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Unit 5 Clinical Judgement and the Nursing Process

Terms in this set (144)

• Clinical decision making involves judgment that includes critical and reflective thinking and action and application of scientific and practical logic.
• Nurses who apply critical thinking in their work focus on options for solving problems and making decisions rather than rapidly and carelessly forming quick, single solutions.
• Reflection involves purposeful thinking back or recalling a situation to discover its purpose or meaning.
• Following a procedure step by step without adjusting to a patient's unique needs is an example of basic critical thinking.
• In complex critical thinking a nurse learns that alternative and perhaps conflicting solutions exist.
• In diagnostic reasoning you collect patient data and analyze them to determine the patient's problems.
• The critical thinking model combines a nurse's knowledge base, experience, competence in the nursing process, attitudes, and standards to explain how nurses make clinical judgments that are necessary for safe, effective nursing care.
• Clinical learning experiences are necessary for you to acquire clinical decision-making skills.
• Critical thinking attitudes help you know when more information is necessary and when it is misleading and to recognize your own knowledge limits.
• The use of intellectual standards during assessment ensures that you obtain a complete database of information.
• Professional standards for critical thinking refer to ethical criteria for nursing judgments, evidence-based criteria for evaluation, and criteria for professional responsibility.
• Meeting regularly with colleagues allows you to discuss anticipated and unanticipated outcomes in any clinical situation to continually learn and develop your expertise.
• Stress over a prolonged period or when extreme can cause distress, leading to poor work productivity and impaired decision making and communication.
Effective communication with patients during an assessment interview requires the following communication skills:
• Courtesy: Greet patients by the name by which they prefer to be addressed. Ask, "Would you prefer I call you by Mrs. Silver or your first name?" Introduce yourself and explain your role (if it is the first time you have met) such as gathering an admission history or exploring a recent symptom or problem. Meet and acknowledge any visitors in a patient's room and learn their names. Remember to ask the patient's permission to conduct the interview in visitors' presence. Assure the patient that the information will be kept confidential among his or her health care providers. HIPAA regulations require patients to sign an authorization before you collect personal health data .
• Comfort: If a patient is having symptoms such as pain, nausea or fatigue, it is difficult for you to gather a thorough and accurate history. In a hospital setting perform any necessary comfort measures before beginning the interview. Maintain privacy by closing room curtains or doors. Be sure the room temperature is comfortable and ensure good lighting. In the home choose a location that is quiet and free of interruptions. Timing is important in avoiding interruptions. If possible, set aside a 10- to 15-minute period when no other activities are planned but realize that this is difficult to plan when you have multiple patients. Avoid overtiring a patient; you can always return for another visit to gather more information
• Connection: It is so important to make a good first impression. If you begin collecting a history by staring at a computer screen to fill in required data fields or talking on a cell phone, patients will perceive you as uncaring or uninterested in hearing their stories. Patients know if you care. Establish eye contact and sit at eye level if possible during an interview. Do not dominate a discussion or assume that you know the nature of a patient's problems. Start with open-ended questions: "How have you been feeling?" or "What questions would you like to discuss?" Listen and be attentive. Use your observational skills—what is the patient's tone of voice, posture, level of energy when talking? Respect silence and be flexible; let the patient's needs, concerns, or questions guide your follow-up questions. Health problems can have multiple causes; do not leap to one cause too quickly
• Confirmation: At the end of an interview, ask the patient to summarize the discussion so there are no uncertainties. Be open to further clarification or discussion; ask the patient "Is there anything else you would like to share"? If there are questions you cannot answer, say so and promise that you will return with a follow-up if possible
• The nursing process is a variation of scientific reasoning that involves five steps: assessment, nursing diagnosis, planning, implementation, and evaluation.
• Assessment is an important first step of the nursing process for learning as much as you can about each patient by partnering together in a therapeutic relationship.
• Assessment involves collecting information from a patient and secondary sources (e.g., health care providers, family members) along with interpreting and validating the information to form a complete database.
• Establishing a nurse-patient therapeutic relationship allows you to know a patient as a person.
• There are two approaches to gathering a comprehensive assessment: use of a structured database format and use of a problem-focused approach.
• Effectively communicating with patients during an assessment interview requires communication skills built on courtesy, comfort, connection, and confirmation.
• Once a patient provides subjective data, explore the findings further by collecting objective data.
• During assessment critically anticipate and use an appropriate branching set of questions or observations to collect data and cluster cues of assessment information to identify emerging patterns and problems.
• In a patient-centered interview an organized conversation with a patient allows the patient to set the initial focus and initiate discussion about his or her health problems.
• An initial patient-centered interview involves: (1) setting the stage, (2) gathering information about the patient's problems and setting an agenda, (3) collecting the assessment or a nursing health history, and (4) terminating the interview.
• When literacy assessment tools are not available, a review of general cognitive ability and educational and/or occupational levels needs to be part of nursing assessment.
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• An assessment needs to adapt to the unique needs of patients of backgrounds and cultures different from your own.
• When collecting a complete nursing history, let the patient's story guide you in fully exploring the components related to his or her problems.
• Successful interpretation and validation of assessment data ensure that you have collected a complete database.
1. Identify a patient's response, not the medical diagnosis . Because a medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. Change the diagnosis Acute Pain related to colectomy to Acute Pain related to trauma of a surgical incision.
2. Identify a NANDA-I diagnostic statement rather than the symptom. Identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. One defining characteristic is insufficient for problem identification. For example, dyspnea alone does not definitively lead you to a diagnosis. However, the pattern of dyspnea, reduced chest excursion, and rapid respiratory rate are defining characteristics that lead you to the diagnosis of Ineffective Breathing Pattern. If a patient has severe chest pain resulting from a rib fracture, the final diagnosis will be Ineffective Breathing Pattern related to chest pain.
3. Identify a treatable related factor or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention. An accurate related factor allows you to select nursing interventions directed toward correcting the etiology of the problem or minimizing a patient's risk. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat. A patient with fractured ribs likely has pain when inhaling; impaired chest excursion; and slower, shallow respirations. An x-ray film may show atelectasis (collapse of alveolar air sacs) in the area affected. The nursing diagnosis of Ineffective Breathing Pattern related to shallow respirations is an incorrect diagnostic statement. Ineffective Breathing Pattern related to chest pain from rib fracture is more accurate.
4. Identify a problem caused by the treatment or diagnostic study rather than the treatment or study itself. Patients experience many responses to diagnostic tests and medical treatments. These responses are the area of nursing concern. The patient who has angina and is scheduled for a cardiac catheterization possibly has a nursing diagnosis of Anxiety related to lack of knowledge about cardiac testing. An incorrect diagnosis is Anxiety related to cardiac catheterization.
5. Identify a patient response to the equipment rather than the equipment itself. Patients are often unfamiliar with medical technology and its use. The diagnosis of Deficient Knowledge regarding the need for cardiac monitoring is accurate compared with the statement Anxiety related to cardiac monitor.
6. Identify a patient's problems rather than your problems with nursing care. Nursing diagnoses are always patient centered and form the basis for goal-directed care. Consider a patient with a peripheral intravenous line. Potential Intravenous Complications related to poor vascular access indicates a nursing problem in initiating and maintaining intravenous therapy. The diagnosis Risk for Infection properly centers attention on the patient's potential needs.
7. Identify a patient problem rather than a nursing intervention. You plan nursing interventions after identifying a nursing diagnosis. The intervention, "offer bedpan frequently because of altered elimination patterns," is not a diagnostic statement. Instead, with the proper assessment data the correct diagnostic statement would be Diarrhea related to food intolerance. This corrects the misstatement and allows proper implementation of the nursing process. More appropriate interventions are selected rather than a single intervention that alone will not solve the problem.
8. Identify a patient problem rather than the goal of care. You establish goals during the planning step of the nursing process. Goals based on accurate identification of a patient's problems serve as a basis to determine problem resolution. Change the goal-phrased statement, "Patient needs high-protein diet related to potential alteration in nutrition," to Imbalanced Nutrition: Less Than Body Requirements related to inadequate protein intake.
9. Make professional rather than prejudicial judgments. Base nursing diagnoses on subjective and objective patient data and do not include your personal beliefs and values. Remove your judgment from Impaired Skin Integrity related to poor hygiene habits by changing the nursing diagnosis to read Impaired Skin Integrity related to inadequate knowledge about perineal care.
10. Avoid legally inadvisable statements. Statements that imply blame, negligence, or malpractice have the potential to result in a lawsuit. The statement, "Acute Pain related to insufficient medication," implies an inadequate prescription by a health care provider. Correct problem identification is Acute Pain related to poor adherence to analgesic schedule.
11. Identify the problem and etiology to avoid a circular statement. Circular statements are vague and give no direction to nursing care. Change the statement, "Impaired Breathing Pattern related to shallow breathing," to identify the real patient problem and cause, Ineffective Breathing Pattern related to incisional pain.
12. Identify only one patient problem in the diagnostic statement. Every problem has different specific expected outcomes. Confusion during the planning step occurs when you include multiple problems in a nursing diagnosis. For example, Pain and Anxiety related to difficulty in ambulating are two nursing diagnoses combined in one diagnostic statement. A more accurate statement would be two separate diagnoses: Impaired Physical Mobility related to pain in right knee and Anxiety related to difficulty in ambulating. It is permissible to include multiple etiologies contributing to one patient problem, as in Complicated Grieving related to diagnosed terminal illness and change in family role.
• The diagnostic process is a clinical judgment that involves reviewing assessment information, recognizing cues, clustering cues into patterns of data, and identifying a patient's specific health care problems.
• Diagnostic conclusions include problems treated primarily by nurses (nursing diagnoses) and those requiring treatment by several disciplines (collaborative problems).
• Nurses manage collaborative problems by using medical, nursing, and allied health interventions.
• The use of standard formal nursing diagnostic statements provides a precise definition of a patient's problem that gives nurses and other members of the health care team a common language for understanding a patient's needs.
• Data analysis and interpretation involve recognizing patterns in clustered data, comparing them with standards such as the NANDA-I classification of nursing diagnoses and defining characteristics, and coming to a reasoned conclusion about a patient's response to a health problem.
• Accurate diagnosis of patient problems ensures the selection of more effective and efficient nursing interventions.
• Defining characteristics are the subjective and objective clinical cues that a nurse gathers intentionally and unintentionally, clusters, and uses to form a diagnostic conclusion.
• When an assessment reveals defining characteristics that apply to more than one nursing diagnosis, gather more information to clarify your interpretation.
• Absence of defining characteristics suggests that you reject a proposed diagnosis.
• A problem-focused nursing diagnosis is usually written in a two-part format, including a diagnostic label and an etiological or related factor.
• A three-part diagnostic statement includes defining characteristics that apply to a patient's condition.
• Assessing the cultural differences that affect how patients define health and illness and want or choose to be treated will assist in making correct diagnostic conclusions.
• The "related to" factor of a diagnostic statement helps you to individualize problem-focused and health promotion nursing diagnoses and provides direction for your selection of appropriate interventions.
• Risk factors serve as cues to indicate that a risk nursing diagnosis applies to a patient's condition.
• A concept map is a visual representation of a patient's nursing diagnoses and their relationship with one another.
• Nursing diagnostic errors occur by errors in data collection, interpretation and analysis of data, clustering of data, or the diagnostic statement.
• After identifying a patient's nursing diagnoses and collaborative problems, establish a plan of care that prioritizes the diagnoses and establishes nursing interventions, patient-centered goals, and expected outcomes.
• Planning involves individualizing a plan of care for a patient's unique needs.
• Priority setting is the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing actions.
• Priorities help you anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems.
• A patient-centered goal or outcome reflects a patient's specific behavior, not your own goals or interventions.
• The use of goals and outcomes in patient care is designed to focus the efforts of all health care team members on a common purpose.
• Outcomes provide the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of a patient's health problems.
• When writing goals and outcomes, use the SMART acronym: Specific, Measurable, Attainable, Realistic, and Timed.
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• During planning select interventions designed to help a patient move from the present level of health to the level described in the goal and measured by the expected outcomes.
• Independent nursing interventions are actions that a nurse initiates without supervision or direction from others, are autonomous based on scientific rationale, and do not require an order from another health care provider.
• Health care provider-initiated interventions require specific nursing responsibilities and technical nursing knowledge.
• Care plans increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another.
• A nurse hand-off transfers essential information (along with responsibility and authority) from one nurse to the next during transitions in care and allows you to ask questions, clarify, and confirm important details.
• A concept map is a visual representation of a patient's nursing diagnoses with links to nursing interventions, helping you learn to make better clinical decisions.
• The NIC taxonomy provides a standardization to help nurses select suitable interventions for patients' problems.
• Correctly written nursing interventions include actions, frequency, quantity, method, and the person to perform them.
• Implementation, the fourth step of the nursing process, formally begins after a nurse develops a plan of care. The nurse then initiates interventions that are designed to achieve patient goals and expected outcomes.
• A direct care intervention is a treatment performed through interactions with a patient that include nurse-initiated, health care provider-initiated and collaborative approaches.
• Always think first and determine if an intervention is correct and appropriate and if you have the resources needed to implement it.
• Clinical guidelines or protocols are evidence-based documents that guide decisions and interventions for specific health care problems.
• Remaining competent and using good communication skills build your ability to participate in interdisciplinary practices.
• A clinical practice guideline establishes evidence-based interventions for specific health care problems or conditions.
• The implementation of nursing care often requires additional knowledge, nursing skills, and personnel resources.
• Before performing an intervention, make sure that a patient is as physically and psychologically comfortable as possible.
• Use good judgment during implementation to ensure that no nursing action is automatic.
• Know the purpose of each intervention, the associated preassessment and postassessment risks, steps in performing the intervention correctly, the current medical condition of a patient, and his or her expected response so you can anticipate what to expect in a given clinical situation and how to modify your approach.
• To anticipate and prevent complications, identify risks to a patient, adapt interventions to the situation, evaluate the relative benefit of a treatment versus the risk, and initiate risk-prevention measures.
• When you administer physical care techniques, protect yourself and the patient from injury, use proper infection control practices, stay organized, and follow applicable practice guidelines.
• When you delegate aspects of a patient's care, you are responsible for ensuring that each task is assigned appropriately and completed according to the standard of care.