Unit 1 Clinical Judgment PDF

Victoria Amalaraj MSN, RN Clinical Judgment Learning Outcomes 1. Describe how clinical judgment guides decision-making at each stage of the nursing process to promote patient-centered care. 2. Identify strategies for collecting accurate, relevant, and valid assessment data. 3. Utilize clinical j...

Victoria Amalaraj MSN, RN Clinical Judgment Learning Outcomes 1. Describe how clinical judgment guides decision-making at each stage of the nursing process to promote patient-centered care. 2. Identify strategies for collecting accurate, relevant, and valid assessment data. 3. Utilize clinical judgment to prioritize nursing care based on patient needs. 4. Compare methods used to plan patient care. 5. Describe the methods nurses use to evaluate nursing interventions.  Critical Thinking Uses evidence, science, and reason Open-minded and reflective Seeks truth and evaluates assumptions Supports evidence-based practice  Nursing Process & Clinical Judgment Nursing Process Clinical Judgment A systemic framework to The thinking and decision- guide care. making during the process. Steps: Assess > Diagnose > Guides prioritization and Plan > Implement > Evaluate adapts care to the situation. Nursing Process Clinical Judgement Model  3 Diagnosis ASSESSMENT  Data Collection COLLECTING, OBSERVATION INTERVIEWS NURSING ORGANIZING, ASSESSMENT VALIDATING, AND DOCUMENTING CLIENT DATA  Subjective Data (Symptoms) From patient or family Thoughts Types of Feelings Beliefs Assessment Objective Data (Signs) Data Measurable Observable Physical assessment  Primary Data Directly from the patient. Subjective (what the Sources of patient says). Data Objective (what you observe). Secondary Data From medical records or caregivers.  Organizing Data Subjective Objective Pain rating 3/10 BP 74/44 Pt c/o abd cramping Abd hard, round, and distended “I can’t breathe!” Shuffling gait “I feel weak” Pt is red and flushed “He seems so sad today” wife states. Pt is using accessory muscles to Pt reported feeling dizzy when breath standing. Pt is tearful  Types of Assessments Initial Focused Ongoing Comprehensive Specific Re-evaluation  Recognize Cues What findings ae most significant? What additional information is need to decide what’s wrong with the patient? What data are relevant? What are not relevant? What information should be collected first as a priority in the assessment? What findings need follow-up? Diagnosis Analyze Cues What patient problems/conditions/diagnoses are consistent with these findings? What findings did you expect? What additional information would help you better understand the significance of these findings? Are there data of particular concern to you? Why?  Prioritization Prioritize Problems Use nursing judgment to rank problems Consider problem urgency, future consequences, and patient preference Label problems as high, medium, or low priority  Prioritization A: airway B: breathing C circulation s: safety D: discomfort E: education F: feelings Prioritization  Prioritize Hypotheses What are possible explanations of the patient’s condition? Explain your thinking. Based on the information in the scenario, what are all possible problems the patient might have? Considering possible problems of this patient, what is the priority? Why? If the patient’s symptoms were X, how would that change your thinking about the patient’s condition? Plan Generate Solutions Which outcomes are most important for this patient? In this situation? What interventions are indicated? What evidence supports each of these interventions? In what ways will the interventions promote the expected outcomes of care? Are there interventions to avoid? Which ones and why? Interventions  Planning Interventions Prioritize Care Realistic, safe, patient-centered Coordinate Care Achievable with available resources Collaborative Effort Patients, peers, other healthcare professionals Evidence-Based Based on science  Types of Interventions Independent Dependent Collaborative Nurses are accountable Prescribed by a Carried out in for these actions physician or advanced collaboration with Performed without a practice nurse other healthcare team provider’s prescription Carried out by the members Examples: nurse Examples: Working Repositioning a client Examples: Medications, with physical therapists, to prevent pressure treatments, IV therapy. physicians, etc. ulcers, providing emotional support to a client experiencing anxiety. Critical pathways and Protocols  Implementation Involves "doing" and "delegating" interventions. Ends with documenting nursing actions. Tied to all steps of the nursing process (assessment, diagnosis, planning, evaluation. Preparing for Implementation: Review the care plan and ensure qualifications. Seek clarification for unclear, incorrect, or inappropriate orders. Assess if the action is safe, consider potential risks, and plan accordingly.  Take Action What interventions are most appropriate? What interventions should be done first? Why? What actions should be taken now? What information would you teach the patient/caregiver prior to discharge? What information, event, or situation should be reported immediately to the manager/health care team/other? Why? Evaluation  Evaluation The nurse and patient Compare patient Three possible together measure how responses to desired outcomes well the patient has outcomes Outcome has been met achieved the specified Outcome partially met goal and progress has occurred Outcome not met  Evaluate outcomes What are important findings to monitor to determine if the patient is improving? Is this patient improving? Why or why? Are the interventions effective? If not, what other interventions and approaches should be considered? What observations would you make, or questions would you ask to assess if the patient/caregiver knows how to (perform the procedure, give oneself the treatment, follow the protocol)? Clinical Judgement Practice Florence, the nurse you were assigned to be with for this clinical shift, wants to see your clinical judgement skills in action.  Recognize Cues Background: Chamroeun Sok immigrated from Cambodia 2 years ago. His wife passed away during childbirth. Boupha has trisomy 21. She had a atrioventricular septal defect that was surgically repaired when she was 4 months old. Situation: Chamroeun brought his daughter Boupha (1F) to the ED, because she is fussy. He can’t seem to calm her down and she hasn’t been eating or able to keep anything down. He states that she feels warm and keeps tugging at her ears. You note that she is sweating and looks flushed. Her vitals are BP 80/55 T 38.1 R 32 HR 124.  Analyze Cues What could be the cause of the symptoms that Boupha is experiencing?  Prioritize Hypotheses Which do you think is most likely, what’s wrong with Boupha? URI Bacterial infection UTI Viral infection Flu Sinusitis RSV Dehydration Ear infection Heat exhaustion Roseola Strep throat Tonsillitis Pneumonia Chicken pox Neutropenia Pertussis Vaccination reaction Meningitis Septicemia  Generate Solutions What can you as Boupha’s nurse do for her?  Take Action What will you do for Boupha?  Evaluate Outcomes Did that help Boupha? How do you know if it did?