Clinical Judgement Through the Nursing Process & Priority-Setting Frameworks

Five level acuity rating

1 is severely ill; 5 is least ill

Maslow's Hierarchy of Needs

1. physiological 2. safety 3. love/belonging 4. self-esteem 5. self-actualization

A nurse is caring for a client who has asthma. Which of the following actions should the nurse identify as the priority? A. Auscultate lung sounds B. Check blood pressure C. Compare bilateral radial pulses D. Determine capillary refill

A Use ABCDE BCD are part of Circulatory

A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions should the nurse take when completing the exposure component of this priority setting method? (Select all that apply.) A. Observe the client's lower extremities for indications of deep vein thrombosis. B. Obtain a respiratory rate for one full minute. C. Measure the client's temperature. D. Check the client for bruising. E. Obtain a blood pressure measurement.

A, C, D B: part of breathing E: part of circulation

acute vs chronic

Acute - manifestations severe and worsen rapidly, priority like asthma attack Chronic - progress and worsen over time

Nursing Process

Assessment Analysis Planning Implementation Evaluation

A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first? A. A client who is scheduled for an abdominal ultrasound B. A client who needs a urine specimen sent to the lab C. A client who has audible wheezing during respirations D. A client who requests their routine pain medication

C

Critical vs Urgent vs Routine vs Extra

Critical: immediate intervention (chest pain, respiratory distress, neuro change) Urgent: pt could suffer mild harm/discomfort with delay Routine: admin meds, assessments Extra: warm blanket, combing

NCSBN Clinical Judgement Model

Layer 0: pt needs influence judgement which feed into decision which feeds back to pt needs Layer 1: shows judgment is used to form/refine hypotheses and evaluations of layer 2 Layer 2: RN forms hypotheses about possible pain relievers Layer 3: RN always goes back to judgement with various influences -> form solutions Layer 4: RN accounts for environment, pt observ., med data, time pressure

unstable vs stable

Unstable - uncontrolled bleeding, resp. Distress, changing BP

urgent vs nonurgent

Urgent - bed alarm Nonurgent - itching, urination pain

Due to increased shortness of breath, an older adult client was brought to an urgent-care clinic by their adult child. The child reported that the client had become increasingly short of breath over the previous two days. The client has a history of anxiety, and has fallen two times within the past week. Their child reports that the client has been upset recently at the loss of their best friend, whom they had known for many years. The client's vital signs are as follows: BP 130/84 mm Hg, pulse 88/min, respiratory rate 24/min, oxygen saturation 90% on room air. The client's adult child asks the nurse what their plan of action is in caring for the client. What should the nurse identify as this client's priority problem?

When using Maslow's hierarchy of needs, the nurse should identify the client's physiological needs as the priority. This client is experiencing increased shortness of breath, and his respiratory rate and oxygen saturation levels are above the expected range. The nurse should administer oxygen to the client.

Clinical Reasoning

mental process used when analyzing the elements of a clinical situation and using analysis to make a decision

survival potential framework

on doing the most good for the maximum number of clients at a time when health care resources are limited due to a large number of injuries Emergent (red)- highest priority/immediate: high chance for survival Urgent/delayed (yellow) - serious and extensive injuries/ do not pose immediate threat to life/ potential for survival even with delay Nonurgent/minimal (green) - less serious and less extensive/ no threat/ can wait Expectant (black) - no potential survival

safety and risk reduction

priority given to whatever finding poses greatest/immediate risk to pt's physical/psychological well-being

triage

ranking of patients to determine their relative priority of need and the proper place of treatment

clinical judgment

reasoning across expanse of time; repetitive

ABCDE Approach

recognize and stabilize the client's most critical issues first, and then move to the next vital system Airway: O2 sat/obstructions Breathing: status Circulation: BP; cap refill; pulse; perfusion Disability: neuro status; LOC; response Exposure: head to toe assessment