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Clinical Judgement
Clinical Judgement
Prepare: Clinical Judgement
Parts of the Nursing Diagnosis Select the statement that includes the correct element to use when documenting a problem-based nursing diagnosis. Subjective data/objective data/hypothesis Problem statement/as evidenced by Diagnostic label/related to statement/defining characteristics Signs and symptoms/reason for seeking care/goals of treatment From Nursing Process to Concept Map The boxes below represent containers on a Care Focused Concept Map. Using the drop-down menu, indicate which step of the nursing process aligns with each container in the care focus concept map. Monitoring the patient for side effects of prescribed medications aligns with the evaluation part of the nursing process. Identifying client signs and symptoms aligns with the assessment part of the nursing process. Administering medications aligns with the intervention part of the nursing process. Describing desired outcomes needed to reach a goal aligns with the planning part of the nursing process. Identifying a problem, risk, or health promotion need aligns with the diagnosis part of the nursing process. Attention to Details Attention to details, or cues, is key to successful patient care. It can also be a challenge. The video below will challenge your ability to see the details despite distractions. As you watch, count the number of times the players in the white shirts pass the ball. Then select your response from the drop-down menu: 13
Self-Check: Identifying Nursing Diagnosis Components: Sami Dabiri
Evidence to Support a Nursing Diagnosis: Sami Dabiri What evidence is present in Sami’s nurses’ note to support a nursing diagnosis? Click the Nurses’ Notes tab to complete this activity. Select the cues that require follow-up by the nurse and can help select the nursing diagnosis.
Self-Check: Health-Promotion Nursing Diagnosis: Sami Dabiri
Clustering Related Cues: Sami Dabiri
After reviewing the nurse’s notes and selecting the cues that require follow-up, the nurse now clusters the related cues to assist in identifying health promotion risk for actual problems Note: Some cues may apply to both clusters
Nursing Diagnosis: Joanne Votaw Review Mrs. Votaw’s electronic health record (EHR). Select the most appropriate nursing diagnosis for Mrs. Votaw by selecting the words or phrases that complete the sentence below: Expected Outcomes: Joanne Votaw Based on your knowledge of Mrs. Votaw’s current health response, use a nursing diagnosis text to select priority collaborative outcomes for the current nursing diagnosis. Select all that apply. Blood pressure less than 120/70 Decreased urine output Decreased chest pain O2 saturation greater than 95% Lungs clear to auscultation SMART Goals for Joanne Votaw Select the words or phrases in the sentences below to create SMART goals for Mrs. Votaw based on the selected priority collaborative outcomes. Nursing Interventions: Joanne Votaw Based on your knowledge of Mrs. Votaw’s current health response, use a nursing diagnosis text to match these interventions with the supporting evidence-based rationale. Evaluating Outcomes Based on the documentation, indicate if Mrs. Votaw met, partially met, or did not meet her expected outcomes. Mapping Care-Diagnosis and Outcomes: Joanne Votaw The home health nurse is seeing Mrs. Votaw for the first time. During the interview, Mrs. Votaw asks what steps she Assess lung sounds every 4 hours and as needed Pulmonary edema will decrease as cardiac output increases. Titrate oxygen to keep oxygen levels above 95% Will increase oxygen levels in the blood and to body tissues. Allow periods of rest between activities Decreases oxygen consumption and decreases the risk of
can take to avoid future hospitalizations. Which diagnosis should the nurse select? Nursing Diagnosis: Readiness for enhanced nutrition
What evidence is present in Maggie’s admission assessment to support a nursing diagnosis related to infection? Select the assessment data or cues that contribute to the Related to
clicking on them. Remember “P.E.S” as the data is reviewed and selected. Click the History & Physical and Nurses’ Notes tabs to complete this activity. Under history & physical Under Nurses notes Nursing Diagnosis Margaret (Maggie) Conner
appropriate diagnosis label and defining characteristics, based on Maggie’s information by selecting the correct words/phrases to complete the Nursing Diagnosis below Click the Nurses’ Notes tab to complete this activity. Selecting Expected Outcomes - Margaret (Maggie) Conner Based on the nursing diagnosis and information in Maggie’s EHR, select the four (4) most appropriate goals of care and drag them to the Expected Outcomes on the Plan of Care (POC). Expected Outcomes on the Plan of Care (POC)
Self-Check: Selecting Interventions
Selecting Interventions - Margaret (Maggie) Conner Sort potential interventions for Maggie’s care according to priority (high, medium, low, or contraindicated) and necessity (essential or non-essential). Drag all essential interventions into the correct category (high, medium, or low). Not all interventions (those that are non-essential or contraindicated) will be sorted into a category. Incomplete Interventions - Margaret (Maggie) Conner While reviewing Maggie’s plan of care the first night of her admission, the nurse taking over her care adds which high priority, essential intervention? contact isolation nothing by mouth (NPO) strict bed rest monitor white blood cells (WBCs)
Reflect: Nursing Application: Clinical Judgement
Evaluating Progress - Margaret (Maggie) Conner Maggie has been in the hospital for two days and is starting to feel better. Her urine and and blood cultures both revealed E coli infection and antibiotics were started. ● Temperature 98° F – 99° F ● WBC greater than 4,000 and less than 12, ● HR 60 – 100 bpm ● Urine output > 0.5mL/kg/hr
Based on the documentation in Maggie’s EHR, the nurse notes that which expected outcomes have been met? Select all that apply. Click the Nurses’ Notes tab to complete this activity. Updating Interventions - Margaret (Maggie) Conner Based on the documented improvement in Maggie’s state of health, which interventions can be decreased in frequency? Select all that apply. Readiness for Enhanced Learning - Margaret (Maggie) Conner On the fifth day after admission to the hospital Maggie is stable and ready for discharge to home. She will be discharged with a peripherally inserted central catheter (PICC) line to complete the final nine days of her intravenous (IV) antibiotic therapy. Maggie does not have a health care background and has not taken care of a PICC line or self- administrated IV fluids in the past but expressed that she and her partner are willing and able to learn what needs to be done so she can go home safely. Based on this information, and using a nursing diagnosis text, select
Readiness for enhanced health management Readiness for enhanced resilience Risk for infection Ineffective health maintenance Completing the Nursing Diagnosis - Margaret (Maggie) Conner Use the drop-down menus on the Nurses’ Notes tab to complete the defining characteristics and related to statement for Maggie’s nursing diagnostic statement. Discharge Teaching Goals - Margaret (Maggie) Conner Since both Maggie and her partner have expressed interest in learning about caring for her PICC and IV medications at home the following goals are mutually set. Indicate the importance of meeting these outcomes for each person by dragging their picture to the correct column (Essential, Desirable, or Not Needed) for each outcome. Discharge Teaching Interventions - Margaret (Maggie) Conner Which topics will the nursing include when teaching Maggie and her partner related to ways to protect the PICC site and signs of adverse events? Select all that apply. Wear clothing that loosely covers the insertion site. How to secure the insertion site with a compression bandage. Do not allow animals in the same room while the medication is infusing. Safe disposal of needles. Change the PICC dressing if it becomes soiled. Avoid strenuous activity using the arm with the PICC. Wash hands prior to connecting or disconnecting the IV tubing.
Steps to clear a blocked PICC line. Signs of local infection at the insertion site. Signs of an occluded PICC line
