Clinical Judgment Process
What are the steps to the Nursing Process?
Data collection
Planning
Implementation
Evaluation
What is Objective data?
What is Subjective data?
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.
Client's complaints of pain; reports nausea; stating they feel depressed
What is Newcomb’s Model of Communication?
Also known as the ABX model.
What is Department of Veterans Affairs, and what year did they start using EHRs??
The U.S. federal agency responsible for providing healthcare, benefits, and support services to veterans
In the 1970s, the federal government began using EHRs at this department.
What are Electronic Documentation Guidelines?
•Never use anyone else’s login information.
•Password must be strong, unique, and should be changed frequently.
•Log off when documentation is complete.
What is Clinical judgement?
Is designed to be used by nurses to think critically and make decisions based on evidence-based practice.
What are the Physiological needs?
These must typically be met before individuals attempt to fulfill higher levels in the Maslow's Hierarchy pyramid.
What is Berlo’s Model of Communication?
Often called the S-M-C-R model for the four components, which are comprised of sender, message, channel, and receiver.
What is a SOAP Note?
A structured clinical documentation - Subjective, Objective, Assessment' and Plan - used by healthcare and mental‑health professionals to record patient or client encounters.
According to HIPAA who can access a clients medical information?
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
When using clinical judgment, what findings indicate the nurse should collect further data from the client before administering antihypertensive medication?
The client reports dizziness when ambulating to the bathroom.
What is the C.U.R.E. Hierarchy?
Nurses can use this hierarchy (critical, urgent, routine, and extras) acronym to prioritize client care when managing numerous clients’ needs.
What is Therapeutic Communication?
A purposeful, goal-oriented method of interacting that helps patients express feelings, understand their health, and participate in their care.
What is Focus Charting?
Charting centers on specific health care problems and changes in condition, client events, and concerns.
What is FACT acronym?
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 what, when, where, why, and how.
Timely - All documentation should be put in chronological order.
What is a task the nurse can delegate to assistive personnel (AP)?
Obtain a daily weight on a client who has heart failure
What is the ABCDE Method?
A - Airway
B - Breathing
C - Circulation
D - Disability
•E - Exposure
What is Health Insurance Portability and Accountability Act (HIPAA)?
Sometimes referred to as Privacy Act
What is included in the electronic health record?
Demographic data about the client, information that relates to the client’s condition, as well as medications, allergies, and medical history
What are the four main prioritization categories based on the injury severity in Triage?
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 is the normal urine output per hour?
30 mL an hour.
What is Safety and Risk Reduction?
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 are ways to communicate better with clients who have speech or hearing impairments?
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 all components of an EHR?
Accounts for every treatment, diagnosis, and provider visit for billing, and can be used in a court of law.
What is Critical Thinking?
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.