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
Assessment barriers
Setting
Time
Task complexity
Interruptions
Examples of cues
-Incision red, draining pus, edges separated
-Tearful. Stated father died of a heart attack.
Examples of inferences
•incision is infected
•anxious about scheduled cardiac catherization
•patient is angry and suicidal
(Assuming, trying to diagnose)
Obtaining a health history
• biographical data
-name, gender, address
•chief concerns/why they are seeking care:
- how long has this been going on
•patient expectations
•present illness of health concern
(P) provokes
(Q) quality
(R) radiate
(S) severity
(T) time
Analyze cues(nursing diagnosis)
-2nd step in nursing process
-links assessment to all steps that follow
- describes pts PRESENT health status
Medical diagnosis
Comes from the physician
Nursing diagnosis
Comes from the nurse; is a potential health issue
Collabrative problem
Involves nurses and physicians interventions
Types of nursing diagnosis
• Problem focused:
This is actually going on w/patient.
• Risk
What could potentially happen.
Problem focused
Evidence (cues) proven issues (symptoms)
Risk
Possibilities; has not occurred
3 part nursing a diagnosis (actual problem)
Problem+etiology+symptoms
2part nursing diagnosis(risk or potential problem)
Problem+etiology
Maslo es hierarchy of needs
5 levels
- physiological needs
- safety & security
- love&belonging
- esteem
- self-actualizacion
What to put in care plan?
-basic needs & activities of daily living (ADLs)
-Medical.multidisciplinary treatment
-nursing diagnoses & collaborative problems
-special discharge needs or teaching
Expected outcome
Willa always be opposite of diagnosis
Patient centered goals
Highest level of function goals for patient
SMART GOALS
S-specific
M-measurable
A- achievable
R- realistic
T- timely
Components of a goal statement
Have 3 things
-subject
-action verb
-performance criteria
-target time
-special conditions
Ex:
The pt will walk to the doorway w/the help of one person by 11/21/17
Take action (implementation)
- 4th step in the nursing process
-begins after plan of care is developed
-Puts the plan into action to promote positive pt outcome
Evaluate outcomes (evaluation)
5th step in the nursing process
Nursing interventions
5 nursing interventions
Direct care interventions
Indirect care interventions
Dependent interventions
Independent interventions
Other provider interventions
Direct care interventions
Directly helping patient; bedside
(Oral care)
Indirect care interventions
What you do on behalf of the patient away from bedside
Advocating, giving report
Dependent intervention
Waiting on physician to give order
(Medication, o2)
Independent interventions
You do not need a physicians order
(Keeping head of bed elevated)
Other provider interventions
Collaborative intervention, giving patient medication, then turning patient
Evaluation measures
Physical: listening to lungs, looking for physiological changes
Behavioral: going by what the patient tells you; relying on what is told
Discontinuing a care plan
A care plan is discontinued once it is effective and has worked
Modifying a care plan
A care plan is modified when it has not work and need a reevaluation
