8/14/2015

Module 13:
Clinical Decision Making
Bladen Community College

Concepts Related to Clinical

Decision Making

Objectives
This module introduces the concept of clinical decision making; emphasis is placed on problem solving,
decision making, nursing process, and critical thinking. Upon completion of this module, the student
will be able to:

Use the nursing process to:

State the problem.

Identify the consequences of the problem.
Apply a systematic approach to the problem
using the nursing process.
Analyze the data using critical thinking.
Evaluate the clinical decision making process.

Critical Thinking

Managing Care
Accountability
Collaboration
Communication
Oxygenation

Clinical decision making following assessment

Critical Thinking

Intellect

Clinical decision making critical

thinking process for choosing best actions
to meet a desired goal
Nurses use whenever choices available
Client outcomes improve
Common attitudes

Ability to learn, understand knowledge

Capacity for thinking, reasoning
intelligently
Salient cues

Indicate negative, positive change in client's

health status
Varies from norms of client population
Indicates developmental delay

8/14/2015

Creativity

Inquiry

Outlet for imagination

Finding unique solutions to unique
problems when traditional interventions
ineffective
"Thinking out of the box
Increases number of alternatives
Requires knowledge of the problem

Reasoning

Reflection

Deductive reasoning
Works from "Top down" approach

Inductive reasoning

Clinical reasoning

"Bottom up" approach

Search for knowledge, facts

To gain clarification, find solutions to
problems
Differs from query
Merely asking question, requesting
information

Action of making sense of occurrences,

situations, or decisions by carefully
considering totality of experience, what
worked & did not work
Debriefing (reflective thinking)

Helps transfer book knowledge to practice

application

Ability to reflect on previous situations,

decisions to improve client care

Intuition

Clinical Decision Making

"Gut reaction"
Use of nursing knowledge, experience,
expertise for understanding without
conscious use of reasoning
Process of continual analyzing

Types of decisions made during process of

solving problems
Value decisions
Time management decisions
Scheduling decisions
Priority decisions

Nurses help clients make decisions.

Strong clinical decision-making skills
needed

Clustering patterns, similarities

Not recommended for new nurses,

students

8/14/2015

Clinical Decision Making, continued

Common steps

Identify situation or problem

List possible alternatives
Compare, evaluate pros and cons of each
Select best one to try
Put it into action
Evaluate success

Problem Solving

Apply phases of nursing process

Assessment, nursing diagnosis, planning,
implementing, evaluation

Trial and error

Intuition
Scientific method

Choosing Between Alternatives

Use intellect, intuition, reasoning
Recognize significant clues, patterns
Plan of action based on past experience
Apply knowledge, skills

Clinical Judgment
Nurse's determination, provision of
appropriate care to client
Dynamic cognitive process

Benner's Skill Acquisition Model

Benners Clinical Competence

Nursing StudentGraduateProfessional

Differences in judgment between senior

nursing students, new nurses, experienced
nurses
Four progressive changes in levels of
competence

Each builds on previous one

Critical thinking skills mastered, confidence
built

8/14/2015

Tanner's Clinical Judgment Model

Lasater's Clinical Judgment Rubric

Different types of knowledge

Length of nursing experience, values,
morals
Intuition, knowing the client
Culture of work environment

Measure, evaluate using simulation

Based on Tanner's model
Noticing, interpreting, responding,
reflecting

Overview
Identifies client's health status, needs
Plans to meet needs, evaluate success of
interventions
Phases

Exemplar 36.1
The Nursing Process

Assessment
Diagnosis
Planning
Implementation
Evaluation

8/14/2015

Assessment

Systematic, continuous data collection

Carried on through all phases of nursing process
Focused on client's response to a health problem
Types of data
Subjective
Client, family
Objective
Physical examination
Database
All information about client
Includes past history

Diagnosis

Use critical thinking skills to:

Cluster assessment data
Identify problems

Ongoing development of nursing

diagnoses
NANDA's Taxonomy II

Assessment, continued

Nursing models
Gordon's 11 functional health patterns
Roy's adaptation model
Maslow's hierarchy of needs
Physiological needs, safety, security needs, love and
belonging needs, self-esteem needs & self-actualization
needs

Non-nursing model
Body systems

Common Terms

Nursing diagnosis

Statement of nursing judgment

Nurses are licensed to treat
Human response to health condition
Changes with time

Diagnostic labels

Risk factors

Standardized NANDA names for diagnoses

Factors that cause client to be vulnerable to
developing health problem

Types of Nursing Diagnoses

Actual diagnosis

Risk diagnosis

Wellness diagnosis

Health promotion diagnosis

Syndrome diagnosis

Ex. Acute pain

Ex. Risk for infection
Ex. Readiness for Enhanced Family Coping

Medical diagnosis
Made by physician, advanced practice nurse,
or physician assistant
Disease process
Does not usually change

Diagnosis, diagnosing
Conclusion regarding nature of phenomenon,
process used to formulate conclusion

Domains
Classes
Nursing diagnoses vs Medical Diagnosis

Nursing Diagnosis Versus Medical

Diagnosis

Organizing data

Ex. Readiness for Enhanced Family Processes

Cluster Nursing Dx that occur together

8/14/2015

Components of a Nursing Diagnosis

Diagnostic label (problem)

Developing a Nursing Diagnosis

Etiology (related factors and risk

factors)
One or more probable causes of health problem

Defining characteristics
Cluster of signs, symptoms that indicate presence of
a particular diagnostic label

Writing a Nursing Diagnosis

Statement

Novices need guidelines

Final check that data makes sense

Identify problems that support tentative

actual, risk, possible diagnoses
Establish client's strengths, abilities to
cope

Avoiding Errors in Diagnostic

Statements

Basic two-part statement

Problem, etiology

Basic three-part statement

Basic one-part statement

Common variations

Problem, etiology, signs and symptoms

NANDA label only

Group, cluster data

Compare data to standards
Client cues for experienced nurses

Approved by NANDA
Qualifiers give additional meaning

Verify
Build good knowledge base, acquire
clinical experience
Have working knowledge of what is
normal
Consult resources
Recognize patterns

Unknown etiology, complex factors,

"secondary to"

Planning

Deliberate, systematic phase

Client goals formulated

Planning, continued

Goals are broad statements about the client's

status.
Desired outcomes are more specific, observable
criteria used to evaluate whether the goals have
been met.

Basis for nursing interventions

To prevent, reduce, eliminate, or improve
nursing diagnosis situation

Involves decision making, problem solving

Client support necessary for effectiveness

Goals and desired outcomes

Purpose of goals and desired outcomes

Provide direction for planning interventions
Serve as criteria for evaluating progress

8/14/2015

Planning, continued

Purpose of goals and desired outcomes

Enable client, nurse to determine when the problem
has been resolved
Help motivate client, nurse by providing a sense of
achievement
Support therapeutic nurseclient relationship
Nursing Outcomes Classification (NOC)
Client status in response to nursing actions

Developing a Goal

Questions to ask

Long-Term and Short-Term Goals

Varying amounts of time for goals to be achieved

Short-term goals
Acute setting
Range of few hours to few days
Long-term goals
Clients at home, nursing homes
Chronic health problems
Range of 1 week to several months

Writing a Goal

What needs to be changed?

Is there a healthy response to correct
problem stated in diagnosis?
How will client look, behave if healthy
response achieved?
What action must client do?

Follow acronym SMART

Single specific action

Measurable
Attainable
Relevant
Time limited

How well must client do it to demonstrate

achievement?

Writing a Goal, continued

Guidelines for writing a goal, desired

outcome
Write in terms of the client responses
Must be realistic
Ensure compatibility with therapies of other
professionals
Derive from only one nursing diagnosis
Use observable, measurable terms
Make sure client considers them to be
important, values them

Writing a Goal, continued

Components of goal, desired outcome

statements

Subject
Verb
Condition or modifier
Criterion of desired performance

8/14/2015

Implementation

Nursing Interventions

Action phase
Relationship to other phases

Actions nurse performs to achieve goals

Types of nursing interventions

Take data from first three phases

Determine appropriate interventions

Independent
Dependent
Collaborative

Two-step process
Identify best priority intervention
Implement these interventions

Nursing Interventions, continued

Considerations when selecting interventions

Determine pros, cons of each
Client-centered, realistic, relevant toward goal
Interventions need to be:

Nursing Interventions, continued

Writing a nursing intervention

Safe, appropriate for client's age, health, condition

Achievable with resources available
Congruent with client's values, beliefs, culture
Congruent with other therapies, standards of care
Based on current best nursing research evidence

Is client-centered
Has specific, concise action
Includes detailed information
Is realistic to individual client
Is relevant to helping client reach goal
Lists only top 35 priority interventions

Implementation

Skills Necessary for Implementation

Preassessment of client
Determining nurse's need for assistance
Implementing nursing interventions
Delegation
Documentation

Cognitive
Problem solving, decision making, critical
thinking, creativity

Interpersonal

Technical

Verbal, nonverbal communication methods

Purposeful, "hands-on" skills
Manipulating equipment, giving injections
Manual dexterity

8/14/2015

Relationship to Other Nursing

Process Phases
Assessment, nursing diagnosis, goal
planning provide basis for actions
performed during implementation
While implementing:

Continue to reassess client at every contact

Some routine nursing activities present new
assessment data

Evaluation
Last phase
Planned, ongoing, purposeful activity
Relationship to other phases
Clients and healthcare professionals
determine

Client's progress toward achieving goals

Effectiveness of nursing plan of care

Drawing Conclusions

Conclusions about client goals

Actual problem resolved, potential problem
prevented with no risk factors
Risk problem prevented but risk factors still
present
Actual problem still exists even though some
goals met

Developing an Evaluation

Collect objective, subjective data

Possible conclusions

Recorded concisely, accurately

Goal was met
Client response same as desired outcome

Goal was partially met

Goal was not met

Revise if partially resolved

Do not revise if client needs more time

Writing an Evaluation

Within time frame

Continuing, Modifying, or Terminating the

Nursing Plan of Care

Evaluation statement

Date, time of evaluation

Conclusion statement about goal

Met, partially met, not met

Supporting statement giving results of how

client did, did not achieve goal

Evaluation continues until goals achieved

or client discharged

Assessment
Nursing diagnosis
Revising client goals
Redesigning nursing interventions
Method of implementation

8/14/2015

Relationship to Other Nursing

Process Phases

Successful evaluation depends on

effectiveness of preceding phases.

Exemplar 36.2
The Nursing Plan of Care

Overview
Guideline that organizes information
about client's or family's care
Begins with first client contact
Constantly updated
Continues until nurseclient relationship
ends (discharge)

Included in client's permanent record

Accessibility
Supports communication with others for
better continuity of care
Commonly kept with medical record
Kardex system

Quick reference for nursing care needs

Guidelines for Writing a Nursing

Care Plan

Date, sign the plan

Use category headings
Use standardized, approved medical or English
symbols and key words
Be specific
Refer to procedure book or other sources rather
than including steps
Tailor the plan to the client
Incorporate prevention, health maintenance
Include ongoing assessment
Include collaborative activities
Include discharge planning, home care needs

10

8/14/2015

Guidelines

Column Guidelines

Can be computerized or written

Format determined by individual facility
Four types

Uses columns to categorize data

Column plan
Concept map
Standardized plan
Clinical pathway

Nursing diagnosis
Goals/desired outcomes
Nursing interventions
Evaluation

Concept Map

Standardized Plan

Holistic view of client

Visual representation

Keep it simple
Post-it notes, software

Specify care for groups of clients with

common needs
Frequently include:
Checklists, blank lines, or empty spaces
Allows nurse to individualize goals,
interventions

Patterned diagram with data, ideas

Categorized by specific age group, client

problem, specialty categories
Written from perspective of what care
the client can expect

Standardized Plan, continued

Different from standards of care, which

include the following:
Describe nursing actions for clients with
similar medical conditions
Describe achievable rather than ideal nursing
care
Define interventions for which nurses
accountable
Written from the perspective of nurse's
responsibilities

Clinical Pathway
Standardized, multidisciplinary
Outlines expected care for clients with
common conditions
Physician writes an order for it
Sequence of care daily through projected
length of stay for specific condition
Also called collaborative or case
management plan

11

8/14/2015

Questions

12