Critical Thinking and Judgement
Directed, purposeful mental activity by which ideas are evaluated, plans are constructed, and outcomes are determined
What is critical thinking?
Symptoms, pain ratings, and feelings reported directly by the patient that cannot be independently measured or observed by the nurse
What is subjective data?
During the planning phase, goals must be SMART. The letter "S" stands for this quality
What is Specific?
The phase of the nursing process where the nurse carries out planned nursing actions and documents patient responses.
What is implementation?
The final step of the nursing process that determines if patient goals were met, partially met, or unfulfilled.
What is evaluation?
The outcome of clinical reasoning, representing the final conclusion or decision reached by the nurse regarding patient care
What is clinical judgment?
Vital signs, lab values, physical assessment findings, and diagnostic test results observed or measured by the healthcare team
What is objective data?
Unlike a medical diagnosis, this type of diagnostic statement identifies human responses to actual or potential health problems.
What is a nursing diagnosis (or problem identification)?
Actions the nurse initiates independently without a direct physician order, such as patient positioning or hygiene care.
What are independent nursing interventions?
If a expected outcome is achieved, the nurse's next logical step in the plan of care.
What is discontinuing (or resolving) that specific goal/care plan item?
This 5-step systematic, problem-solving framework guides all clinical decision-making and nursing actions.
What is the nursing process?
The primary source of assessment data for a client who is conscious, coherent, and oriented.
Who is the patient (or client)?
This critical priority rule dictates that Airway, Breathing, and Circulation issues take precedence over all non-emergent needs.
What is the ABC framework?
Interventions carried out under a physician's explicit order, such as administering intravenous medications or inserting a urinary catheter.
What are dependent nursing interventions?
If a patient shows no progress toward an outcome, the nurse must do this with the assessment and care plan.
What is revise or modify the plan of care?
Prioritizing nursing actions using this psychological theory places physiological safety and basic needs above self-esteem or belonging.
What is Maslow's Hierarchy of Needs?
This type of assessment focuses on a specific body system or a presenting complaint, such as acute shortness of breath or surgical site pain.
What is a focused assessment?
High-priority nursing interventions designed to prevent life-threatening complications, such as pressure injuries or deep vein thrombosis (DVT).
What are preventative (or risk-reduction) interventions?
Transferring responsibility for performing a specific nursing task to an AP/UAP while retaining accountability for the outcome.
What is delegation?
Continuous evaluation requires that the nursing process be viewed not as a linear checklist, but as this shape.
What is a dynamic or cyclic process?
In clinical reasoning, this is the cognitive skill of recognizing subtle changes or cues in a patient's condition before an overt problem occurs.
What is cue recognition (or noticing)?
Family members, medical records, and diagnostic reports serve as this type of data source when the patient is unable to communicate.
What are secondary sources?
These target dates or timelines specified in patient outcomes determine when an intervention should be measured for effectiveness.
What are target times / short-term and long-term goals?
The step performed immediately prior to executing any nursing skill or intervention to verify safety and rationale.
What is re-assessing the patient (and checking orders/identifiers)?
Quality improvement activities where patient outcomes are systematically audited against established professional standards of nursing practice.
What are quality assurance (or outcome evaluation) audits?