hi this is Sharon Celestine clinical instructor with Delgado lecture on clinical decision making when we talk about clinical decision making we are asking questions we are answering questions about who or what patient we should see first what should i as a nurse do next or why do I have to do this now or when should I complete a particular class when we talk about clinical decision making we understand that it's a process that nurses use in the clinical setting to evaluate and select the best action to meet a desired goal when we talk about clinical decision making it affects every aspects of nursing care from direct client care at the bedside to professional behavior and accountability as a nurse clinical decision making requires good quality judgment including critical thinking some of the examples of how we Implement clinical decision making with the decisions we make for example what patient should I see first how do you determine what patient you will see first what can I teach my patient with CHF about low sodium diet when we look at CHF congestive hard failure we know that our patient is retaining fluid we also know that with Sal it also retains fluid so do we really want to give a patient that have congestive heart failure that already have edema do we want to give them a diet that's high in sodium another question another example do I hold the medication or administered when we talk about clinical decision making these are the decisions you have to make with the information that you have so an example of holding the medication or administering it if a patient has elevated blood pressure on that particular day you're assessing your patient the blood pressure happens to be low let's say the blood pressure is 9 over 60 as a nurse you have to make a decision on whether you whether or not you are to administer that medication so again when we talk about the concept of clinical decision making we understand that it's a process you evaluating information and you're making the best decision based on the patient what's going on with the patient there are certain characteristics that you will have to implement when you're making your decision as a nurse one ethical and value based that's the decision in which the actions and its consequences could compromise the beliefs privacy dignity Identity or other moral or value based aspect of the patient's being prioritization it's the decision in which the nurse must decide quickly what is the most important in given in in that given situation what must be done personally what can be delegated and what can weit as we go on into our lecture we're going to talk a lot more about prioritization how do you prioritize in addition to that time management time management as as a nurse it's key it's the decision in which the nurse consider the most efficient use of time for each patient based on the specific Factor you're looking at what's going on with the patient and how much time do you have to complete that task scheduling scheduling is the decision that abound by a set perimeter for example if a doctor wrote in order stat we know that stat is something that needs to be done immediately you're not going to wait till the end of the day to complete that task so scheduling is also important personal and professionalism nurses make decisions surrounding where to work certifications to obtain and what career path to take again even that is considered a decision that you make as a nurse now we are going to look at what are some of the components for applying clinical decision making what components do you need to make a good clinical Decision One critical thinking two clinical reasoning and when we talk about clinical reasoning we're going to look at the nursing process or what is sometime called the clinical judgment model we also need time management and we also incorporate evidence-based practice let's define critical thinking according to the national league for nursing accreditation commission it states that critical thinking it's the deliv nonlinear process of collecting interpretating analyzing drawing conclusions about presenting and evaluating information that is both factual and belief-based critical thinking it is currently considered an essential component of nurses professional judgment and clinical decision making the American Association of College of Nursing the essential core comp y of professional Nursing education defines critical thinking as a skill of using logic and reasoning to identify the strengths and the weaknesses of alternative healthare Solutions um conclusion or approaches to clinical or practice problem when we talk about critical thinking critical thinking it is a skill it's very important in the nursing field because they are it defines what you do how you prior prioritize and make key decisions that can save a patient life nurses give Critical Care 24/7 so the critical thinking skill of nurses can really mean the difference between someone living or dying critical thinking skills they are very essential for nurses they are a necessity for the provision of safe high quality clinical care nurses today we are caring for a lot of patients with complex C cultural diversity Health needs making the importance of critical thinking in nursing even more par Paramount critical thinking in nursing it is a learn skill that increases the quality of care given to patients and improve outcome to Be an Effective nurse it's important to step back and see the bigger picture and this means that you have to be able to analyze your patients condition and their current treatment to predict some of the outcomes and identify potential issues the importance of critical thinking in nursing it cannot be overstated patients are diverse their clinical presentations are unique nurses must be capable of making rational clinical decision and solving problems in order to provide safe high quality care so this mean there are times when nurses may have to think ahead think in action and think back to get the job done critical thinking is vital for nurses to meet the challenges of caring for increasingly complex patients some of the attitudes of critical thinker will go over some Independence you do your own thinking being fear minded you have a neutral judgment cannot use bias a way of self self-limits know exactly what what you're doing based on your experience Integrity challenge own ideas and methods of doing nursing care you're choosing the right thing to do over the popular thing to do perseverance has a stick with it motivation to send the best result confidence know the extent and limitation of existing knowledge some more critical thinking skills intellect the ability to think understand and reason creativity which allows a nurse to find unique solutions to a unique problem when traditional interventions are not effective inquiry a form of research a search for knowledge reasoning the ability to walk into a patient's room and immediately observe significant data come to a conclusion about the patient and begin appropriate action reflect the action of retrospectively making sense of occurrences experiences situations or decisions and consequently learning from them intuition the gut feeling something is wrong when working with a patient definitely guys pay attention to your intuition if you walk into a room and you sense that six sense sense something is wrong please act on it note that critical thinking Remains the Cornerstone of nursing care and patient intervention so here's a little scenario about trying to see if you understand how to apply critical thinking so here we have an evening supervisor stopped by to check on a new grad who was in charge for the first time the new grad appeared to be in over her head she was nervous and running around calmly the supervisor acts how are things going and she replied fine except for the patient in room 2 or three his temperature was 104 about an hour ago we drew cultures and started him on antibiotics now we're asking her what is the patient temperature now so when you apply critical thinking of course there may be an order for let's say every four hours for Vital Signs in this case though do you want away till 4 hours later to take a patient temperature who we know had a temperature of 104 so when you apply critical thinking of course yes it's okay 4 hours later that's the order but as a nurse applying critical thinking you would want to take that temperature a little bit sooner just so you know what's going on with that patient now we're going to take a look at the nursing process which is also called the clinical judgment model the nursing process function as a systemic guide to client centered care with five sequential steps these are assessment diagnosis planning implement ation and evaluation when we talk about clinical judgment it is the cognitive process through which nurses solve problems by applying clinical reasoning critical thinking and decision-making skills the components of clinical judgment model it includes recognizing cues analyzing cues generating hypothesis generating Solutions taking actions and evaluating outcome both of them what exactly it does it helps us to identify a client's Health Care status and the actual or potential health problem to establish plans to meet the identified needs and to deliver specific nursing interventions to address these needs here we can take a look at side by side the phases of the nursing process next to clinical judgment model so we see assessing when we're assessing we are collecting data we are organizing data we are validating data and we are documenting data when we look at the clinical judgment model we are also doing the same thing we assessing for cues and we are analyzing cues when we look at the nursing process we look at diagnosing you're analyzing data you're identifying health problems risk and strength formulating diagnostic statements when we're planning we are prioritizing the problems we are diagnosing um giving a nursing diagnosis formulating goals and desired outcomes selecting nursing interventions and right nursing interventions during this phase we're just planning now we actually going to act in what do we exact what we are going to do now you reassess the client determine the Need For assistance you're implementing nursing intervention you're supervising um delegated task and you're documenting the nursing activi again with nursing process we also evaluating you're collecting data related to the outcome you're comparing the data with outcome you relate nurseing actions to the client goals drawing conclusions about the problems you con continue to modify or terminate the client's care plan when we look at it with the clinical judment model basically doing the same thing you're assessing for qes you're analyzing Q's you're prioritizing hypothesis you're generating Solutions taking actions and evaluating those actions those outcome what did you do for this patient did it really work so this chart here it just reiterate um the previous slide which is basically showing you the difference between clinical um clinical judgment model which exactly it's not different but just the terms that they use is different so now we're going into the nursing process and the acronym adpie adpie again it stands for assessment diagnosing planning intervention and evaluating when we begin to implement assessment what exactly is assessment with assessment it is the first step and it involves critical thinking skills and collecting data whether it's subjective dat data or objective data as we know that subjective data involves verbal statement from the patient or the caregiver objective data is measurable as a nurse this is what we are doing tangible data such as Vital Signs intake output and other other information such as height and weight the data may come from the patient directly or from a primary caregiver who may or may not be in direct relation with the family member friends can play a role in data collection too also we can use electronic health records to May populate data in or assist in the assessment again when we're talking about assessment you're looking for cues you're recognizing cues you're identifying relevant information needed um in the client's condition when we are talking about analyzing cues the main purpose of assessment phase is to validate subjective and objective data important me methods of collecting are the patient the most important method it would be the patient what the patient see but again we can use other information the physical examination you guys are doing hetal assessment observation of the patient even looking at a patient's lab work this is all information that you can use to better treat your client or your patient again here we're going to reiterate that you can get information that is subjective data objective data medical records past history healthc Care Professionals social data psychological data and lifestyle remember always to assess first now we're going to look at the nursing process when we talk about diagnosis or clinical judgment model where we are um analyzing the cues and prioritizing hypothesis when we talk about diagnosis we are analyzing the data we are identifying health problems risk and strength and we are formulating a diagnostic statement with a nursing diagnosis it is a clinical judgment concerning a human's response to health condition life process or a vulnerability for that response by an individual family group or communicate Community the formulation of a nursing diagnosis is um by employing clinical judgment is assists in planning and in the implementing phase of a patient's care so when we talk about the nursing process the clinical judgment with diagnosis as a nurse you are describing what's going on with your patient for example if you have a patient that's having difficulty breathing you're not going to go into the room and say oh by the way this patient has COPD no as a nurse You're Going to describe what you see ineffective breeding patterns shortness of breath you are describing what it is you see there's a difference between a nursing diagnosis and a medical diagnosis with a nursing diagnosis again you are describing the patient's physical social cultural psychological or spiritual response to illness or a health condition whereas with a medical diagnosis it's referring to the disease process as a nurse you're just using nursing judgment with a medical diagnosis that's what's made by either a licensed provider or doctor a nurse practitioner or a physician assistant here are some examples of a nursing diagnosis versus a medical diagnosis so again as mentioned before a patient is having difficulty breathing as a nurse You're Going to describe it as ineffective breathing pattern whereas the doctor May express it as Chon chronic obstructive pulmonary disease which is COPD you may describe a patient is having activity intolerance whereas the doctor may come in and say hey this patient have AC CVA acute pain the patient may be having pain in the lower extremity whereas the doctor may come in and say femur fracture again understanding with nurses you are basically describing what you see opposed to actually giving it a term or a diagnosis here are four different types of nursing diagnosis problem Focus diagnosis risk nursing diagnosis health promotion diagnosis and syndrome diagnosis as you go into the clinical setting your instructor once you start doing your care plans they are going to go go into more details about the discussion of the diagnosis the different types of diagnosis we're going to discuss some of the components of a nursing diagnosis so according to Nanda and what exactly is Nanda Nanda is the North American nursing diagnosis Association and what they do they provide nurses with an upto-date list of nursing diagnosis so when you go into your clinical setting this is something that your instructor will allow you to do to to use to help you come up with nursing diagnosis but basically with nursing diagnosis you're describing the patient's health status in a clear clear with only a few words you identifying topics Direct in formation of the patient goal and the desired outcome and it may suggest some of the nursing interventions but they need to be specific they need to reflect nursing judgment intensify focus of the diagnosis and give its specific meaning what are some of the components of a nurseing diagnosises was one of them then we talk about the ethiology it's the related factors and risk factors it identifies one or more probable cause of the hell problem it gives directions to required nursing it enables nurses to individualize Patient Care remember regardless of what's going on with the patient let's say you have four patients and they all have diabetes as a nurse You're Still individualizing each of the patient care you differentiate among probable causes is essential the cause of each problem may require different nursing intervention defining characteristics you're looking for signs for example if a patient is having difficulty breathing you may notice that they're using accessory muscles you may notice that they're breathing in through their nose there are certain things that you may notice and these are all called clusters of signs and symptoms that indicate the presence of a particular diagnostic labor and they may differ according to the type of nursing diagnosis when you're writing a nursing diagnosis it can be in a two-part statement with a problem and the E theology meaning that the problem what is the problem what's going on with the patient or you may also use it with what's causing the problem there's another basic three-part statement using problem ethiology and adding the signs and symptoms what's going on with the patient what does it look like there's also a basic one part statement and again like I said in Nanda you'll be allowed to do this you'll be giving you information on how to apply and how to look for nursing diagnosis the common variations may be unknown ethiology complex Factor secondary 2 and again you'll go into more Det details as you go into clinicals with our no nursing diagnosis once we identify a nursing diagnosis we also need to know how to prioritize so when we're talking about prioritizing we're looking at what am I going to do first so I have it here cab whether it's cab or ABC or BCA it's Airway breathing circulation you always look at a away breathing circulation first what do I mean by that let's just say you going into a patient's room to do let's say wound care but when you go into the room you notice that the patient is having difficulty breathing as a nurse what are you going to do hopefully you're thinking that let's stabilize her breathing and then we can do the wound care it's not that the wound care is not needed to be done but if you go into a room and you have to prioritize you always want to look head Airway breathing or circulation first okay now let's look at Vital Signs because sometimes you may have a patient where their breathing is fine the next concern you would look at is their Vital Signs what's going on with this patient is this patient stable enough for me to go ahead and do what I need to do so now that becomes a priority same difference if the patient labs are unstable do you want to go ahead and continue with probably taking care of a womb opposed to looking at the patient's Labs that may indicate something is going on with the patient so again when we talk about prioritization and how we look at our patients and which patients we are going to see first we're going to our identify our patient that's having difficulty breathing as our first priority what does that mean to you giving patient care in the hospital let's say you go and you for your assignment today you have one patient that's having difficulty breathing they're wheezing and you have another patient that needs antibiotic and you have another patient that needs their blood pressure medication but their blood pressure is stable if you had to make a choice then definitely your choice should be the patient that's having difficulty breathing in addition to that let's look at Marlo hierarchy of needed also allows us to prioritize when we talk about applying maslo hierarchy of need according to maslo he is saying that the basic needs have to be met first so if before we go to advance care we want to make sure that our patients basic need the basic physiological needs are met for example nutrition water and food elimination toileting ear was suctioning breathing oxygen circulation all of these needs have to be met before we go to the next level now let's look at the planning phase generating Solutions you are generating Solutions here you have identified the problem the patient has a problem during your assessment you have identified a nursing diagnosis now you're going into the planning phase during the planning step of the nursing process the nurse Works in partnership with the patient and the family to establish priorities identify and write expected outcomes self- evidence-based nursing intervention and communicate the plan of Nursing Care during the planning stage is where goals and outcomes are formulated that directly impact the patient care based on evidence-based guidelines these patient specific goals and the attainment of such assist in ensuring a positive outcome nursing care plan are essential in this phase of goal set and care plans as we said before they provide a course of direction for personalized care tailored to the individual unique needs overall conditions and comob conditions play a role in this structor of a care plan so when we look here at the planning phase what exactly are we doing it's a deliberate systemic phase the nurse what you're doing you're taking the information from the assessment data that you collected the nursing diagnosis for directing into formulating the patient goals now when we talk about a goal the goal is observable patient response that response to hope to achieve so basically you're setting a goal for the patient and when we talk about outcome is specific observable criteria used to evaluate whether the goal has been met the goal now becomes the basis for nursing intervention what you're going to do so you're setting goals and now later on you will be actually implementing so when we talk about um goals it's developed to prevent reduce eliminate or improve nursing diagnosis it's important for us as nurses and patients to make sure that we include a support person to participate in the development of the plan remember that nurses don't plan for patients but encourage patients to participate actively patients family members caregivers will implement the plan in the home setting so basically what we saying let's say you identify a patient let's say a patient is diabetic but they're not the one that's cooking at home it will be okay if you implemented the family member because that's the person that's cooking to help with that patient's diet remember that when we are planning nurses it's a nurse patient partnership in identifying a goal for each nursing intervention planning what it does it provides dire direction for selecting nursing intervention it serves as a basis for evalu evaluating patients progress it enables closure of nursing diagnosis situation when patient nurse determines the goal has been achieved it also helps motivate the patient and the nurse by providing a sense of achievement and what it does it also support therapeutic nurse patient relationship when we are looking at the goals we are setting goals it's important that you understand the difference between a short-term goal and a long-term goal with a short-term go it may be using the cute care set it's achievable in a range of maybe a few hours to a few days or even a few minutes because if you have a patient that's having difficulty breathing you would want that to be short-term goal that they are breathing properly within x amount of time now when we look at a long-term goal it's often used for patients at home in the nursing home or other long care term facilities it's also used in the hospital too let's just say you have a patient with a chronic health problem diabetes whatever you're teaching your patient there in the accute second upon discharge this is something that you want the patient to continue to do let's say you've been ident the patient have been identified as having diabetes in the hospital when they go home they're still going to have diabetes so whatever you're teaching them the goals that you're teaching them sometimes it also include you teaching them long-term goals with planning we're developing goals for each nursing diagnosis has one goal for the patient to achieve an example of this would be impaired physical Mobility the goal would be to improve Mobility um ability to bear weight on the left leg when you are looking at goals you want to make sure that they are single specific action you want to make sure that they are measurable attainable relevant and Tim limited planning goals their statement form so and your clinical set your instructor may also go over how do you write a goal so it has to have a subject a verb a goal and a Time an example of that would be the patient will demonstrate giv herself insulin injection using aseptic techniques by discharge you have a subject a verb a goal and a time time limit another example the patient will identify six foods to avoid that are high in salt content in 4 hours from 1:30 again again there's a subject verb goal and time now let's look at the implementation phase with the implementation phase you are actually now taking action you are doing something with implementation it's the step which involves action or doing and actually carrying out the nursing intervention outlining the plan of care this phase requires nursing intervention such as applying a cardiac monitor um or even doing O2 SATs direct or indirect medication administration standard treatment protocol um according to evidence-based standards now you're actually acting it's a intervention you are actually doing something to that patient so if that patient is having difficulty breathing your plan was to let's say Elevate the head of the bed administer O2 this is what you're actually doing now you're promptly and actually accurately performing nursing action based on prioritized nursing problems you should have incorporate your patient preference and the need when performing your nursing action so the action phase again it takes data from the first three phases and determine the appropriate intervention this could be a two-step process you identify the best priority intervention what am I going to do first and Implement these interventions accordingly again with the implementation phase it includes the nurse taking action it could be you the nurse us the nurse delegation of a task documentation completed to help the patient achieve the goal based on the nursing diagnosis it's focus on assessing to observe for changes in the patient status preventing any type of complication reducing risk factors treating through teaching and providing physical care improving Health through health promotion achieving higher levels of Wellness correct identification of e ethiology during assessment and nursing diagnosis phase what it does it provides a framework for choosing the correct intervention during the implementation um phase the T taken action phase you're implementing the nursing intervention your consideration When selecting interventions you have to select the interventions most likely to achieve the desired outcome you have to prioritize potential interventions including and you must include the patient's input determine the pros of con of each potential intervention requires nursing knowledge experience your interventions needs to be safe appropriate for the patient's age health and condition it needs to be achievable with the resources that you have available conru congruent with the patient's value belief and culture and congruent with other therapy what else is going on with the patient what are the therap therapy entities that are coming in to also assist with the patient based on the current best nursing research evidence and it must be done within established standards of care determined by the state laws professional association and the policies that's in place for that particular facility when writing a nursing intervention common characteristics of nursing intervention it has to be patient centered has to be specific concise action includes detail information is realistic to individual patient is relevant to helping the patient reach their goal only top to only top three to five priority intervention usually listed for each diagnosis nursing students often includes rationale so when you go into the clinical set your professor or your clinical instructor may ask you to provide a rational why are you doing a particular action what's the rational for your action now we'll look at the evaluation aspect of the nursing process or the clinical judgment model this is the final step the final step of the nursing process or clinical judgment model is vital to a positive patient outcome whenever Health Care Providers intervene or Implement care they must reassess or evaluate to ensure that the desired outcome has been met evaluation of the desired outcome after implementation of a n nuring care patient and Healthcare professionals determine the patient progress towards achieving the goal or the effectiveness of the nursing plan of care on basis of evaluation nursing care plan is continued modified or terminated so when what you're doing here now you're looking to see if your actions have worked in solving the problem that you identify during the assessment phase patient and support person and encourage to participate as much as possible evaluation evaluation continues until goal achieve or patient discharge it's done druin or immediately after implementation of a nursing action enables on the spot modification evaluation at disart it includes the status of the goal achievement self-care abilities with regards to follow up again when we're talking about evaluation we are looking to see if all of the goals have been met and if it have not been met what am I going to do next so basically you are reassessing the nurse apply all that is known about a client and the client's condition as well as experiences with previous client to evaluate whether nursing care was affected the nurse conducts evaluation measures to determine if the expected outcome was met and if it was not met what am I going to do again here we continue to look at evaluation developing and evaluation use collecting objective subjective data some data may require interpretation for example you may have had to do Labs that require interpretation the data must be recorded concisely and accurately if goals were written properly relative simple to determine whether it was met both nurse and patient play an active role in this in determining whether goals were met one of the three possible conclusion was the goal met patient response same as your desire to come was the goal partially met short-term goals achieved but long-term goal was not achieved or desired outcome only partially attained for example a patient is having difficulty breathing let's say their O2 SATs were 88 at the beginning but now it's 92 here it has been partially met it's not where you want it to be so you may have to reass ESS and Implement another intervention was the goal not met then again you would have to evaluate assess reassess and Implement a new nursing process at the end we want to write um the evaluation choosing the best priority nursing intervention the nurse writes them in the patients plan of care again you will be doing this when you go into the hospital and you start doing your care plan you want to make sure that you have the date and the time of the evaluation you want to make sure you have whether or not the goal was met partially met or not met at all evidence to support the conclusion subjective and objective data is necessary for this as discussed before time management is an an important component of making sure you are able to make a good clinical decision making when we talk about time management for nurses we understand that it helps nurses meet the demands of their job with so much to do and many important decision to make nurseing time management help you to prioritize on the spot what needs to be done based on what's going on with your patient when you're in the hospital setting or even now studying as in a student you want to plan your day out in advance make a list of everything you must get done today then make a note of how long it will take according to the to what's going on you rank the job in order of important again that's called prioritization start looking at tasks and seeing when you will have time in your day to get it done whether it's one item two items or your entire day what needs to be done focus on the most important activity first when you make the list above also focus on the items with the highest priority as you complete your task check them off on a on your list it will give you a sense of accomplishment and make your stress level drop remember also to keep yourself and your Works Space organized being organized saves time at the beginning of the day make sure all equipment is clean and ready for use this will lower your stress level and make your day easier learn to delegate a task now remember when you delegating your task it's important that you delegate with with what's within a person scope of practice for example you delegate a UAP that patient can take vital signs but you wouldn't delegate a UAP to administer your medication for you so remember that you have to look at the Rights of Delegation the right order right instruction right skills right tools and right frame uh right time frame keep yourself again your workplace organized remember that time management is about making your day easy and more productive now we're going to discuss evidence-based practice so it's described as the practice of Nursing in which the nurse makes clinical decisions on the basis of the best available current research evidence their own clinical expertise and the need and the preference of patients it is basically it's the process of collecting processing and implementing research finding to improve clinical practice the work environment or the patient outcome evidencebased nursing is the foundation of professional nursing practice based on problem solving approach to healthcare delivery nursing care practices and protocols based on the best evidence from research studies and expertise of clinician when we talk about implementing um evidence-based practice approach to the in practice it helps us provide the highest quality and the most coste efficient patient care possible research Studies have shown that evidence-- based practice leads to higher quality Care improved patient outcome reduced cost and greater nerve satisfactions what is some of the steps of evidence-based practice one we want to develop questions search and Cate best evidence evaluate the quality of the evidence integrate evidence into practice evaluate outcomes of practice change and disseminate the evidence with evidence-based practice it provid specific support for nurses in clinical thinking process making decisions and using clinical judgment as evidence changed so must practice again I am to this is a example of evidence-based practice you can read through it it was a Midwestern 532 bed acute K tiary magnet designated hospital identified concerns about for rate and patient and nurse satisfaction score so they use the research and they said research has shown that the implementation of bedside report has increased patient safety and patient and their satisfaction so what they know no that was during a certain time of day patients were fallen so normally towards the end of the shifts the near the patients were having fall so now they gathered all the information and in order to stop this they came up with a new um imple implementation for patients and now a patient and nurses so now the bedside report came about so now the nurses are now giv care to the end of the shift exchanging information at the patient's bedside an evidence-based practice change incorporating bedside report into the standard nursing care was implemented and evaluated over a 4mon period once they have done that now what they did they looked at the results what's going on they saw that the fall rates had decreased because now the nurses were actually in the room towards the end of the shift instead of at the nurses station giving reports so now the patient is getting care so again these are example this is an example of evidence-based practice and a particular task coming in place because of all of the information that they gather the research that they gather to make this effective and improve Nursing Care thank you guys remember keep calm and think like a nurse