Session 5: Clinical Judgement + Nursing Process

Question 1

What are the 3 components of EBP?

Answer 1

1. Best research evidence
2. Patient values
3. Clinical expertise

Question 2

The ____________ is a 5 step clinical decision making approach that focuses on patients specific needs.

Answer 2

Nursing Process

Question 3

The nursing process format is specific to nursing, but allows for ______ in all clinical settings.

Answer 3

Flexibility

Question 4

Learn the nursing process steps as _____, but use them ______.

Answer 4

Linear, dynamic

Question 5

Gather and analyze data

Answer 5

Assessment

Question 6

Make a judgement - identify the patient response to health response

Answer 6

Nursing Diagnosis

Question 7

Create a POC — includes setting goals/ expected outcomes, selecting interventions

Answer 7

Plan

Question 8

Carry out the plan/ POC

Answer 8

Implementation

Question 9

Evaluate patient response

Answer 9

Evaluation

Question 10

— Deliberate & systematic collection of info
— Two steps – collect data / interpret & validate
— From the patient (primary source)
o Interview, observation, physical exam
— From other sources (secondary)
o Family, other HC professionals, medical record

Answer 10

Assessment

Question 11

• Review info collected
• Classifies health problems within the domain of nursing — addresses pts response to their medical condition
• Medical vs Nursing
• Collaborative Problem
• NANDA

Answer 11

Diagnosis/ Problem

Question 12

• Setting priorities
• Severity / importance
• Identifying goals & expected outcomes
  o Pt centered, long/short term
  o Goals – broad / expected outcomes specific &
  measureable
• Selecting nursing interventions

Answer 12

Planning

Question 13

• Interventions to achieve the goal(s)
  o Direct / indirect
  o Practice guidelines and Standards of Care

Answer 13

Implementation

Question 14

• Have the goals been met?
• Evidence of expected outcomes?
• Ongoing
• Revision needed? Discontinue?
• Document

Answer 14

Evaluation

Question 15

Four Components
- noticing
- interpreting
- responding
- reflecting

Answer 15

Tanner Model of Clinical Judgement

Question 16

• Focused Observation
• Recognize Deviations from Expected Patterns
• Seeking Information — What additional information is
  needed?

Answer 16

Effective Noticing

Question 17

• Prioritizing Data
  
  • Identify the MOST RELEVANT and the MOST
    IMPORTANT data
  • Making Sense of Data
  • Make sense of complex, conflicting, or confusing
    data
  • Make sense of patterns
  • Use nursing knowledge and Intuition

Answer 17

Effective Interpretation

Question 18

• Examine ideas / inferences about patient problems• What information is needed to narrow down these possibilities – rule them “in” or “out”

Answer 18

Effective interpretation

Question 19

ID Problems and Determine what the nursing
considerations should be included.
• What are the client needs?
• What are the priorities?
• What is relevant and what is not?

Answer 19

Effective Interpretation

Question 20

• calm, confident manner
• clear communication
• good planning
• competent clinical skills

Answer 20

Effective responding

Question 21

• evaluation
• self-analysis
• commitment to improving

Answer 21

Effective reflecting