Concept - Clinical Judgement

Tanner's Model of Clinical Judgement

1. Noticing 2. Interpreting 3. Responding 4. Reflecting

Differentiate among the three types of physical assessment:

A complete physical examination is typically performed on admission to the hospital, at an initial visit to a specialist, or during an annual physical. Focused assessments are most often done at the beginning of each shift but can be done more often, depending on the patient's condition, evolving complications, and health care facility policies and guidelines. Emergency assessments, including triage, are conducted in emergent situations to quickly assess the extent of patient injuries and determine care priorities.

Differentiate among the three types of nursing diagnostic statements:

Actual nursing diagnoses describe the response of a patient to a current need, problem, or life process. Risk nursing diagnoses identify specific potential problems in individuals vulnerable to developing complications due to their current disease state or life experience. Health-promotion nursing diagnoses are clinical judgments based on the expressed desire of patients, families, or groups for change (NANDA-I, 2012).

Outline nursing diagnoses with appropriate components:

Actual nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion nursing diagnoses are also written with only two sections: a diagnosis label and defining characteristics.

Clinical Judgement - definition

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.

Identify methods used during the assessment phase of the nursing process:

Assessment requires observation; a patient interview, including collection of demographic data; a health history; a review of systems; and a physical examination.

Nurses design interventions that are:

Based on clinical reasoning and expected to help the patient meet goals quickly

Apply strategies used to conduct a patient interview, health history, and review of systems:

Controlling the physical environment, preventing interruptions, and limiting the number of people present are essential to conducting a thorough patient interview that protects patient privacy. Various forms of therapeutic communication are used to encourage patient sharing of critical information. Using a structured order for collecting data during the interview process facilitates completion of a thorough patient health history. Data may be collected and organized according to body system, from head to toe, or by Gordon's functional health patterns. Health assessment questions help to identify concerns related to each area of the body during the review of systems.

The nurse uses clinical judgment to compare actual nursing outcomes to the expected nursing outcomes to:

Determine if progress is made or to determine if revisions are needed.

Describe different types of direct-care interventions:

Direct care refers to interventions that are carried out by having personal contact with patients. Direct nursing interventions include reassessing patients, assisting with ADLs, giving physical care, counseling, and teaching.

Articulate nursing actions that take place during the planning process:

During planning, the professional nurse prioritizes the patient's nursing diagnoses, determines short- and long-term goals, identifies outcome indicators, and lists nursing interventions for patient-centered care.

Describe the steps in the nursing process:

During the assessment step of the nursing process, patient care data are gathered. In the diagnosis step, patient data are analyzed to identify patient problems and then are stated as specific nursing diagnoses. During the third step of the nursing process, planning, the nurse prioritizes the nursing diagnoses and identifies goals with specific outcome identification. The implementation step includes initiating specific nursing interventions designed to help achieve established goals. During the evaluation step, the nurse determines goal attainment, the effectiveness of interventions, and whether the plan of care should be discontinued, continued, or revised.

who should report to a RRT?

ER nurse, respiratory therapist, nursing supervisor, charge nurse from the unit, the patient's nurse

Identify formats in which patient-centered plans of care can be developed:

Each health care facility or agency has its own electronic health record or form on which patient care plans are formulated and documented. In some agencies and specialty units, standardized care plans, which must be individualized for each patient, are available to guide nurses in the planning process. The conceptual care map (CCM) is a format for nursing students to use when developing patient care plans. It helps students to accurately collect, analyze, and synthesize patient data that are used to identify appropriate nursing diagnoses, goals, and interventions.

Illustrate an understanding of goal development:

Goals need to be patient centered, realistic, and measurable. Using measurable verbs and time limits when writing goals assists the nurse in evaluation of patient goal attainment.

Describe the historical development of NANDA-I and the nursing taxonomy:

In 1973, the first conference of nurses met to develop a nursing taxonomy. The group continued to meet every 2 years and officially became the North American Nursing Diagnosis Association in 1982. In 2002, the group became NANDA International to acknowledge worldwide interest in nursing taxonomy. It continues with the original goals of generating, naming, and implementing nursing diagnostic categories, as well as revising the taxonomy, promoting research, and encouraging nurses to use the taxonomy in practice.

Identify examples of independent nursing interventions:

Independent nursing interventions are tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order. The extent to which nurses can implement independent nursing interventions is often determined by the area in which care is taking place.

Differentiate among various forms of indirect-care interventions

Indirect care includes nursing interventions performed to benefit patients without face-to-face contact. Indirect nursing interventions include communicating and collaborating with other health care team members, making referrals, doing research, advocating, delegating, and engaging in preventive actions such as patient education and health promotion.

Use the four physical assessment techniques when examining each body system:

Inspection, palpation, percussion, and auscultation techniques are used to various degrees in assessing each body system. Auscultation precedes palpation and percussion during abdominal assessment to avoid stimulation of bowel sounds that may cause erroneous assessment findings.

Describe various measures used in prioritizing patient care:

Maslow's hierarchy of needs and the ABCs of life support in the health care setting are helpful resources in prioritizing care. Collaboration with patients while developing goals can decrease the incidence of conflicting priorities.

Four key aspects of the Clinical Judgement Model and the sequence in which they occur.

Noticing, interpreting, responding, reflecting

Explain the significance of implementation and evaluation in the nursing process:

Nurses and other members of the interdisciplinary health care team provide care through interventions designed to promote, maintain, or restore a patient's health during the implementation phase of the nursing process. Implementation consists of performing a task and documenting each intervention. Evaluation focuses on the patient and the patient's response to nursing interventions and outcome attainment. Evaluation data are used by the nurse to adapt a plan of care on the basis of the patient's changing health status.

Explain basic nursing diagnosis methodology

Nursing diagnosis is the second step of the nursing process. When deciding on an accurate nursing diagnosis for a patient, the nurse makes clinical judgments about a patient's experiences and responses to identified problems or life events expressed during the data collection process.

Responding

Once the patient data have been sorted and interpreted, the nurse uses his or her interpretation to respond to the particular patient issue through one or more nursing interventions.

what is the purpose of the nursing process?

Organizing the ways nurses think about patient care

Describe the relationship between outcome identification and goal attainment:

Outcome identification, added by ANA in 1991 as a specific aspect of the nursing process, involves listing observable behaviors or items that indicate attainment of a goal.

Discuss the environmental and patient care activities that should be completed before and during history taking and physical examination:

Patient safety and comfort are primary concerns during physical examination. Room temperature, drafts, accessibility of the examination table, and availability of blankets and pillows to assist with positioning and comfort are taken into consideration. Physical assessment equipment is collected and organized before initiation of an examination. Patients are gowned and draped as needed to ensure access to assessment areas. Family members or care providers may be present during an examination to assist in positioning and to prevent patient injury from falls. Permission for others to be present during the physical examination is obtained from competent adult patients.

Categorize the types of data collected during the assessment process:

Primary data are obtained directly from a patient, whereas secondary data consist of information collected from family members, other members of the health care team, and medical records. Subjective data are symptoms or spoken information. Objective data are signs or information that is observed.

Reflection-in-action

Reflection-in-action refers to the nurse's understanding of patient responses to nursing actions while care is occurring

Reflection-on-action

Reflection-on-action is consideration of the situation after the patient care occurs. In reflection-on-action, the nurse contemplates a situation and considers what was successful and what was unsuccessful.

A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first?

Severity and duration of the nausea and vomiting. an emergent situation, the nurse initially focuses on the patient's chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.

Use strategies to validate patient assessment data:

Sometimes, the nurse can use laboratory and diagnostic test results to validate subjective data. In some cases, cues validate symptoms reported by patients. In other cases, confirming the validity of collected data requires verbally checking with the patient to see whether the nurse's assumptions or conclusions are correct.

Antecedents of clinical judgement

Sound judgement skills, analytical reasoning skills, awareness of patient and self, creativity/inquisitiveness, sound knowledge base, persistence

Describe techniques used during physical assessment:

The assessment techniques of inspection, palpation, percussion, and auscultation are performed one at a time in this order for each body system except during assessment of the abdomen. During abdominal assessment, auscultation precedes palpation, and percussion.

3 components of knowledge from which the nurse's "noticing" of the clinical situation is derived.

The background of the nurse (including intrapersonal characteristics, ethical grounding for what is right, previous experiences, and theoretical knowledge), the nurse's relationship with the patient, and the context of care.

Describe the historical development and significance of the nursing process:

The five primary steps of the nursing process were clearly identified by the early 1960s and have remained virtually unchanged since then, with only the addition of a subcategory to planning, outcome identification, in the early 1990s. Professional nursing practice in all types of settings is based on the nursing process. It is used to assess individuals, families, and communities; diagnose needs; plan attainable goals; implement specific interventions; and evaluate degrees of goal attainment.

Define the nursing process:

The nursing process is the scientific method through which professional nurses systematically identify and address actual or potential patient problems. Critical thinking, using the nursing process, allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs, establish realistic goals, and customize interventions with members of the health care team.

Articulate the characteristics of the nursing process:

The nursing process requires nurses to think critically. It is dynamic, organized, and collaborative, and it is universally adaptable to various types of health care settings.

What does Tanner mean by "reflect"?

Understanding of patient's responses while the care is occurring (in observations and interactions with the patient the nurse determines the patient's status and adjusts accordingly). Real time thinking during patient care. A critical step in evaluating the patient's response to interventions.

Interpreting

Using the particular patient data as well as germane theoretical and experiential knowledge, the nurse begins to assemble all the information to make sense of it.

what is the rapid response team used for?

assisting staff members in assessing and stabilizing a patient's condition and organizing information to be communicated to the physician.

3 attributes of clinical judgement

holistic view of the patient situation, process orientation, reasoning an interpretation

deductive reasoning

involves generating facts or details from a major theory, generalization, or promise (general to specific)

critical thinking

involves the application of knowledge and experience to identify patient problems and to direct clinical judgements and actions that result in positive patient outcomes

reasoning

logical thinking that links thoughts in a meaningful way

processes that depend of critical thinking

problem solving, decision making, reasoning, judgement

Elements of critical thinking

problem solving, diagnostic reasoning, decision making, clinical judgement (deciding course of action), nursing process

Interrelated concepts - clinical judgement

safety, health care quality, leadership, patient education, evidence, professionalism, care coordination

SBAR

situation, background, assessment, response/recommendations

failure to rescue

the inability to save a patient's life after the development of a complication (complication occurring after the 2nd day in hospital or after sx)

Example of Reflection-in-action

the nurse chooses a pain medication dose based on many factors; while administering the medication intravenously, the nurse is continually assessing and reflecting on the patient's response to medication. This is an example of reflecting-in-action. If the desired response is not achieved, the nurse may need to return to interpreting the data in order to respond with a different intervention.

Example of Reflection-on-action

the nurse may take some time at the end of his or her shift to analyze why he or she intervened in a specific way for this particular patient and to consider whether the intervention was successful. Reflection-on-action is when significant learning from practice occurs and it is important to the development of increasing skillfulness as a nurse.

validation

the process of gathering information to determine whether the information or data collected are factual and true

clinical reasoning

uses critical thinking, knowledge, and experience to develop solutions to problems and make decisions in a clinical setting

inductive reasoning

uses specific facts or details to make conclusions and generalizations; it proceeds from specific to general