Clinical Judgment Model Part 1 PDF

NURS 3000 - Professional Nursing Clinical Judgment Model, Part 1 Clinical Judgment Model Part 1 Harding University - Active Learning Guide Module 2 Name: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on...

NURS 3000 - Professional Nursing Clinical Judgment Model, Part 1 Clinical Judgment Model Part 1 Harding University - Active Learning Guide Module 2 Name: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client scenarios. All of these activities will assist in your preparation for exams, help you plan and implement care in the clinical setting, and facilitate your development as a Christian nurse servant. You will submit your completed guide to the instructor at the end of the week. The completed learning guide will be worth a maximum of 10 points. If you have questions or are unsure about your answers you may email your instructor for clarification. Note: The Active Learning Guide provides a general outline of topics covered in this module; it is not all-inclusive of all information needed for the exam. You are responsible for all content in readings and activities throughout the module. Clinical Judgment Model Part 1 I. Chapter 9: Critical Thinking and Clinical Reasoning 1. What is the purpose of critical thinking? P 151 The purpose of critical thinking is to process his or her own thoughts to determine an ideal outcome. To ascertain an appropriate outcome using the process of critical thinking, the nurse will need to discern between factual statements, opinions and judgment. The nurse will be required to think about the results or their actions based on their skill set, experience and what they have learned. This in time process is called reflective thinking. Critical thinking will provide a nurse with options when rapid changes occur. Critical thinking allows the nurse to identify signals and modify and change interventions and adapt to the new needs of the client. 2. Box 9.1 Personal Critical Thinking Indicators: Behaviors, Attitudes, and Characteristics p. 153 Review these and discuss 5 which you believe you can cultivate and/or improve in yourself. Self-aware: Being self aware is the aptitude to be able to see how others see us, clearly see ourselves and have the understanding of where we fit into our environment. To cultivate this characteristic, I can start a daily journal of my nursing experiences, the interventions used and outcomes. Request feedback from management and other trusted sources for critique. If I was NURS 3000 - Professional Nursing Clinical Judgment Model, Part 1 involved in a conflict on a particular day, how did I handle it? Reflect on how I made someone feel on a particular day. Curious and inquisitive: Curiosity is the want or desire to look for the meaning, learn and pursue new information. Curiosity is an attribute that comes from within. To increase my curiosity, I can first understand my motivations and concerns. I can be accepting and willing to be uncomfortable and challenged while staying focused on the goal. I can improve the type of questions to ask about new subjects. I can learn to keep the questions open ended to and can not be apprehensive or nervous when doing so. Alert to context: Is the ability to change ones approach depending on the circumstances. Being able to read the room and act accordingly. To improve being alert to context, nurses can improve active listening skills and learn how to identify context clues. Nurses can become more sensitive to context by reflecting on their experiences and decisions made. Reflective and self-corrective: The nurse has the ability to examine new data and interactions with others. The nurse can be alert to potential mistakes by self, others and is able to correct thinking and prevent mistakes. There are benefits to becoming more reflective. Improve relationships, improved decision making skills, improved confidence in stressful situations and improved problem solving. To improve reflection and self correction, journaling is a way to organize thoughts and emotions. It is also a way to catalog and chart your progress. Ask for help with reflection. Confide in a family member, close friend or a professional. Maintain a set time to intentionally reflect and make it a priority. Confident and resilient: An able nurse is able to show faith in skills, to learn new skills and to reason. Ways to build resilience are to find your purpose, believe in yourself, welcome change, treat yourself, develop problem solving skills, establish goals, understand building skills takes time and take action. 3. Review Table 9.1 Differentiating Types of Statements p. 154 NURS 3000 - Professional Nursing Clinical Judgment Model, Part 1 4. Describe and give examples of using inductive and deductive reasoning in caring for a client. p. 153-154. Inductive reasoning, is the process of taking a generalized premise or group of examples and moving to a generalized conclusion. Example, While emptying a catheter bag you notice there is purulent discharge (premise), you can make a non specific general determination the patient has a UTI. Deductive reasoning, is the process of taking a generalized premise or group of examples and moving to a specific conclusion. Example, bachelors are unmarried men. Dave is an unmarried man. Consequently, Dave is a bachelor. 5. How is the nursing process similar to the problem-solving process? P 154 NURS 3000 - Professional Nursing Clinical Judgment Model, Part 1 These processes are similar due to the gathering of information that refines the problem and indicates a possible resolution. The nursing process specifically uses an assessment of the patient. The nursing process is “ADPIE” Assessment, Diagnosis, Planning, Implementation and Evaluation. 6. Describe clinical judgment. Clinical judgment is the result of critical thinking combined with clinical reasoning. 7. What are attitudes that foster critical thinking? P 162 Critical thinkers have intellectual humility, independence, insight, intellectual courage and challenge the status quo and ritualistic ideas. They have perseverance, confidence, curiosity and integrity. 8. What is clinical reasoning? How is it related to clinical judgment? P 157 Clinical reasoning characterizes the thinking and decision making process that goes along with clinical practice. Clinical reasoning is in time the analyzing of a clinical circumstance as it unfurls. II. Chapter 10: Assessing 1. Table 10.1 Overview of the Nursing Process p. 165 List and describe the five steps.      Assessing (Cue Recognition)→ Obtaining, categorizing, verifying and recording client information Analyzing (Generating Hypotheses)→ Join, consolidate or combine the data to form a diagnosis. Planning (Generating Solutions)→ Prepare how to resolve or reduce the patient’s determined priority. Implementing (Taking Action)→ Performing and recording the nursing interventions. Evaluating (Evaluating Outcomes)→ Recording the measured progress of the outcomes or objectives have been obtained and determining factors that impact the goal in a positive or negative manner. 2. Figure 10.1 The nursing process in action p 166-167 See examples of application. Assessing→ Head to Toe assessment. Diagnosing→ Contrast data versus standards. Planning→ Record goals and desired measurable outcomes. Implementing→ Note or report care and the patients reaction to implemented care. NURS 3000 - Professional Nursing Clinical Judgment Model, Part 1 Evaluating → Assess or determine if desired measurable outcomes have been achieved. 3. Discuss how the steps of the process overlap and depend on the accuracy of each other. Each part of the nursing process is interdependent and related to all of the other steps. If the information obtained during the assessment phase is fraudulent or bad, those oversights will impact and be reflected in all of the following steps. 4. Assessing (also known as Cue Recognition): What is included in this step? How/when can assessing be considered evaluating? P 164 Data aggregation made up of subjective and objective information. Data must be reliable. Determining what is important and unimportant data. Preparing and managing data systematically. The nursing process is a continuous cycle that fluctuates depending on the current step in progress. After implementation of an intervention, the patient is being evaluated for the desired outcome. Example, vital signs are given before and after medication is administered. 5. Types of Data: See Table 10.4: Examples of Subjective and Objective Data. p 172 Subjective→ Data from the pov of the patient. Example, I feel weak when standing. Not measurable. Self reported. Objective→ Data that is measurable. Vital signs are measurable. 6. Sources of Data: p 172 Primary→ The patient will always be the primary source of data. Secondary→ All other forms of data are secondary. This includes, family members, health professionals, diagnostic labs, and any other medical records. 7. Organizing and Validating Data: Why is this important? See Table 10.7 Validating Assessment Data, p 182 The assessment phase of the nursing process is the basis for the nursing diagnoses and interventions that will be determined assist in resolving the priority problem. Validating is the process of checking or confirming the data is factually accurate. How do cues and inferences differ? P 182 Cues come from the subject or patient. Subjective and Objective data can be considered cues. An inference is how the nurse interprets or comes to a NURS 3000 - Professional Nursing Clinical Judgment Model, Part 1 conclusion based on the cues that consist of the Subjective (information from patient) or Objective (What the nurse can see, feel, measure and smell). 8. Documenting Data: Give an example of factual documentation versus making a judgment or assumption. p 182 Factual Documentation is the accurate recording of a patients measurable intake. A judgment or assumption as in “routine consumption” or “big appetite” can mean different things to different people. III. Chapter 11: Diagnosing 1. Analysis (Generating Hypotheses): Discuss what this step includes. Is the consideration of each singular piece of data, subjective or objective to infer a conclusion. 2. What does NANDA stand for? North, American, Nursing, Diagnosis, Association 3. What is a nursing diagnosis? p 186 The nursing diagnosis is comprised of a diagnostic phrase (statement of the clients priority problem) followed by the etiology phrase (the relationship between the clients priority problem and it’s risk factors. How is it different from a medical diagnosis? Table 11.3 p 189 Nursing Diagnosis describes the human response to a disease or health complication, that nurses are licensed to treat. Medical Diagnosis describes the pathology of a disease, that a physician can treat. Human responses are not considered. 4. List and describe the four types of nursing diagnoses/hypotheses p 191 Functional Health Pattern→ Nutrient-Metabolic (incorporates hydration). Description of health priority based on client cue clusters. Client Cue Clusters→ Hasn’t been thirsty since last night. Subjective Data. Inferences→ Speculative Identification of problem. Nurse interpretation or conclusion made from client cue clusters. Diagnostic Statements→ Are made up of the clients priority problem and contributing factors that cause the patients human response. The two part NURS 3000 - Professional Nursing Clinical Judgment Model, Part 1 statement is joined by “related to.” Related to, denotes a relationship, not a cause. These statements should be written or stated as normal conversation. 5. Components of a Nursing Diagnosis: p 193  Problem→ Statement of the patient’s response (nursing diagnostic label).  Etiology→ The factors that are contributing to a likely cause of the human response connected by related to  How do you determine the wording for the problem? For the etiology? Table 11.6 p. 195 NURS 3000 - Professional Nursing Clinical Judgment Model, Part 1 6. What is data clustering? p. 190-191 The process of deducing if the validated cues are related in anyway, if they are significant, isolated or if any patterns exist. 7. Table 11.5 Examples of nursing diagnosis/hypothesis statements. All parts of the hypothesis must be supported by data. Review examples p 190. 8. Give an example of Two-part statements and three-part statements p. 193194 Box 11.1 Two-part statements use the phrase related to to join two parts. Constipation related to pregnancy. Three part statements consist of the Problem, Etiology and Signs and Symptoms 9. Variations: One-part statements; Unknown etiology; possible; secondary to; Review all of these. p. 194 10.Describe errors in wording hypotheses. p. 195-196 An error is likely to happen during any part of the nursing diagnosis process: info collection, info interpretation and info clustering.