Clinical Judgment Process
Data collection
Planning
Implementation
Evaluation
What are the steps to the Nursing Process?
Clients current B/P is lower than preoperative reading; Urine output has been 150 mL over the past 3 hours; right calf is red and warm to the touch.
Clients complaints of pain; reports nausea; stating they feel depressed
What is Objective data?
What is Subjective data?
Also known as the ABX model.
What is Newcomb’s Model of Communication?
In the 1970s, the federal government began using EHRs at this department.
What is Department of Veterans Affairs, and what year did they start using EHRs??
•Never use anyone else’s login information.
•Password must be strong, unique, and should be changed frequently.
•Log off when documentation is complete.
What are Electronic Documentation Guidelines?
Is designed to be used by nurses to think critically and make decisions based on evidence-based practice.
What is Clinical judgement?
These must typically be met before individuals attempt to fulfill higher levels in the Maslow's Hierarchy pyramid.
What are the Physiological needs?
Often called the S-M-C-R model for the four components, which are comprised of sender, message, channel, and receiver.
What is Berlo’s Model of Communication?
Subjective, Objective, Assessment; and Plan.
What is a SOAP Note?
Reflects that client medical information is confidential and should only be accessed by those health care team members who are directly involved in caring for the client
What is HIPAA?
The client reports dizziness when ambulating to the bathroom.
When using clinical judgment, what findings indicate the nurse should collect further data from the client before administering antihypertensive medication?
•Nurses can use this hierarchy (critical, urgent, routine, and extras) acronym to prioritize client care when managing numerous clients’ needs.
What is the C.U.R.E. Hierarchy?
A purposeful, goal-oriented method of interacting that helps patients express feelings, understand their health, and participate in their care.
What is Therapeutic Communication?
Charting centers on specific health care problems and changes in condition, client events, and concerns.
What is Focus Charting?
Factual - Documentation should contain concrete, objective, and descriptive information.
Accurate - Documentation should establish accuracy by including exact descriptions and measurements.
Complete - Documentation must be complete; it must contain the what, when, where, why, and how.
Timely - All documentation should be put in chronological order.
What is FACT acronym?
Obtain a daily weight on a client who has heart failure
What is a tasks the nurse can delegate to an assistive personnel (AP)?
•A - Airway
•B - Breathing
•C - Circulation
•D - Disability
•E - Exposure
What is the ABCDE Method?
Sometimes referred to as Privacy Act
What is Health Insurance Portability and Accountability Act (HIPAA)?
Demographic data about the client, information that relates to the client’s condition, as well as medications, allergies, and medical history
What is included in the electronic health record?
Red Tag Category, emergent or immediate - includes clients who must be transported away from the scene immediately.
Yellow Tag Category, urgent or delayed - includes clients who have a serious injury that does not pose an immediate threat to life.
Green Tag Category, nonurgent or minimal - includes clients who have only minor injuries.
Black Tag Category, expectant - includes clients who are either deceased or not expected to survive
What are the four main prioritization categories based on the injury severity in Triage?
30 mL an hour.
What is the normal urine output per hour?
Priority is given to whatever finding poses the greatest or immediate risk to the client's physical or psychological well-being; issues that would cause the greatest risk to the client’s psychological or physical well-being are deemed a priority.
What is Safety and Risk Reduction?
Face the client; Make appropriate eye contact, do not turn away or walk around while communicating, and be sure to take measure to ensure a quiet environment; Ensure the assistive hearing device is working.
What are ways to communicate better with clients who have speech or hearing impairments?
Accounts for every treatment, diagnosis, and provider visit for billing, and can be used in a court of law.
What is all components of an EHR?
•The skill of learning to analyze and interpret data to solve a problem to achieve a desired outcome. Includes questioning, analysis, synthesis, interpretation, intuition, inductive and deductive reasoning, intuition, application, and creativity.
What is Critical Thinking?