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Clinical Decision Making in Nursing Review

Exam 2 CDM Study Guide
1. Validation of client assessment data
Once you learn normal you can learn abnormal
Validate abnormal findings with a more experienced nurse or recheck the results of vital
signs or blood sugars prior to intervening.
2. Open-ended questions
3. Nursing process
o How RN’s manage care, their scope of practice
o Systematic problem-solving method for determining health care needs of all individuals
o Used in exact order
4. Documentation principles & be able to recognize appropriate documentation
5. Clarification of information
When seeking clarification from a patient, use language such as am I correct in
understanding? Avoid long drawn-out stories or having the patient repeat themselves
over and over, or questioning the patient in a demeaning or accusatory manner
Pay attention to nonverbal communication from the patient.
6. Collaboration
o Get input from physician and other providers in your plan of care
o Get appropriate orders from physician for nursing interventions such as physician therapy
o Round on the patient with other providers so that the plan of care is developed with input
from all involved
7. De-escalation
Do not
Do not engage
Do not get
Be assertive and maintain boundaries
Be clear and direct
Do not respond to rude questions or name calling
Attain a calm and neutral appearance
Do not engage in arguments
Do not get defensive or recite policy and procedure
Leave the area if safety is endangered or you are being harassed, abused, or
Get help
8. Developing rapport
o Smile
o Make eye contact
o Sit down at eye level to make patients more comfortable
o Touching conveys compassion and trust
o Speak gently to show that you are not in a hurry and are kind and compassionate
Exam 2 CDM Study Guide
Small talk
Call the patient by their preferred name
o Really listen to what the patient is saying
o Nod or say something to indicate you hear them
o Don't interrupt
o Allow for pauses
o Don't rush
o Use interpreters
9. Prioritization
The purpose of prioritization is to make sure that the client's or group of patient's needs
are being met the most important to the least important. One diagnosis does not have to
be completed before you work on the other diagnoses. As a nurse you will be working on
multiple diagnoses at a time with multiple patients/clients.
Risk and wellness are not always the bottom of the prioritization list, it depends on the
Exam 2 CDM Study Guide
10. Dosage
• Want/have= need
11. Abdominal assessment
12. SMART goals/outcomes
o S- Specific
o M- Measurable
o A- Attainable
o R- Realistic
o T- Time Bound
13. Independent versus dependent nursing interventions
o Independent Interventions:
o interventions that a nurse can perform or delegate based on their own skills and
knowledge and not reliable on a physician order
o Dependent interventions:
o those that are prescribed by a physician and require an order such as
medications, IV therapy, diagnosis tic testing, diet, etc
14. Assessment
o The continuous collection, analysis, and recording of patient data
o First step in creating a plan of care
o A data base (baseline data) of the patient's condition that allows for trending of patient
o Part of nursing scope and standard of practice
o Access only to information needed and only by those who should have it for patient care
of billing purposes.
o Rules apply to both electronic and paper documentation
o Rules Include:
§ Do not leave screen open and walk away
§ Do not allow access to the record by the patient or visitors without
checking the policy and speaking to the leadership team
§ Screen should have protection on it so the record cannot be read from
the side
§ Do not access a record of yourself, family, friends or a patient whose
care you are not involved in. HIPPA violations are usually immediate
§ Each facility has their own system and policies regarding documentation
and HIPPA interpretation, read the policies
§ Do not share your passwords with anyone or allow anyone to use your
passwords to document or view patient’s charts.
16. Trusting/helping relationship
o Nursing communication should be intentional and planned. With every interaction there
should be a purpose, even if only to build rapport with the patient and family
o Focus on the patient's needs and desires, include cultural practices into the IPOC. By
including a patient's culture into the plan of care and when designing health
promotion activities, you ensure that the patient receives quality care. Use open
ended questions.
o A trusting helping relationship is fostered through introducing yourself to the patient,
explaining who you are and why you are there. Patients should not be considered a room
number or diagnosis. While it is important to round on your patients frequently, over
Exam 2 CDM Study Guide
rounding without a need can be detrimental to your relationship with the patient, looks
17. The medical record
o Purpose:
Planning of care;
working toward a
common goal of
providing safe care
Reimbursement for
the hospital and
physician, not
Evaluating and
improving patient
Serving as a legal
education, and
The record is a compilation of patient health information including patient-specific data
and information that is used for quality, evidence-based patient care, serve as financial
and legal records, help in clinical research, and support decision analysis.
The Joint Commission specifies that nursing care, data related to patient assessments,
nursing diagnoses or patient needs, nursing interventions, and patient outcomes are
permanently integrated into the patient record.
Components of the
Medical Record
Patient database
Physical (assessment)
Vital signs
Arrival time and condition
Plan of care
Medication reconciliation
Education provided
Admission database
Discharge information
of Medical
Components of the Medical Record
Vital signs
Intake and output
Height, weight (growth charts)
Allow for easy trending of patient's data
• Education
Plan of care
EMAR/medication administration record
Physician and ancillary department's progress
notes and plan of care
• Physician H&P (history and physical)
• Lab, diagnostic testing results
• Surgery or procedural records
Components of the Medical Record
Flow sheets: Are designed to help nurses
to track data easily and are best for the
following data:
information to
regulatory agencies
Progress notes (narrative charting)
• Augment assessments and flow sheets
• Document data not found in other areas
Discharge summaries
Written upon discharge of the patient to home or another facility
Includes medication reconciliation
Follow up information
When to call physician
Specific instructions for at home care and/or treatments
Any at home agencies with phone numbers
Client's condition at discharge
Activity and self-care level
Who instructions were given to, include the caregivers and support system with patient's permission
Where the patient is going upon discharge and transportation method
Education provided
Patient must be accompanied to their care by a staff member or facility volunteer to ensure safety
18. SBAR
o Situation: Who you are, where you are, who you are concerned about
o Background: Quickly what are you calling and any pertinent information
o Assessment: What you are seeing, hearing, smelling, etc
o Recommendations: What you want, need
• Usually utilized for nurse to physician communication but is being adapted for bedside shift report
and other forms of health care communication.
Exam 2 CDM Study Guide