W5 Nursing Process & Clinical Judgement Model

Question 1

What was the purpose of the Nursing Process in the 1950s?

Answer 1

Guide and promote safe, competent, quality patient care

Question 2

When was the clinical judgement model created?

Answer 2

2019

Question 3

Subjective data?

Answer 3

What the patient states
-Nausea
-Light headedness
-Discomfort in the stomach

Question 4

Objective Data?

Answer 4

What you find in nursing assessment
-Temp 100F
-Blood pressure 120/80
-Red rash on midsection

Question 5

Independent nursing intervention?

Answer 5

Can do as a nurse w/o oversee
-Assessment
-Monitor
-Teach
-VS
-I&O
-Height/ weight

Question 6

Dependent nursing intervention?

Answer 6

Requires HCP
-labs
-meds
-treatments needed

Question 7

When creating a nursing intervention what are the 3 questions that need answered?

Answer 7

1. What intervention
2. Why doing it
3. How frequently
   Ex. Teach about insentive spirometer use and encourage use Q1 hour x15

Question 8

What are the steps of the nursing process?

Answer 8

1. Assessment
2. Diagnosis
3. Planning
4. Implement
5. Evaluate

Question 9

Assessment phase of Nursing Process?

Answer 9

Gather information about the patients condition
-Assessment
-H&P
-MAR
-Report
-Patients history

Question 10

Diagnosis phase of nursing process?

Answer 10

Identify the patients problem

-Pt came in with Pneumonia but they can’t cough well so your diagnosis would be “ineffective airway clearance” and now can think about what you are going to do to help

Question 11

Planning phase of nursing diagnosis

Answer 11

Set goals of care and desired outcomes
-SMART goals
-Ex. GOAL: I want my respiratory btwn 12 & 20 throughout my shift
INTERVENTION: Keep head of bed >55 degrees and check vitals Q4

Question 12

Implement phase of nursing diagnosis

Answer 12

Perform the nursing action identified in planning
-Assess
-Monitor
-Implement
-Collaborate
-Teach
-Psychosocial

Question 13

Evaluate phase of nursing diagnosis

Answer 13

Determine if goals and expected outcomes are achieved

Question 14

What are the steps if the clinical judgement model?

Answer 14

1. Recognize cues
2. Analyze cues
3. Prioritize Hypothesis
4. Generate solutions
5. Take action
6. Evaluate outcomes

Question 15

Recognize cues phase of clinical judgement model

Answer 15

Identify and recognize relevant clinical data
-assessment
-report
-health record
-labs/diagnosis

Question 16

Analyze cues phase of clinical judgement model

Answer 16

Be able to interpret cues, organize, and recognize patterns in order to link the patients clinical presentation to a problem
-cluster cues/findings
Ex. A bunch of respiratory cues means respiratory problems

Question 17

Prioritize hypotheses phase of clinical judgement model

Answer 17

Narrow problems down to the most pressing problems
-ABCs
Airway
Breathing
Circulation

Question 18

Generate solutions phase of Clinical judgement model

Answer 18

Determine desired outcomes and the best solutions. Determine resources needed
-Who do I need? Do I need equipment Do I need order from HCP
-Ex. Assess vitals Q4, call respiratory, head of bed up, get up to chair

Question 19

Take Action phase of clinical judgement model

Answer 19

Implement nursing intervention based on your plan

Question 20

Evaluate outcomes phase of clinical judgement model

Answer 20

Compare observed outcomes to the desired/ expected outcomes

Question 21

Assessment is what in CJ

Answer 21

Recognize cues

Question 22

Diagnosis is what in CJ

Answer 22

Analyze Cues

Question 23

Planning is what in CJ

Answer 23

Prioritize Hypothesis & Generate Solutions

Question 24

Implementation is what in CJ

Answer 24

Take action

Question 25

Evaluation is what in CJ

Answer 25

Evaluate outcomes

Question 26

Define SBAR

Answer 26

Situation
Background
Assessment
Recommendation

A structured communication technique used clinically & is designed to convey a great deal of info in a succinct and brief manner

Question 27

What should you not include in SBAR?

Answer 27

Things that do not directly influence why the problem is a high priority

Ex. Calling HCP bc pt has fallin and may of broke something; don’t include that they had 2 bowel movements earlier

Question 28

What are the 2 types of SBAR

Answer 28

Problem based and Patient focused

Question 29

Describe problem based SBAR

Answer 29

When you identify a problem/ concern that is worth dialoguing with the HCP about:
1. Pick up the phone and call- vs
2. Wait for the (scheduled/predictable) interdisciplinary rounds to occur

Question 30

Describe patient focused SBAR

Answer 30

When you are giving report to night shift or to the unit where the patient is being transfered

Question 31

What are the 5 steps to take before calling HCP for SBAR?

Answer 31

1. Identify the problem and why you feel it warrants a call to HCP
   Ex. Pt fell and think they broke ankle
2. Identify focused assessment
   E. Pain level? LOC? Respiratory? Open or closed fracture? Appearance
3. Know medical history (if plays role)
   Ex. Arthritis? Brittle bone disease? Previous fracture? Age? Osteoprosis?
4. Look for trend data in chart
   Ex. Look in H&P, nursing note, admission note
5. Include Critical cues to help “tell story”
   -Admission reason
   -Allergies
   -Meds
   -Labs
   -Physical assessment
   Ex. labs may not help but if taking benedryl could cause drowsiness