Nursing Assessment and Prioritization Quiz

Clinical Judgment

• Clinical judgment guides decision-making throughout the nursing process to promote patient-centered care.
• Strategies for collecting accurate, relevant, and valid assessment data are crucial.
• Clinical judgment is used to prioritize nursing care based on patient needs.
• Methods for planning patient care should be compared and contrasted.
• Nurses should be able to describe the methods used to evaluate nursing interventions.

Critical Thinking

• Critical thinking utilizes evidence, science, and reason.
• It involves being open-minded and reflective, seeking truth and evaluating assumptions.
• It supports evidence-based practice.

Nursing Process & Clinical Judgment

• The nursing process is a systematic framework for guiding care.
• Assess > Diagnose > Plan > Implement > Evaluate are the steps of the nursing process.
• Clinical judgment involves the thinking and decision-making during the nursing process.
• Clinical judgment guides prioritization of care and adapts care to the specific situation.

Nursing Process (Details)

• Assessment: Gathering patient data is a key aspect of the nursing process.
• Diagnosis: Identifying patient problems is part of the assessment process.
• Plan: Establishing goals and outcomes is part of planning.
• Implement: Performing interventions is a crucial component.
• Evaluate: Checking outcomes and adjusting care is crucial.

Clinical Judgement Model

• Recognize cues (What matters most)
• Analyze cues (What does it mean?)
• Prioritize hypotheses (Where do I start?)
• Generate solutions (What can I do?)
• Take action (What will I do?)
• Evaluate outcomes (Did it help?)

Assessment

• Data Collection: Involves collecting, organizing, validating, and documenting client data.

• Methods: Observation, interviews, and nursing assessments are used.

• Types of Data:

  • Subjective: Data from the patient or family (thoughts, feelings, beliefs, symptoms)
  • Objective: Measurable and observable data (signs, vital signs, physical assessment findings)

• Sources: Primary (directly from patient) and secondary (medical records, caregivers)

• Organizing Data: Separating subjective and objective data.

• Types of Assessments:

  • Initial/Comprehensive
  • Focused/Specific
  • Ongoing/Re-evaluation

• Recognize Cues: Identifying significant findings and needing additional information.

• Understanding which data are relevant for patient problems.

• Prioritizing which information should be collected first.

• Understanding which findings involve follow-up.

Analyze Cues (Diagnosis)

• Determining the causes of patient symptoms.
• Recognizing the potential diagnoses or conditions associated with the collected data.
• Identifying relevant additional information necessary for detailed understanding.
• Pinpointing data of specific concern.

Prioritization

• Ranking patient problems by urgency, future consequences, and patient preference.
• Prioritizing problems as high, medium, or low priority.
• Using the ABCs (airway, breathing, circulation) and other essential elements to focus on critical issues.
• Using Maslow's hierarchy of needs (physiological, safety, love/belonging, esteem, self-actualization) to guide prioritization.

Prioritize Hypotheses

• Determining potential explanations for patient conditions.
• Identifying potential problems that may be associated.
• Prioritizing these problems in order of importance and severity.

Plan and Implement

• Generate Solutions: Identifying appropriate interventions.
• Defining the importance of certain outcomes.
• Describing the supporting evidence and interventions.
• Listing interventions to avoid.
• Planning care with a focus on realistic goals safely achievable with available resources.
• Teamwork from patients, healthcare professionals, etc.
• Types of Interventions:
  • Independent: Actions nurses perform without a provider's prescription.
  • Dependent: Actions prescribed by a healthcare professional (physician or advanced practice nurse).
  • Collaborative: Actions performed in conjunction with other healthcare team members.
• Implementation: Involves performing and delegating interventions.
• Documenting actions and following up is crucial.

Take Action

• Choosing the right interventions promptly, identifying priority actions.
• Communicating needed information to the patient/caregiver before discharge.
• Reporting necessary information immediately to the health care team or manager.

Evaluation

• The nurse and patient measuring the patient's response to the intervention to achieve desired outcomes.
• Evaluating whether interventions promote achievement of expected outcomes.
• Evaluating interventions and adjusting as needed.
• Outcome options are: - Outcome has been met. - Outcome partially met, progress occurred
  • Outcome not met.
• Monitoring important findings and determining their improvement.
• Determining if patient improvement is evident.

Clinical Judgement Practice

• Florence, the assigned nurse, observes clinical judgment skills in action.

Recognize Cues (Case Study)

• Background on Chamroeun Sok and his daughter Boupha.
• Presenting patient scenario: a fever, pain, refusal to eat, etc.
• Patient's medical history, including surgical procedure.
• Details of patient presentation and symptoms.

Analyze Cues (Case Study)

• Potential causes for the symptoms.
• Considering medical possibilities.
• Possible diagnoses.
  • Ear infection
  • RSV
  • Sinusitis
  • Dehydration
  • UTI

Prioritize Hypotheses (Case Study)

• Ranking the possible diagnoses.
• Determining the most likely and serious issues.
• Likely diagnoses: Dehydration, ear infection, sinusitis.

Generate Solutions (Case Study)

• Actions nurses can take for the patient.

Take Action (Case Study)

• Priority interventions to implement
• Identifying actions to be done first.

Evaluate Outcomes (Case Study)

• Evaluating whether chosen actions helped the patient.
• Demonstrating how patient's progress can be known.

Test your knowledge on the key principles of nursing assessment and prioritization. This quiz focuses on identifying high, medium, and low-priority problems during patient evaluations. Understand the essential elements for effective care coordination and clinical judgment in nursing.