, Comparison of intervention, Outcome of interest , Total patients involved B. Patient population or patient condition of interest, Intervention, Comparison of interest , Outcome of interest , Time C. Patient population or patient condition of interest , Intervention, Comparison of intervention, Overarching alignment with practice , Time D. Patient disease or illness , Intervention , Comparison of interest , Outcome of interest , Total patients involved

B. Patient population or patient condition of interest, Intervention, Comparison of interest , Outcome of interest , Time

A nurse who works on a pediatric unit asks, "I wonder if children who interact with therapy dogs have reduced anxiety when they are in the hospital." In this example of a PICOT question, which of the following is the O? A. Children B. Therapy dogs C. The pediatric unit D. Anxiety

D. Anxiety

A client with congestive heart failure is having difficulty breathing. Before leaving the room the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A. Delegating a task B. Priority-setting C. Conflict resolution D. Critical thinking

D. Critical thinking

Reflecting (tanners)

using cognitive processes to review a clinical situation; considering appropriateness of assessment data obtained in the situation, actions taken, and positive ad negative outcomes for the patient; making mental response adjustments for similar future situations; learning from actions

A nurse is reviewing methods created to assist nurses in using evidence-based practice. Which of the following is a NCSBN® model that can assist the nurse with critical thinking and decision making? A. Clinical judgment B. Critical thinking C. Clinical reasoning D. SMART goal

A. Clinical judgment