Clinical Judgment Flashcards
4 steps of Tanners Model of Clinical Judgment
Noticing
Interpreting
Responding
Reflecting
ADPIE
Assessment
Dx(Nursing)
Planning
Implementation
Evaluation
NANDA
North American Nursing Diagnoses Association- national
3 Types of Nursing Diagnoses
- Actual
- Risk
- Health Promotion
The PES format
(Problem) Nursing Dx——-(Etiology) related to——–(symptoms) as evidenced by.
S. M. A. R. T goals
Specific. Measurable. Attainable. Realistic. Timetable
3 Ws and 2Hs for interventions
- Who will do it
- What will be done
- When will it be done
- How much will be done
- How often will it be done
Evaluating what the PATIENT did:
Describe as Met, Not Met, or Partially Met ( if one of the two goals were met)
Evaluation:
Goals/ Outcomes
Evaluating what the NURSE did
Described as:
Effective, Not Effective, or Partially Effective
Evaluation:
Interventions
The interpretation or conclusion about a patients needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patients response
Clinical Judgment