Clinical Decision Making and Nursing Process

What goes into decision making for a nurse?

• The patient

• The evidence

• Your experience

• Family preferences

Clinical judgement is...

• thought process that allows the ability to memorize medical facts

• thought process that is a method of conducting laboratory tests

• the though process of judging what the patient needs based off of what they think they need for themselves, using subjective data as a guideline

• the thought process that allows healthcare providers to arrive at a conclusion based on objective and subjective information about a patient

Decision making skills and clinical expertise/judgement + client preferences + evidence=?

What are steps of nursing process?

• Observation, Treatment, Recovery, Discharge
• Assessment, Treatment, Follow-up, Review, Evaluation

• Assessment, Diagnosis, Implementation, Monitoring, Feedback, Evaluation

• Assessment, Diagnosis, Planning, Implementation, Evaluation

The assessment part of the nursing process includes:

• Gathering data

• Giving the patient's problem a name

• Prioritization of clients needs

• Action phase

The assessment phase is not a continuous collection of data.

• True

• False

What are examples of subjective data?

• Patient states, "I am having trouble catching my breath."

• Patient appears to be short of breath.

• Family member mentioned a history of tachypnea.

• Patient is using pursed lip breathing.

Which are examples of objective data?

• Patient blood pressure is 158/98.

• Patient reports feeling dizzy.

• Family member reports family history of hypertension.

• Patient appears to be short of breath.

What is a primary source of data?

• Client Family Member

• Primary Care Provider

• Attending nurse

• The client

Which nursing process step includes giving the problem a name?

• Diagnosis

• Assessment

• Implementation

• Contacting the patient primary care doctor