Ch 16 Flashcards
What is clinical judgement?
A conclusion drawn about pt needs and appropriate actions to take.
Helps:
Make informed and timely decisions
Deliver holistic, patient centered care
What is Nursing process?
•5 step process
• applies critical thinking skills
•application of evidence- based practice
What are the 5 steps I. The nursing process?
A-assessment
D-diagnosis
P-planning
I-implementation
E-evaluation
Clinical judgement steps
6 steps
•recognizing cues
•analyze cues
•prioritize hypotheses
•generate solutions
•take action
•evaluate outcomes
Recognize cues
Identifying relevant & important info from different sources(medical history, vital signs)
Analyze cues
Organizing & linking the recognized cues to the clients clinical presentation
-what client conditions are consistent w/the cues?
Prioritize hypotheses
Evaluating & ranking hypotheses according to priority(urgency, likelihood, risk, difficulty, time, etc)
Generate solutions
Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.
-what are the desirable outcomes
Take action
Implementing the solutions that address the highest priorities
Evaluate outcomes
Comparing observed outcomes against expected outcomes.
-what signs point to improving/decking/unchanged status?
-were the interventions effective
What is assessment?
Gathering of information
Assessment steps
-collect data
-interpret information
What helps you identify meaningful patterns
Cues you see
Applications of critical thinking
5— knowledge base
Environment
Experience
Standards
Attitudes
Types of assessment
There are 2
-patient centered interview:
•patient history-acute or chronic issue
• main complaint
•review medication
-periodic assessments
•conducted ongoing
• assessing each time you enter the room
Subjective data
What the patient tells you
Objective data
What you see; measurable output
- vital signs
Primary data
The patient provides
Secondary data
Information from family, friends, nurses, or anything in the medical records.
Patient centered interview
Orientation: introduction; tells the pt why you are there
Working phase: talking, collecting data, setting a mutual goal
Termination phase: summarizing the data/info to ensure it is accurate