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CLINICAL
JUDGMENT
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CCBC Definition
▸An interpretation or conclusion about health
needs, concerns or problems and/or the decision
to take action (or not), use or modify standard
approaches or improvise new ones as deemed
appropriate after evaluating the response.
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Critical Thinking
Processes to make Clinical Judgments Using:
▸ Scientific Method – linear and methodical way to answer a question
▸ Problem Solving and Decision Making – identify the situation, decide what
to do next and keep trying solutions until something works
▸ Data Gathering and Analysis – what information do you need, how it fits
together, does it have meaning
▸ Knowledge Base (Experience) – what do you know about…
▸ Patient-Centered – what is best for this patient at this time
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Levels of Critical Thinking
Level 1 Student Nurse: Concrete and based on rules
Level 2 New Graduate Nurse: Has more knowledge and ability to analyze data
and think of different solutions
Level 3 Experienced Nurse: Has the knowledge and experience to critically
think through every situation and make clinical judgments
NOVICE
EXPERT
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Skills and Abilities to Develop Critical Thinking
▸Intellect: having the ability to think, understand and
reason
▸Creativity: finding unique solutions to unique problems
▸Inquiry: always asking the WHY
▸Reasoning: using data and knowledge to predict or
conclude
▸Reflection: retrospective thinking to learn from
experiences
▸Intuition: use of knowledge without reasoning
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Developing Critical Thinking Abilities
▸Reflection
▸Shared
Dialogue
▸Spirit of Inquiry –
Ask the WHY
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NCSBN Clinical Judgment Model
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Nursing vs.
Medicine
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Nursing versus Medicine
MEDICINE
Purpose and Goal is to diagnose and
treat medical conditions
Example: Breast Cancer
Task: identify type and extent of the
cancer
NURSING
Purpose and Goal is to focus on the
human response to a disease or
condition
Example: Fear, Grieving, Anxiety, Pain,
Disturbed Body Image
Task: identify and address how the
patient responds to the condition
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Nursing versus Medicine
MEDICINE
Interventions are aimed at
treatments, medications and
surgery needed to eliminate or
treat the cancer
NURSING
Interventions are aimed at promoting
and restoring optimal health and
wellbeing while the patient is
undergoing medical or surgical
treatment.
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Nursing Process and
The Clinical Judgment Measurement
Model
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Steps of the Nursing Process and Clinical Judgment Measurement
Model
1. Assessment (Recognizing Cues)
2. Diagnosis/Analysis (Analyze Cues)
3. Planning (Prioritize and Generate
Solutions)
4. Implementation (Take Action)
5. Evaluation (Evaluate Outcomes)
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Step 1
Assessment
(Recognize Cues)
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Assessment (Recognize Cues)
Purpose: the systematic collection of data that can be
used in diagnosing, planning and implementing care
Activities:
▸ Collect data
▸ Validate data
▸ Organize and Interpreting data
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Data Collection
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Observation
Health History and Interview *
Physical Assessment
Client Report (Shift Report)
Medical Record
Scientific Literature
Experience
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Objective versus Subjective Data
Subjective Data is the client or
family perception
Objective Data are the physical
findings from a physical
assessment of the client or other
factual data
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Validation of Data
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“Double checking”
Interpretation of conflicting data
Clarify client’s statements
Compare to previous data
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Organizing and Interpreting Data
Cluster Data:
▸ Group signs and symptoms together
▸ Recognition of Patterns
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Lippincott Advisor
1. Log into thepoint.lww.com
2. Click on Lippincott Advisor
3. Look under Care Planning
▹Click on Problem-Based Care Plans
Note: The categories (left-hand column) …
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Step 2
Diagnosis / Analysis
(Analyze Cues)
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NANDA International Nursing Care Plans
1953: The term ‘nursing diagnosis’ was first introduced
1973: ANA Standards included ‘diagnosis’ as a nursing function and
NANDA language was introduced.
1990: ‘Nursing Diagnosis’ was defined and NANDA’s Nursing Journal
was first published
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Nursing Diagnoses
Definition: Clinical judgments concerning a
human response to health conditions/life
processes, or vulnerability for a health
condition and which can be treated by a
licensed nurse
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Medical Diagnosis versus Nursing Diagnosis
MEDICAL
Identification of a disease or
condition
Disease/Condition-centered
Example: Muscle Weakness
NURSING
Clinical judgment about a
human response to a
disease or condition
Patient-centered
Example: ADL Deficit
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Change from NANDA to Problem-Based Care Plans
WHY??
▸ NANDA terminology being phased out of practice
▸ Formatting not practical
▸ Not Collaborative
▸ NCLEX does not test on NANDA
▸ ANA does not mandate that a nursing diagnosis must be
in NANDA format
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Problem-Based Care Planning
ASSESSMENT data
+
Client’s disease process
=
What is the main problem that can be
treated by the nurse
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Example:
You are caring for a client with heart failure. When assisting the
client to the bathroom, you note an increase in RR, and a
decrease oxygen saturation from 95% to 89%.
Disease process or issue: Heart failure. The heart is not able to
pump enough blood to provide enough oxygen to the body.
There is an imbalance between supply and demand with
exertion.
Main Problem: Activity Intolerance
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Lippincott Advisor
1. Log into thepoint.lww.com
2. Click on Lippincott Advisor
3. Look under Care Planning
▹Click on Problem-Based Care Plans
Activity Intolerance
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Example 2
Your client now has a cough …
Think about YOUR client:
Client was admitted after having a stroke and has to be
fed. Coughing coincides with eating…
Aspiration Risk
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Example 3
Ms. Wilkins is morbidly obese and makes an appointment with
a nurse practitioner for assistance with learning how to eat a
healthy diet and ways to safely exercise.
What is the problem?
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Step 3
Planning
(Prioritize and Generate
Solutions)
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Prioritization
Ordering of nursing diagnoses by urgency and
importance to establish a preferential order for
nursing interventions.
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Low, Medium or High Priority
Nonacute, Acute, Critical, Imminent Death
ABCs – Airway, Breathing, Circulation
Maslow’s Hierarchy of Needs
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Prioritization using Low/Medium/High Priority
LOW:
Problems that can be resolved easily and
with minimal intervention
MEDIUM:
Problems that are more complex and
requiring more intervention but not lifethreatening
HIGH
Life-threatening problems requiring prompt
intervention
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Prioritization using Nonacute/Acute/Critical/Imminent Death
Nonacute: Low urgency – delays will not affect outcomes
Acute: Medium priority – low potential for becoming lifethreatening if not accomplished in a short time frame
Critical: Medium-high priority – must respond quickly due to
high potential for serious consequences
Imminent Death: Any delay will result in death
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Prioritization using ABCs
Airway: FIRST client intervention – anyone with airway issues –
an inability to get oxygen into the lungs
Breathing: SECOND client intervention – anyone having
breathing problems
Circulation: THIRD client intervention – anyone having
circulation issues
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Prioritization using Maslow’s Hierarchy of Needs
A system of
classifying
human needs.
Lower-level
needs must be
met before
high-level
needs.
CLICK HERE
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Failure to Rescue
▸“Loss of life among hospitalized
clients resulting from inadequate
recognition and treatment of
life-threatening complications”
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Rapid Response Teams
▸PURPOSE: multidisciplinary team that can be activated to
manage an acutely deteriorating client
▸MULTIDISCIPLINARY: physician, respiratory therapist,
critical care nurse, nursing supervisor, pharmacist, client’s
nurse
▸OUTCOMES: has improved client outcomes, reduced the
number of clients requiring a higher level of care, increased
availability of critical care beds
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Outcomes / Goals
What do you want to achieve?
OUTCOME: An outcome is defined as a
measurable individual, family, or community
state, behavior or perception that is measured
along a continuum in response to nursing
interventions.
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Writing Nursing Outcomes / Goals
▸Be SMART:
▹ Specific – Addresses only ONE behavior/response specific to
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your client’s problem and situation
Measurable – Must be able to evaluate if met outcome
Attainable – Is something the client WILL do
Realistic – Is something the client CAN do
Timed – Specific time frame by when to complete
** Think LONG-TERM **
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Writing Nursing Outcomes / Goals
▸ALWAYS start with ‘The client will…’
▸ONE outcome per nursing diagnosis
What would be a good outcome for a client with
a diagnosis Risk for Injury?
What would be a good outcome for a client with
a diagnosis of Chronic Pain
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SMART Outcomes / Goal
▸The client will maintain a pain level of 3 or
▸Specific
▸Measurable less by discharge.
▸Attainable
▸The client will remain free from symptoms of
▸Realistic
infection during hospital stay
▸Timed
▸The client will regain integrity of skin surface
by follow-up appointment with surgeon in 4
weeks.
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Interventions (Actions)
Purpose: Actions by the nurse to assist the client in
achieving the expected outcomes
▸ Specific to the nursing diagnosis and outcomes
▸ Need to be specific to helping the client achieve the
outcome / goal
▸ Can do more than one intervention
▸ Can be NURSING or COLLABORATIVE
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EXAMPLE
Mrs. Green fractured her pelvis in a car accident and is
unable to turn in bed without assistance. As a nurse, you
know that this client is at risk of Pressure Injuries.
? Outcome:
? Interventions:
PRESSURE INJURY RISK
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Types of Interventions
▸Independent Nursing Interventions: Nurse-initiated actions
that don’t require a healthcare provider’s order
Example: turning and repositioning a client
▸Dependent Nursing Interventions: Actions that require a
healthcare provider’s order
Example: giving medication
▸Collaborative Interventions: Actions that are initiated by or
performed in conjunction with other care providers.
Example: assisting a physician with inserting a central line
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Writing Interventions
▸Should be specific, measurable and realistic
v What should be done
v How should it be done
v When should it be done
v How long or how much
Will someone else understand how to carry out the
intervention in your nursing care plan?
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Step 4
Implementation
(Take Actions)
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Implementation Phase
Purpose: Carrying out the interventions outlined in
the nursing care plan with the intention of assisting
the client to achieve outcomes.
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Interventions can be …
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Assisting client with Activities of Daily Living (ADLs) such as bathing,
eating and dressing
Delivering skilled care – medications, dressing changes, insertion of
catheters, vital signs
Monitoring/Assessing client’s responses to care
Counseling
Teaching
Promotion of wellness and prevention of illness
Collaboration with other HC disciplines
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Step 5
Evaluation
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Evaluation Phase
Purpose: to determine client’s progress or lack of progress toward
achievement of expected outcomes / goals
Activities:
1. Review the outcomes /goals
2. Collect data
3. Determine whether outcome was achieved
4. Revise/modify nursing care plan
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Evaluation Phase
Ask Yourself:
Have client outcomes been
…met?
…partially met?
…not met?
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If outcome is not achieved…
▸ Recognize errors
▹Was the outcome not attainable or realistic?
▹Were the interventions not written clearly?
▹Were the interventions not carried out
▸Has the client’s status changed, and this care plan is no longer
applicable for this client?
▸What other factors (variables) may have affected achievement of the
outcome? (Family issues? Client not on unit for interventions? New
client issues or complications that adversely affected the client?)
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Putting it Together
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Vignette
Mr. Jones will be having a right
knee replacement tomorrow.
He had his left knee done 6
months ago and experienced
difficulties with constipation.
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Nursing Care Plan
Nursing Diagnosis: Constipation Risk
Outcome: The client will remain free from constipation through
recovery process
Interventions:
▸ Assess the client’s abdomen and bowel sounds Q4H.
▸ Collaborate with the practitioner to evaluate medications that may
be putting the client at risk for constipation.
▸ Assist and encourage the client to take in a high-fiber diet of at
least 25 g of fiber daily
▸ Encourage adequate daily fluid intake of at least 2 liters daily.
narcotics slow things down
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Vignette #2
Mrs. Miller resides in a nursing home. She
needs assistance to bathe and dress, but
once in her wheelchair she is fairly
independent.
Mrs. Miller ends up with an illness that
results in a 3-week hospital stay. When she
returns to the nursing home, she can no
longer support herself in her wheelchair,
can’t push her wheelchair, and can’t feed
herself.
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Let’s try making your own…
Problem-Based Nursing Care Plan Template:
1. What ASSESSMENT data does the nurse find as pertinent (recognize cues)?
2. What is the DISEASE PROCESS OR CONDITION causing these assessment
findings (analyze cues) (describe the pathophysiology causing the assessment
findings)?
3. What is the main PROBLEM with the client that the nurse can treat (prioritize)?
4. What is the OUTCOME for the client (generate solutions and take action) (be
SMART)?
5. What INTERVENTIONS will the nurse implement (generate solutions and take
action)?
6. How will the nurse EVALUATE the client's response (evaluate outcomes)?
7. What other problems could the nurse link to this client problem?
1. can't support herself in her wheelchair, can’t push her
wheelchair, and can’t feed herself.
2. Loss of muscle mass due to prolonged hospital stay, loss of muscles
mass due to weakness.
3. Muscle weakness
4. The client will be able to push self in wheelchair in 1 month
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1. What ASSESSMENT data does the nurse find as
pertinent (recognize cues)?
1. She can’t support herself in a wheelchair
2. She can no longer push her wheelchair
3. She can’t feed herself
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2. What is the DISEASE PROCESS OR CONDITION causing
these assessment findings (analyze cues)
▸Loss of muscle mass due to a prolonged hospital stay
▸Loss of muscle mass = weakness and loss of strength
▸Mrs. Miller needs to rebuild her muscles to improve muscle
strength
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3. What is the main PROBLEM with the client that the nurse
can treat (prioritize)?
WHAT IS THE MAIN PROBLEM WITH THE CLIENT THAT THE
NURSE CAN TREAT?
Muscle Weakness
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4. What is the OUTCOME for the client (generate solutions
and take action) (be SMART)?
Diagnosis: Muscle Weakness
Outcome:
The client will be able to push self in wheelchair in 1
month.
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5. What INTERVENTIONS will the nurse implement
(generate solutions and take action)?
▸ Collaborate with a physical therapist on an exercise
program for Mrs. Miller
▸ Implement the exercise program outlined by the
physical therapist
▸ Assist client to use hand weights for 5 minutes, 3
times a day
▸ Encourage independence as much as possible
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6. How will the nurse EVALUATE the client's
response (evaluate outcomes)?
▸Is there improvement in the
client’s ability to push self in her
wheelchair.
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7. What other problems could the nurse link to this
client problem?
Other problems related to her
loss of mobility:
▸ Social Isolation
▸ Malnutrition
▸ Constipation
▸ Pneumonia
▸ Pressure Injuries
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The End
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