What is clinical judgment - ANS - consist of both opinions and decisions based on theoretical knowledge and experience
- a nurse knows what to look for, draws valid conclusions about what the signs mean, and knows what to do about it.
Clinical reasoning - ANS Refers to ways ...
What is clinical judgment - ANS - consist of both opinions and decisions based on
theoretical knowledge and experience
- a nurse knows what to look for, draws valid conclusions about what the signs mean, and
knows what to do about it.
Clinical reasoning - ANS Refers to ways of thinking about patient care issues
- determining, preventing, managing patient problems
Nursing Process: Assessment - ANS Collect and analyze date about a client, first step in
delivering nursing care. Includes physiological data, psychological, sociocultural, spiritual,
economic, and lifestyle factors as well.
ex: fearful, refusal to eat
Nursing Process: Diagnosis - ANS The nurses clinical judgement about the clients
response to actual or potential health conditions or needs.
ex: respiratory infection
Nursing process: outcomes/ planning - ANS Based on assessment and diagnosis, nurse
sets measurable and achievable short-and long range goals for this patient that might include
moving from bed to chair at least 3 times per day.
Nursing Process: Implementation - ANS Nursing care is implemented according to the
care plan, so continuity of care for the patient during hospitalization and in preparation for
discharge needs to be assured.
Nursing Process: Evaluation - ANS Both the patients status and the effectiveness of the
nursing care must be continuously evaluated, and the care plan modified as needed.
Subjective data - ANS things a person tells you about that you cannot observe through
your senses; symptoms
Objective data - ANS information that is seen, heard, felt, or smelled by an observer;
signs
ex: physical exam results, laboratory testing, medical histories
Nursing process - ANS A scientific, clinical reasoning approach to client care that includes
assessment, analysis, planning, implementation and evaluation.
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