Clinical Judgement Flashcards
What are 2 levels of knowledge in nursing practice?
Basic - foundational thinking
Highest- critical thinking
Define foundational thinking
the ability to recall AND comprehend information that is foundational to nursing practice
Define critical thinking
Thinking skills used to determine action to take including:
Interpretation
Analysis
Evaluation
Inference
Explanation
What is involved in interpretation?
Recognize, describe, and understand data and communications
What is analysis?
Examine, organize, validate, and prioritize
Includes signs and symptoms, data, beliefs, and communications
What is evaluation
Assess sources of info for validity and strength of evidence
what is inference?
The ability to draw conclusions based on evidence, identify the difference between a hypothesis and conclusion, and recognize where there are gaps in understanding
What is explanation?
Clarifying reasoning and conclusion with evidence, concepts, context (written or oral with provider)
Define clinical judgement
The decision made about a course of action based on critical analysis of data
What are the steps of the clinical decision making process?
- Identify the problem
- Analyze and interpret the data.
- Make inferences based on this data to come up with potential causes
- List all possible courses of action
- Evaluate each course of action and possible outcome.
- Choose the best option,
The end result of the process is clinical judgement
What are the 5 stages of nurse competency
Novice
Advanced Beginner
Competent
Proficient
Expert
T or F: your client is only your patient
False. The client can be the patient, family, community, or groups
Steps of the nursing process
Assessment: collecting subjective and objective data
Analysis: drawing conclusions about what the data indicates
Planning: development of plan of care to meet pt goals
Implementation: put the plan into place
Evaluation: determine if plan was effective
What is the Plan-Do-Study-Act cycle?
A plan for quality improvement involving:
Plan changes
Implement changes
Study whether changes worked
Act to implement modifications
Describe the process audit
Evaluates the process of delivering care (assumes there is a relationship between the care process and quality of care)
Describe the structure audit
Determine the impact of structure on the provision of care (ex: staff ratios, supply availability, etc)
Describe the outcome audit
Examines patient outcomes in connection to care, such as pt satisfaction, wait times, treatment success, length of stay
What is root cause analysis?
A response to a sentinel event, like death
Determines the cause of the event so action can be implemented to prevent it from occurring again
What is the Privacy Act of 1974?
Protects pt’s right to privacy by allowing them to prevent disclosure of health info to other’s, including providers
What is the Health Insurance Portability and Accountability Act of 1996?
Establishes guidelines required to maintain pt confidentiality
What agency creates National Patient Safety Goals?
The Joint Commission
