W5 Nursing Process & Clinical Judgement Model Flashcards
What was the purpose of the Nursing Process in the 1950s?
Guide and promote safe, competent, quality patient care
When was the clinical judgement model created?
2019
Subjective data?
What the patient states
-Nausea
-Light headedness
-Discomfort in the stomach
Objective Data?
What you find in nursing assessment
-Temp 100F
-Blood pressure 120/80
-Red rash on midsection
Independent nursing intervention?
Can do as a nurse w/o oversee
-Assessment
-Monitor
-Teach
-VS
-I&O
-Height/ weight
Dependent nursing intervention?
Requires HCP
-labs
-meds
-treatments needed
When creating a nursing intervention what are the 3 questions that need answered?
- What intervention
- Why doing it
- How frequently
Ex. Teach about insentive spirometer use and encourage use Q1 hour x15
What are the steps of the nursing process?
- Assessment
- Diagnosis
- Planning
- Implement
- Evaluate
Assessment phase of Nursing Process?
Gather information about the patients condition
-Assessment
-H&P
-MAR
-Report
-Patients history
Diagnosis phase of nursing process?
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
Planning phase of nursing diagnosis
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
Implement phase of nursing diagnosis
Perform the nursing action identified in planning
-Assess
-Monitor
-Implement
-Collaborate
-Teach
-Psychosocial
Evaluate phase of nursing diagnosis
Determine if goals and expected outcomes are achieved
What are the steps if the clinical judgement model?
- Recognize cues
- Analyze cues
- Prioritize Hypothesis
- Generate solutions
- Take action
- Evaluate outcomes
Recognize cues phase of clinical judgement model
Identify and recognize relevant clinical data
-assessment
-report
-health record
-labs/diagnosis
Analyze cues phase of clinical judgement model
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
Prioritize hypotheses phase of clinical judgement model
Narrow problems down to the most pressing problems
-ABCs
Airway
Breathing
Circulation
Generate solutions phase of Clinical judgement model
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
Take Action phase of clinical judgement model
Implement nursing intervention based on your plan
Evaluate outcomes phase of clinical judgement model
Compare observed outcomes to the desired/ expected outcomes
Assessment is what in CJ
Recognize cues
Diagnosis is what in CJ
Analyze Cues
Planning is what in CJ
Prioritize Hypothesis & Generate Solutions
Implementation is what in CJ
Take action
