Fundamentals of Nursing 11th Edition - Lecture Notes

Introduction to Clinical Judgment Model

• Objective: Enhance nursing students' ability to become expert clinicians.
• Definition: Clinical judgment involves concluding a patient's needs or health issues, which guides actions or modifications in care approaches.
• Key Components:
  • Nursing knowledge
  • Experience
  • Environmental factors
  • Critical thinking standards

Process of Clinical Judgment

• Purpose: Deliver safe, evidence-based patient care.
• Development: Evolves from the nursing process and critical thinking.
• Student Development: Aids students in developing cognitive skills for competent practice and sound clinical judgments.

Understanding the Nursing Process

Initial Patient Encounter

• Expert Nurse Actions:
  • Review medical record factors: diagnosis, medications, medical history.
  • Use knowledge and experience to understand treatments and symptoms.

Patient Assessment

• Objective: Gather comprehensive patient information.
• Critical Questions & Observations: Driven by known and newly learned data.

Application of Critical Thinking

• Examples:
  • Understanding symptoms (e.g., pain) and conducting unique assessments.
  • Considering environmental factors (e.g., room comfort).
  • Ensuring thorough data coverage with critical thinking attitudes.

Nursing Diagnosis

• Description: Clinical judgment to describe patient responses or vulnerabilities.
• Purpose: Alerts to care problems, aids in communication and consistency.

Planning and Prioritizing Care

• Involves:
  • Prioritizing diagnoses
  • Planning interventions
  • Setting expected outcomes
• Example: Fall risk - outcome is no falls during hospitalization.
• Incorporating Standards: Apply critical thinking to include care standards.

Delivering Interventions

• Objective: Minimize or eliminate nursing diagnoses.
• Collaboration: Work with assistants and family to reinforce care.
• Individualization: Adjust interventions as needed.

Evaluation

• Purpose: Determine intervention success and impact on patient condition.
• Process:
  • Compare initial and evaluation data.
  • Decide if interventions resolved issues or need revision.

Conclusion

• Continuous critical thinking is essential in all steps, from assessment to evaluation, to ensure effective patient care and improved clinical outcomes.