Clinical Judgment Flashcards
What is Clinical Judgment
Nurses conclusion and interpretation of data to determine the best response for the patient.
APPIE
The nursing Process
What does A stand for in APPIE?
Assessment
Assessment
Involves collecting data and information from pt.
What does the first P stand for in APPIE?
Nursing Problem
Problem
-Not a medical diagnosis
-What is the problem I identified from the data?
-analyze and interpret Cues
Problem focused statement
______(problem) related to ________(related factors/etiology) as evidenced by _______(defining characteristics/symptoms)
Risk Statement
Risk for _____ related to ____(risk factors)
What does the second P stand for in APPIE?
Planning
Planning
-Set priorities
-Goals
-Nursing Interventions
-Collaborate with pt, family and providers
Goals
SMART format
Patient Focused
Customized for pt
SMART
Specific, Measurable, Attainable, relevant,Timely
What does I stand for in APPIE?
Implement
Implementation
Perform interventions
Continually re-assess pt.
What does E stand for in APPIE
Evaluation
Evaluation
Reflection
Determine if goals and expected outcomes are achieved
Tanners Model
Noticing
Interpreting
Responding
Reflecting
Noticing
Collect data
Identify signs and symptoms
Assessment
Interpreting
Cluster related info
Recognize inconsistencies
Check accuracy and reliability
Distinguish relevant and irrelevant
Create nursing problems
Responding
Course of action
Implement a plan
Set priorities
Nursing skills
Reflecting
Process of thinking and learning experiences
Reflection in action
In real time while care is occurring
Reflection on action
After the pt care occurs
Objective
What you see
Subjective
Things that you are told
