Review of Clinical Judgement, Nursing Process and Care Plans Flashcards
clinical judgement
interpretation or conclusion about a patient’s needs, concerns or health problems, and/or the decision to take action (or not), use or modify standard approaches, or develop new ones as deemed appropriate by the patient’s response (outcome)
clinical reasoning
the processes by which nurses make judgments, including generating alternatives, weighing them against evidence, choosing the most appropriate; also involves recognizing patterns, using intuition, and tacit knowledge
noticing
focused observation, recognizing deviations from expected patterns, information seeking
interpreting
developing a sufficient understanding of the situation, involves using one or more reasoning patterns to interpret the meaning of the data and determine an appropriate course of action, making sense of and prioritizing data
responding
deciding on a course of appropriate action for the situation
reflecting
involves both reflection-in-action and reflection-on-action
assessment
deliberate, systematic collection of subjective and objective data
planning
nurse sets client-centred goals, outline expected outcomes, plans nursing interventions that will resolve the client’s problems
implementation
similar to responding; requiring cognitive interpersonal and psychomotor skills
evaluation
similar to reflection; enables you to determine the client’s response to nursing care
Nursing Process: ADPIE
assessment, diagnosis, planning, implementation, evaluation
what is a nursing care plan?
a step by step process that nurses use to provide appropriate and effective nursing care
NANDA International
the authoritative organization for developing and approving nursing diagnoses
subjective data
what a person says about him or herself; only clients provide subjective data
objective data
data from a general survey, physical examination and laboratory or diagnostic studies
primary data
comes from the client
secondary data
family and s/o, HC team, medical records
tertiary data
literature and nurses’ experience
what does a nursing diagnosis do?
determines health problems within the domain of nursing
what is a nursing diagnosis a clinical judgement about?
the individual, family, or community response to an actual or potential health problem, rather than on the physiological event complication or disease
collaborative nursing diagnosis
nurses also encounter client problems that must be managed collaboratively w/ other personnel from other health disciplines
what are the components of a nursing diagnosis?
diagnostic label (problem), the etiology identified from the pt’s data base (“related to”) and defining characteristics (supporting evidence)
types of nursing diagnoses
actual client problem, health risk, health promotion challenge, wellness
actual client problem
a problem the client actually has; sufficient assessment data are actually available to say this is a problem for the client
health risk
a problem that could develop in a vulnerable individual
health promotion challenge
a person expresses readiness to enhance specific health behaviours
wellness
this represents a level of wellness the client has achieved, but the client could move to a higher level of wellness, improving the level of coping in a client
who or what may you need to collaborate with in nursing planning?
the family, HC team, client and related literature
priority setting
the ranking of nursing diagnoses or client issues, determining which problem is more important or urgent; establish a preferential order for nursing actions and requires critical thinking
what consideration must be made in priority setting?
you must attend to the client’s most important need first, considering their physiological condition; the order of priorities changes as a client’s condition changes
what questions must you consider when setting goals?
what do you plan to achieve? what specific client behaviours do you want to see? what specific physiological responses do you expect? how will you know you have achieved your goal?
expected outcome
a specific measurable change in a client’s status
nursing intervention
any treatment based on clinical judgement and knowledge, to enhance client outcomes, and are evidence informed + based on client needs
cognitive skills
the use of critical thinking
interpersonal skills
the nurse has a trusting relationship, a caring attitude and communicated clearly with the client
psychomotor skills
this is the integration of cognitive and motor activities
