Clinical judgement process Flashcards
Unit 1
What is critical thinking?
A thought process that is systematic and logical in reviewing information and data in order to make informed decisions.
What is clinical decision-making?
Decisions made using both experience and evidence based practice guidelines.
What does clinical reasoning require?
Clinical reasoning requires the nurse to have critical thinking abilities that are then applied to the practice setting (client care)
How is the nursing process used to make clinical judgements that present optimal outcomes?
Clinical judgment is clinical reasoning across an expanse of time. The nurse uses clinical reasoning in every nursing situation, repeatedly throughout the shift, and throughout the entirety of the nursing career. Clinical reasoning is a constant and repeated action that nurses use in practice. Clinical judgment is the idea of clinical reasoning that happens repetitively and forms a major nursing skill.
What is the nursing process?
A framework that guides nurses in delivering client-focused care that takes the entire person into consideration (spiritual, mental, and physical).
What are the steps of the nursing process?
Assessment (Recognize cues)
Analysis (Analyze cues & Prioritize Hypotheses)
Planning (Generate solutions)
Implementation (Take Actions)
Evaluation (Evaluate Outcomes)
Assessment
The initial step of the nursing process, in which the nurse collects, organizes, and validates data by using critical-thinking skills. The nurse thinks critically to perform a comprehensive assessment of subjective and objective information.
Objective data vs Subjective data
Data that can be observed by the nurse through the senses. VS Data that is based upon the client’s (subject’s) feelings, perception and assumptions.
Analysis
During analysis, the RN reviews the client’s assessment findings to determine the client’s problem(s). The nurse identifies patterns or trends, compares the data with expected standards or reference ranges and draws conclusions to direct nursing care.
Planning
The RN makes plans to address the client’s problems by formulating individualized interventions and goals to ensure the client achieves a positive outcome.
What is a plan of care?
A plan including the client problem (analysis), plans and goals, implementation, and responses; it is used by the interprofessional health care team.
What is an interprofessional healthcare team?
A group including members from different disciplines who work collaboratively with the client to make decisions and set goals.
Implementation
Involves taking action to provide nursing care as outlined in the client’s plan of care. During this step the nurse will also delegate and supervise care and document the care and the client’s response.
Evaluation
he RN evaluates the effectiveness of the interventions provided and documents the client’s response. During this step the nurse will also assess client/staff understanding of instruction, the effectiveness of interventions, and identify the need for further intervention or the need to alter the plan.
What are the steps in the nursing process for LPNs?
Data collection
Planning
Implementation
Evaluation
