0133427269 Module36 ClinicalDecisionMaking LectureOutline

Module 36 Clinical Decision Making The Concept of Clinical Decision Making Clinical decision making ( a process nurses use in the clinical setting to evaluate and select the best actions to meet desired goals Applies across the continuum of nursing care Nurse must evaluate each clients needs and preferences as well as time-constraining activities to make appropriate decisions for each client Critical-thinking Critical thinking is cognitive process ( an individual reviews data and considers potential explanations and outcomes before forming opinion/making decision Problem-solving process ( process where a dilemma identified and corrected Critical thinking, problem solving, decision making are interrelated processes Decision making also used in situations not involving problem solving Intellect Intellect includes the ability to learn and understand knowledge. Salient cues ( significant data that inform and influence conclusions Indicates a negative or positive change in a clients health status or pattern Varies from norms of the client population Indicates a developmental delay Salient cues fit together within a clinical situation They can be clustered for relatedness to determine whether any patterns are present. Creativity ( finding unique solutions to unique problems Creativity is a means to finding unique solutions when traditional interventions are not effective. Creative thinkers must have knowledge of the problem. Inquiry ( a search for knowledge or facts Examine objective information to gain clarification and find solutions to problems Critical thinking requires nurses to use inquiry to examine the facts Reasoning Three major types Deductive reasoning Work from the top down Start with a conclusion Analyze for valid significant cues Inductive reasoning Work from bottom up Put significant cues together to reach a conclusion Clinical reasoning Use of careful reasoning in the clinical setting to improve client care Requires critical thinking and the ability to reflect on previous situations and decisions to evaluate their effectiveness Reflection ( the action of making sense of occurrences, situations or decisions by carefully considering the totality of the experience What worked or did not work What could have been done differently to achieve better outcome See Box 36-1 GUIDED REFLECTION, p. 2321 Intuition ( the use nursing knowledge, experience and expertise for understanding without conscious use of reasoning Gut reactions Intuition is a process ( data that is continuously received through senses is not always recognized consciously Gut reaction Use of Clinical decision making Types of decisions include Value decisions Time-management decisions Scheduling decisions Priority decisions Nurses also help clients make decisions Common steps used to make decisions Identify the situation or problem List all possible alternatives and information about them Compare pros and cons Select the best option or alternative to try Put the alternative into action Evaluate the success Choosing between alternatives Analyze the alternatives to make sure there is an objective rationale for choosing one alternative over another Use intellect, intuition, and reasoning to make decisions Recognize significant cues that form patterns Problem-solving Norm rather than exception for routine nursing responsibilities Used to determine possible options that may be appropriate when problem arises Obtain information, suggest possible solutions, evaluate possible solutions Nursing process Nurses make decisions at every step in nursing process Experienced nurses also base decisions on past experiences, knowledge, nursing research findings, and skills Assessment First step in nursing process Nurse makes decisions about what data to collect, meaning of normal/abnormal findings, data relevant to clients condition Nurse makes decisions about how to react to assessment findings Diagnosis Nurse reviews all data and makes decisions regarding clients priorities for care Clients with multiple problems require higher degree of decision making Chief complaintsymptoms causing need for admission or contact with healthcare team Planning Nurse makes decisions regarding client goals and best interventions to address chosen nursing diagnosis Goals decided, then interventions can be chosen Implementation Nursing care plan put into action Requires great deal of critical thinking and decision making Evaluation Planned, ongoing, purposeful activity in which client and healthcare professionals determine Clients progress toward achievement of goals/outcomes Effectiveness of nursing interventions Requires collection of further data and comparing it to previously gathered data Trial and error One method for solving problems Trying out a solution and seeing if it works Intuition An aspect of critical thinking Relevant to problem solving The scientific method Formalized, logical, systematic approach that is most successful when working in a controlled situation Case Study A ( Anna Nadine, 64 years old, is admitted to the medical unit at a local healthcare facility with a medical diagnosis of pulmonary edema secondary to left-sided heart failure, p. 2324 Clinical judgment Clinical judgment ( end product of the complex process of clinical decision making Combines critical thinking abilities, evaluative decision making, and nursing experience Dynamic cognitive process brings together all elements of critical thinking and clinical decision making Benners skill acquisition model ( see Figure 36-6, p. 2325 Tanners clinical judgment model ( see Figure 36-4 and Table 36-4, p. 2326 Lasaters clinical judgment rubric ( see Figure 36-5, p. 2327 Review The Concept of Clinical Decision Making Relate Link the Concepts Refer Go to Nursing Student Resources Reflect Case Study Exemplar 36.1 The Nursing Process Overview Term nursing process gained legitimacy in 1973 Purpose Identify client health status Identify actual or potential healthcare problems or needs Establish plan to meet the identified needs Deliver specific nursing interventions to meet those needs Evaluate the success of those interventions Client may be an individual, family, or group See Figure 366, THE NURSING PROCESS IN ACTION, p.2329 Phases of the nursing process Different terms may be used to describe phases of nursing process activities of nurse similar Phases are overlapping, continuing subprocesses Each phase affects the others See Table 365, THE PHASES OF THE NURSING PROCESS, p. 2330 See Figure 367, THE FIVE OVERLAPPING PHASES OF THE NURSING PROCESS, p. 2331 Assessment First phase of nursing process Systematic, continuous collection of data about client Purpose determine clients current/ongoing health status, predict clients risk to health, identify appropriate health-promoting activities Focuses on clients response to a health problem Includes subjective and objective data Data is then organized according to one of several models Gordons fuctional health patterns, Roys adaptation model, body systems See LIFESPAN CONSIDERATIONS Assessment of Children, p. 2334 Case Study Assessment ( Amanda Aquilini, a 28-year-old married attorney with one child, was admitted to the medical unit of the local hospital with a medical diagnosis of pneumonia throughout her right lung , p. 2331 See Figure 368, ASSESSMENT FOR AMANDA AQUILINI, pp. 2332 Diagnosis Second phase of nursing process Critical thinking skills used to interpret assessment data and identify client problems NANDA Nursing diagnosis ( a clinical judgment about individual, family or community responses to actual or potential health problems/life processes Nursing diagnosis provides the basis for selection of interventions To identify nursing diagnoses and then create a nursing plan of care, nurses need to know Common terms used with nursing diagnoses The difference between a nursing diagnosis and a medical diagnosis Types of nursing diagnoses Components of a nursing diagnosis Common terms Diagnosis ( statement or conclusion regarding nature of a phenomenon Diagnostic labels ( standardized NANDA (North American Nursing Diagnosis Association) names for the diagnoses Etiology ( causal relationship between a problem and related or risk factors Nursing diagnosis ( clients problem statement Diagnostic label etiology Risk factors ( factors causing client to be vulnerable to developing health problem Nursing diagnoses versus medical diagnosis Nursing diagnosis ( a statement of nursing judgment and refers to a condition that nurses are licensed to treat Medical diagnosis ( refer to disease processes Types of nursing diagnoses Actual diagnosis ( client problem present at time of nursing assessment Risk nursing diagnosis ( clinical judgment that a problem does not exist presence of risk factors indicates problem likely to develop unless nurse intervenes Wellness diagnosis ( describes human responses to levels of wellness that have a readiness for enhancement Health promotion diagnosis ( clinical judgment of motivation/desire to increase well-being and actualize human health potential Syndrome diagnosis ( associated with a cluster of diagnoses Components of a nursing diagnosis The diagnostic label First component of nursing diagnosis Describes clients health problem or response for which nursing care is given Clear, concise, specific When the word specify follows a NANDA label, the nurse states the area in which the problem occurs Qualifiersgive additional meaning to diagnostic statement See Table 36-6 EXAMPLES OF THE COMPONENTS OF A NURSING DIAGNOSIS, p. 2336 The etiology (related factors and risk factors) Second component of nursing diagnosis Identifies one or more probable causes of health problem Gives direction to required nursing therapy Enables nurse to individualize care See Table 367 EXAMPLES OF A NURSING DIAGNOSIS WITH DIFFERENT ETIOLOGIES, p. 2336 Defining characteristics Third component of nursing diagnosis Cluster of signs/symptoms that indicate presence of particular diagnostic label For actual nursing diagnoses, defining characteristics are clients signs/symptoms For risk nursing diagnoses, no subjective/objective signs present Developing a nursing diagnosis Critical thinking is used to analyze and apply reasoning to formulate nursng diagnoses See Table 36-8 EXAMPLES OF CLIENT CUES COMPARED TO STANDARDS/NORMS, p. 2337 See Table 36-9 EXAMPLES OF FORMULATING NURSING DIAGNOSES FROM CLIENT CUES, p. 2337 See Figure 36-10 DECISION TREE , p. 2338 Writing a nursing diagnosis statement Basic two-part statement Problem (P) NANDA label Etiology (E) related to Two parts joined by phrase related to If NANDA label contains specify, must add words to indicate the problem more specifically See Table 3610 EXAMPLES OF TWO-PART NURSING DIAGNOSIS STATEMENTS, p. 2338 Basic three-part statement ( PES format Problem (P) NANDA label Etiology (E) related to Signs and symptoms (S) defining characteristics of the problem Cannot be used for risk diagnoses See Box 3611, EXAMPLE OF A THREE-PART NURSING DIAGNOSIS STATEMENT, p. 2339 Basic one-part statement Wellness diagnoses and syndrome nursing diagnoses Common variations Unknown etiology when nurse does not know contributing factors Complex factors when many etiological factors involved Secondary to to divide etiology often pathophysiological process or medical diagnosis Add second part to general response or NANDA label to make more precise See Table 3612, GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENT, p. 2339 Avoiding errors in diagnostic reasoning Verify all diagnoses Build a good knowledge base and acquire clinical experience Have a working knowledge of what is normal Consult resources Base diagnoses on patterns rather than on isolated incident Improve critical-thinking skills Case Study B Diagnosis ( Nurse Medina wants to use the assessment data she obtained during the admission assessment of Mrs. Aquilini to identify the top priority nursing diagnosis, p. 2340 Planning Deliberative, systematic phase for formulating goals Goals vs outcomes ( see Box 36-2 THE DIFFERENCE BETWEEN A GOAL AND AN OUTCOME, p. 2341 Goals become the basis for the nursing interventions Clients and nurses plan goals together Long-Term and Short-Term Goals Short-term goals are useful for clients who require health care for a short time Long-term goals are used for clients who live at home and have chronic health problems. Developing a goal ( ask the following questions What about the nursing diagnosis needs to be changed for or by the client Is there a healthy response to correct a problem stated in the nursing diagnosis that the client can achieve as a goal How will the client look or behave if the healthy response as a goal is achieved What action must the client do and how well must the client do it to demonstrate problem resolution or achievement of the goal Writing a goal Client centered Specific and concise single actions Single in number for each nursing diagnosis Directional for nursing interventions Measurable Quantifiable Attainable for the individual client Realistic to the individual client Relevant to an individual client Time limited SMART ( mnemonic for writing a goal statement Specific single action Measurable Attainable Relevant Time limited See Table 36-13 SMART FORMAT, p. 2343 Case Study Planning ( Nurse Medina has formulated the diagnostic statement to be top priority for Mrs. Aquilini based on the assessment cluster of significant cues , p. 2344 Implementation Implementation ( the action phase of the nursing process Doing and documenting specific nursing actions needed to carry out interventions Nursing interventions Nursing interventions focus on Assessments to observe for changes in the clients status Prevention to avoid complications Reduction of risk factors Treating through teaching and providing physical care Improvement of health through health promotion and achieving higher levels of wellness Types of nursing interventions Direct care ( intervention performed through interaction with the client Indirect care ( intervention performed away from, but on behalf of, the client Independent interventions ( activities that nurses are licensed to do within their scope of practice Collaborative interventions ( actions nurses carry out in collaboration with other health care team members Dependent interventions (actions employed by nurses under a physicians orders Considerations when selecting nursing interventions Usually several potential interventions can be identified for each goal Nurses must select those that are most likely to achieve the client outcomes Interventions need to be Safe and appropriate for the clients age, health, and condition Achievable with the resources available Congruent with clients values, beliefs, and culture Congruent with other therapies Based on current best nursing research evidence Within established standards of care Writing a nursing intervention Common characteristics of a nursing intervention Is client centered Has a specific and concise single action Includes detailed information about the action Is realistic for the individual client Is relevant to helping client reach goal Implementation Preassessment of the client Determining the nurses need for assistance Delegation Documentation Skills necessary for implementation Cognitive skills Interpersonal skills Technical skills Relationship to other nursing process phases First three phases assessment, nursing diagnosis, goal planning provide the basis for the nursing actions performed during the implementation Nurse continues to reassess the client at every contact Case Study Implementation ( The goal for Mrs. Aqulini is The client will drink 3,000 mL of fluids daily by 8/12 , p. 2348 Evaluation Last phase of nursing process Planned, ongoing, purposeful activity Client and healthcare professionals determine Clients progress toward goals/outcomes Effectiveness of nursing care plan Continuous Drawing conclusions When goals have been met The actual problem stated in the nursing diagnosis has been resolved or the potential problem is being prevented and the risk factor no longer exists The risk factor is being prevented, but the risk factors are still present The actual problem still exists even though some of the goals are being met When goals have been partially met or not met The plan of care needs to be revised since the problem is only partially resolved The plan of care does not needs revision because the client merely needs more tie to achieve the goal Developing an evaluation Nurse collects data to determine whether goals have been met Three possible conclusions The goal was met The goal was partially met The goal was not met Writing an evaluation Evaluation statement ( consists of Date and time evaluation was done Conclusion statement about whether goal was met, partially met, or not met Supporting statement giving the results of how the client did or did not achieve the goal Continuing, modifying, or terminating the nursing plan of care See Table 36-16 EVALUATION CHECKLIST, p. 2351 Assessment Nursing diagnosis Revising client goals Redesigning nursing interventions Method of implementation See Table 36-17 EXAMPLES OF EVALUATION OF OUTCOMES AND GOALS WITH NOTES ABOUT NURSING INTERVENTIONS, p. 2352 Relationship to other nursing process phases Successful evaluation depends on the effectiveness of the phases that precede it Case Study Evaluation ( It is 8/12 and time for Nurse Medina and Mrs. Aqulini to evaluate whether or not Mrs. Aquilini has reached her goal, p. 2353 Review The Nursing Process Relate Link the Concepts and Exemplars Refer Go to Nursing Student Resources Reflect Case Study Exemplar 36.2 The Nursing Plan of Care Nursing plan of care( written or electronic guideline organizing information about care Purposes Individualization Continuity of care Documentation Reimbursement Guide to staff assignment Accessibility Nursing plans of care need to be accessible to all team members involved with the care of the client Kept at bedside or with the medical record Guidelines See Table 3618 GUIDELINES FOR WRITING THE NURSING PLAN OF CARE, p. 2355 Can be computerized or written Case Study B ( Mrs. Fisher is a 52-year-old woman whose husband of 35 years died 5 weeks ago , p. 2354 Formats Column plan Concept map Standardized plan Clinical pathway Column plan Plan of care that uses columns to categorize data for each phase of the nursing process See Figure 36-16 FIVE-COLUMN NURSING CARE PLAN , p. 2356 Concept map Visual representation of a nursing plan of care in a patterned diagram with data and ideas See Figure 36-17 STEPS FOR BUILDING A CONCEPT MAP, pp. 2358-2359 Standardized plan Plan of care that specifies the nursing care for groups of clients with similar needs Frequently includes checklists, blank lines, or empty spaces to allow nurses to individualize them See Figure 36-18 EXAMPLE OF STANDARDIZED PLAN OF CARE , p. 2360 Clinical pathway Standardized, evidence-based, multidisciplinary plan that outlines expected care required for clients with common, predictable conditions See Figure 36-19 CLINICAL PATHWAY FOR MOTHER AND BABY, p. 2361 See Figure 36-20 CLINICAL PATHWAY FOR PEDIATRIC ASTHMA , p. 2362 Review The Nursing Plan of Care Relate Link the Concepts and Exemplars Refer Go to Nursing Student Resources Reflect Case Study Exemplar 36.3 Prioritizing Care Overview Term priority means one particular task gets attention before another task Identifying what to prioritize Two qualities to consider Effectiveness ( doing the right things Efficiency( doing things right Assessment Making observations Asking questions to gather information necessary to make decisions The nursing process Used as a method of organizing nursing care of clients Maslows hierarchy of needs Can be used to rank client needs Low priority Medium priority High priority See Table 3619 EXAMPLES OF NANDA NURSING DIAGNOSES OF LOW, MEDIUM, AND HIGH PRIORITY CLIENT CIRCUMSTANCES, p. 2366 Categorizing priorities Time constraints Some nursing interventions have time constraints or deadlines The urgency factor Time priority ( means a time constraint is present when completing the action Urgency factor ( way to illustrate how much time can safely lapse before doing interventions without compromising client outcomes Nonacute(low urgency factor Acute(medium priority Critical(medium-high urgency Imminent death(highest urgency Ranking activities Priority 1 or must do Priority 2 or should do Priority 3 or nice to do Triage Emergent or immediate Urgent or delayed Nonurgent or minor Factors to consider when prioritizing care Ethics Safety Availability of resources Time management Multiple clients Client preferences Change in client condition The unexpected Pitfalls of prioritization Prioritizing without assessment Incomplete assessment Relying solely on anothers assessment Failing to do periodic reassessments Poor time management Not involving clients in their care Inappropriate delegation Doing the easiest tasks first Review Prioritizing Care Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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