lOMoARcPSD|64026470
NR 226 EXAM 1 REVIEW
CLINICAL JUDGEMENT
CLINICAL DECISION
Establish and weigh criteria in deciding the best choice of therapy for a patient
NURSING PROCESS
Profession’s universal, systematic decision-making approach to organizing and providing care
Deliver personalized, evidence-based care as members of a multi-disciplinary heath care team
ADPIE
ASSESS – information collection – data gathering
DIAGNOSE – information interpretation – stating problem, risk, health promotion needs
PLAN – setting nursing goals, desired outcomes, planning interventions
IMPLEMENT – performing nursing interventions
EVALUATE – patient’s status/effectiveness of interventions
CLINICAL JUDGEMENT: NURSING PROCESS
6 CLINICAL JUDGEMENT FUNCTIONS
clinical presentation, filter information from different sources
RECOGNIZE a. Signs + symptoms
CUES b. Health History
c. Current Environment
link recognition cues to a client’s clinical presentation + establish client’s needs,
ANALYZE concerns, or problems
CUES
establish prioritizing of care based on client’s health problems
PRIORITIZE a. Lab values
HYPOTHESES b. Diagnostic tests
c. Risk Assessments
Identify expected outcomes and related nursing interventions to client’s needs
GENERATE
SOLUTIONS
Implementation planned expected outcomes
TAKE
ACTIONS
Evaluate client’s response to nursing interventions and reach a nursing
EVALUATE judgement regarding the extent to which outcomes have been met
OUTCOMES
CLINICAL JUDGEMENT
Conclusion about a patient’s needs or health problems,
decisions needed to take or avoid action
use or modify standard approaches
create new approaches based on the patient’s response
ASSESSMENT
subjective data (what the person says about himself or herself during history taking)
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objective data (what you as the health professional observe by inspecting, percussing,
palpating, and auscultating)
NCLEX WORDS THAT INDICATE ASSESSMENT NEEDS TO BE MADE:
- Ascertain, assess, check, collect, determine, find out, identify, monitor, observe, obtain
information, and recognize
Select cues within assessment
Clients’ response to
findings
interventions and the evaluation
Recognize cues:
Met
Signs
Not Met
Symptoms
Health History
Intervention/
implementation of planned
and expected outcomes Write a diagnosis based on
Take Action! selected cues
Analyze cues: link cues to
clinical presentation and
establish
Generate solutions: identify Needs
expected outcomes and relate to Concerns
nursing interventions
Problems
Client Needs
Plan nursing intervention to
improve client’s health
Prioritize Hypothesis: based on
client’s health problems
Risk Assessment
Labs
Diagnostic Tests
DIAGNOSTIC LABEL - NURSING DIAGNOSIS
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focused on the alteration related to statement =
in pt health. not medical etiology contributes to -->
diagnosis medical diagnosis
diagnostic related to
label statement
problem-
focused defining
contains all 3 objective cues or symptoms
characteri
nursing
diagnosic label
diagnosis sticswhich the nursing diagnosis
related to... is based on
defining characterisitics...
ACTUAL PROBLEMS POTENTIAL PROBLEMS OPPORTUNITIES FOR
ENCHANCED WELLNESS
(Related to/As Evidenced By) (Risk For) (Health Promotion)
Diagnostic Label Risk factors but no evidence of Client desires enhanced
Related To Statement actual problems wellness and well-being
Defining Characteristics
(3-Part) (2-Part) (1-Part)
Ex. Impaired physical mobility Ex. Risk for infection related to Ex. Readiness for enhanced
related to decreased muscle compromised host defenses resilience
control as evidenced by
inability to control lower
extremities
HEALTH PROMOTION
Help individuals maintain or enhance their health, like exercise and good nutrition
3 PART NURSING DIAGNOSIS = P E S N – North
A – American
P – problem or NANDA-1 label N – Nursing
E – etiology/related to statement D – Diagnosis
S – symptoms/defining characteristics A – Association
PLANNING
Goals: general statements describing a desired change and outcomes are measurable changes
needed to reach a goal.
Goal must be in relation to the patient and changes needed to support their heath
o S - SPECIFIC – goals reflect a specific patient behavior response
o M - MEASUREABLE – must be able to measure/observe whether change takes place
o A - ATTAINABLE – goal/outcomes is achievable when mutually set with pt
o R - REALISTIC – set goals/outcomes that is realistic for pt
o T - TIME – set time for each goal/outcome to be met
TYPES OF INTERVENTIONS
NURSE INITIATED (Independent)
messages.downloaded_by
NR 226 EXAM 1 REVIEW
CLINICAL JUDGEMENT
CLINICAL DECISION
Establish and weigh criteria in deciding the best choice of therapy for a patient
NURSING PROCESS
Profession’s universal, systematic decision-making approach to organizing and providing care
Deliver personalized, evidence-based care as members of a multi-disciplinary heath care team
ADPIE
ASSESS – information collection – data gathering
DIAGNOSE – information interpretation – stating problem, risk, health promotion needs
PLAN – setting nursing goals, desired outcomes, planning interventions
IMPLEMENT – performing nursing interventions
EVALUATE – patient’s status/effectiveness of interventions
CLINICAL JUDGEMENT: NURSING PROCESS
6 CLINICAL JUDGEMENT FUNCTIONS
clinical presentation, filter information from different sources
RECOGNIZE a. Signs + symptoms
CUES b. Health History
c. Current Environment
link recognition cues to a client’s clinical presentation + establish client’s needs,
ANALYZE concerns, or problems
CUES
establish prioritizing of care based on client’s health problems
PRIORITIZE a. Lab values
HYPOTHESES b. Diagnostic tests
c. Risk Assessments
Identify expected outcomes and related nursing interventions to client’s needs
GENERATE
SOLUTIONS
Implementation planned expected outcomes
TAKE
ACTIONS
Evaluate client’s response to nursing interventions and reach a nursing
EVALUATE judgement regarding the extent to which outcomes have been met
OUTCOMES
CLINICAL JUDGEMENT
Conclusion about a patient’s needs or health problems,
decisions needed to take or avoid action
use or modify standard approaches
create new approaches based on the patient’s response
ASSESSMENT
subjective data (what the person says about himself or herself during history taking)
messages.downloaded_by
, lOMoARcPSD|64026470
objective data (what you as the health professional observe by inspecting, percussing,
palpating, and auscultating)
NCLEX WORDS THAT INDICATE ASSESSMENT NEEDS TO BE MADE:
- Ascertain, assess, check, collect, determine, find out, identify, monitor, observe, obtain
information, and recognize
Select cues within assessment
Clients’ response to
findings
interventions and the evaluation
Recognize cues:
Met
Signs
Not Met
Symptoms
Health History
Intervention/
implementation of planned
and expected outcomes Write a diagnosis based on
Take Action! selected cues
Analyze cues: link cues to
clinical presentation and
establish
Generate solutions: identify Needs
expected outcomes and relate to Concerns
nursing interventions
Problems
Client Needs
Plan nursing intervention to
improve client’s health
Prioritize Hypothesis: based on
client’s health problems
Risk Assessment
Labs
Diagnostic Tests
DIAGNOSTIC LABEL - NURSING DIAGNOSIS
messages.downloaded_by
, lOMoARcPSD|64026470
focused on the alteration related to statement =
in pt health. not medical etiology contributes to -->
diagnosis medical diagnosis
diagnostic related to
label statement
problem-
focused defining
contains all 3 objective cues or symptoms
characteri
nursing
diagnosic label
diagnosis sticswhich the nursing diagnosis
related to... is based on
defining characterisitics...
ACTUAL PROBLEMS POTENTIAL PROBLEMS OPPORTUNITIES FOR
ENCHANCED WELLNESS
(Related to/As Evidenced By) (Risk For) (Health Promotion)
Diagnostic Label Risk factors but no evidence of Client desires enhanced
Related To Statement actual problems wellness and well-being
Defining Characteristics
(3-Part) (2-Part) (1-Part)
Ex. Impaired physical mobility Ex. Risk for infection related to Ex. Readiness for enhanced
related to decreased muscle compromised host defenses resilience
control as evidenced by
inability to control lower
extremities
HEALTH PROMOTION
Help individuals maintain or enhance their health, like exercise and good nutrition
3 PART NURSING DIAGNOSIS = P E S N – North
A – American
P – problem or NANDA-1 label N – Nursing
E – etiology/related to statement D – Diagnosis
S – symptoms/defining characteristics A – Association
PLANNING
Goals: general statements describing a desired change and outcomes are measurable changes
needed to reach a goal.
Goal must be in relation to the patient and changes needed to support their heath
o S - SPECIFIC – goals reflect a specific patient behavior response
o M - MEASUREABLE – must be able to measure/observe whether change takes place
o A - ATTAINABLE – goal/outcomes is achievable when mutually set with pt
o R - REALISTIC – set goals/outcomes that is realistic for pt
o T - TIME – set time for each goal/outcome to be met
TYPES OF INTERVENTIONS
NURSE INITIATED (Independent)
messages.downloaded_by
