These are the two primary skills that clinical judgement relies on
What are: critical thinking and clinical reasoning?
This acronym represents the steps of the nursing process
What is ADPIE?
This type of care is characterized by personal contact with patients
What is direct care?
These are the three phases of the nurse-patient relationship
What are: orientation, working, and termination?
This is the order in which nursing diagnoses are prioritized
What is: actual diagnoses over risk, and risk over health-promotion?
The Tanner Clinical Judgement Model consists of these four key aspects
What are...
1) Noticing
2) Interpreting
3) Responding
4) Reflecting
The CCC, or Clinical Care Classification System, is this kind of classification system for EMR integration
What is taxonomic?
It is appropriate to chart something only after this
What is: You have done it, or need to explain why you didn't do it
This kind of data is difficult to quantify and can also be known as symptoms
What is: subjective data?
This refers to the process of looking for patterns and related data to support a specific nursing diagnosis
What is data clustering?
These four environmental factors can influence clinical judgement skills
What are:
Task complexity, time pressure, interruptions, and special area/autonomy
Under chapter 5, effective goals are described as these three things
What are: patient or group focused, realistic, and measurable?
This type of intervention is within the nursing scope, but requires a PCP order
What is a dependent intervention?
This person stated that the interpersonal process occurred in three phases: Orientation, working, and resolution
Who is Peplau?
A problem focused nursing diagnosis should be written like this
What is: Diagnosis label related to _________ (related factors) as evidenced by ________ (defining characteristics)?
Name at least one of the attributes required for successful clinical judgment
Strong knowledge base
Proficient technical skills
Early Problem Recognition
Previous experience, confidence, intuition
Reflection
These are the five steps of the nursing process
What are: assessment, diagnosis, planning, implementation, and evaluation?
When evaluating goals, these are the three potential outcomes
What are goal was...
Met
Partially met
Unmet
Before completing an interview, the best way to follow HIPAA guidelines is to do this
What is allow for privacy, or ask before discussing private health information in front of other parties.
A risk diagnosis should be written like this
What is: Risk for _______ (finish label with risk) related to _________ (risk factors or related factors)?
The National Council of State Boards of Nursing Clinical Judgement Measurement Model consists of these six clearly defined steps
What are:
1) Recognize cues
2) Analyze Cues
3) Prioritize Cues
4) Generate Solutions
5) Take Actions
6) Evaluate Outcomes
These six words represent the characteristics of the nursing process
What are: analytical, dynamic, organized, outcome oriented, collaborative, and adaptable?
These are the five rights of delegation
What is: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation?
When completing an abdominal assessment, we use techniques in this order
What is: inspect, auscultate, percuss, palpate?
A health promotion diagnosis should be written like this
What is: Readiness for enhanced _______ (finish label with health promotion) as evidenced by ________ (defining characteristics)?