Clinical Judgement Clinical Judgement Prepare: Clinical Judgement Parts of the Nursing Diagnosis

Clinical Judgement Clinical Judgement

Prepare: Clinical Judgement

Parts of the Nursing Diagnosis Select the statement that includes the correct element to use when documenting a problem-based nursing diagnosis.Subjective data/objective data/hypothesis Problem statement/as evidenced by Diagnostic label/related to statement/defining characteristics Signs and symptoms/reason for seeking care/goals of treatment From Nursing Process to Concept Map The boxes below represent containers on a Care Focused Concept Map. Using the drop-down menu, indicate which step of the nursing process aligns with each container in the care focus concept map.Monitoring the patient for side effects of prescribed medications aligns with the evaluation part of the nursing process.Identifying client signs and symptoms aligns with the assessment part of the nursing process.Administering medications aligns with the intervention part of the nursing process.Describing desired outcomes needed to reach a goal aligns with the planning part of the nursing process.Identifying a problem, risk, or health promotion need aligns with the diagnosis part of the nursing process.Attention to Details Attention to details, or cues, is key to successful patient care. It can also be a challenge. The video below will challenge your ability to see the details despite distractions.As you watch, count the number of times the players in the white shirts pass the ball. Then select your response from the

drop-down menu: 13

Self-Check: Identifying Nursing Diagnosis Components: Sami Dabiri

Evidence to Support a Nursing Diagnosis: Sami Dabiri

What evidence is present in Sami’s nurses’ note to support a nursing diagnosis? Click the Nurses’ Notes tab to complete this activity.Select the cues that require follow-up by the nurse and can help select the nursing diagnosis.Self-Check: Health-Promotion Nursing Diagnosis: Sami Dabiri

Clustering Related Cues: Sami Dabiri

After reviewing the nurse’s notes and selecting the cues that require follow-up, the nurse now clusters the related cues to assist in identifying health promotion, risk for, or actual problems.Note: Some cues may apply to both clusters. This study source was downloaded by 100000857336479 from CourseHero.com on 03-28-2023 08:52:02 GMT -05:00 https://www.coursehero.com/file/167211410/NR-226-Fundamentals-Patient-Care-Week-1-Conceptsdocx/

Self-Care: Selecting Expected Outcomes: Sami Dabiri

Selecting Nursing Diagnosis: Sami Dabiri

After reviewing the nurse’s notes and selecting the cues, the nurse now selects a nursing diagnosis. Using a nursing diagnosis textbook, select the most appropriate diagnosis label and related to statement, based on Sami’s information.Nursing Diagnosis: Risk for infection transmission related to exposure to a contagious respiratory disease.Nursing Diagnosis: Interrupted family processes related to disrupted normal routine as evidenced by inability to meet physical and emotional needs of family due to quarentine.Self-Check: Selecting Interventions: Sami Dabiri

Prioritizing Nursing Diagnosis: Sami Dabiri

After reviewing the nurse’s notes and selecting the cues, the nurse now selects a nursing diagnosis. Using a nursing diagnosis textbook, select the most appropriate diagnosis label and related to statement, based on Sami’s information.Which is the priority nursing diagnosis? Risk for infection transmission related to exposure to a contagious respiratory disease.Self-Check: Care Focused Concept Map: Sami Dabiri Care Focused Concept Map – Sami Dabiri Drag each item (taken from Sami’s Nursing Diagnosis and Plan of Care) to the correct location on the Care Focused Concept Map.After reviewing the nurse’s notes and selecting the cues, the nurse now selects a nursing diagnosis. Using a nursing diagnosis textbook, select the most appropriate diagnosis label and related to statement, based on Sami’s information.

Reflect: Clinical Judgement

Clustering Cues: Joanne Votaw

Review Mrs. Votaw’s electronic health record (EHR). Remember, the information will change as her case study unfolds across the following questions, just like an actual EHR, so you should check each tabbed section with each question.Using a nursing diagnosis text, match the cues from the admission assessment to type of data for each potential nursing diagnosis.NOTE: Cues may be associated with more than one potential nursing diagnosis. This study source was downloaded by 100000857336479 from CourseHero.com on 03-28-2023 08:52:02 GMT -05:00 https://www.coursehero.com/file/167211410/NR-226-Fundamentals-Patient-Care-Week-1-Conceptsdocx/

Nursing Diagnosis: Joanne Votaw

Review Mrs. Votaw’s electronic health record (EHR).Select the most appropriate nursing diagnosis for Mrs. Votaw by selecting the words or phrases that complete the

sentence below:

Expected Outcomes: Joanne Votaw

Based on your knowledge of Mrs. Votaw’s current health response, use a nursing diagnosis text to select priority collaborative outcomes for the current nursing diagnosis. Select all that apply.Blood pressure less than 120/70 Decreased urine output Decreased chest pain O2 saturation greater than 95% Lungs clear to auscultation SMART Goals for Joanne Votaw Select the words or phrases in the sentences below to create SMART goals for Mrs. Votaw based on the selected priority collaborative outcomes.

Nursing Interventions: Joanne Votaw

Based on your knowledge of Mrs. Votaw’s current health response, use a nursing diagnosis text to match these interventions with the supporting evidence-based rationale.Assess lung sounds every 4 hours and as neededPulmonary edema will decrease as cardiac output increases.Titrate oxygen to keep oxygen levels above 95%Will increase oxygen levels in the blood and to body tissues.Allow periods of rest between activities Decreases oxygen consumption and decreases the risk of hypoxia.Evaluating Outcomes Based on the documentation, indicate if Mrs. Votaw met, partially met, or did not meet her expected outcomes.

Mapping Care-Diagnosis and Outcomes: Joanne Votaw

The home health nurse is seeing Mrs. Votaw for the first time. During the interview, Mrs. Votaw asks what steps she can take to avoid future hospitalizations. Which diagnosis should the nurse select?Nursing DiagnosisReadiness for enhanced nutrition This study source was downloaded by 100000857336479 from CourseHero.com on 03-28-2023 08:52:02 GMT -05:00 https://www.coursehero.com/file/167211410/NR-226-Fundamentals-Patient-Care-Week-1-Conceptsdocx/

Measurable Expected Outcomes Verbalizes foods she can eat that are low in sodium content

Mapping Care-Interventions and Rationale: Joanne Votaw

Based on Mrs. Votaw’s newest nursing diagnosis and outcome, select appropriate interventions with matching rationale for her care.Intervention #1 Teach to identify sodium content on food labels. Matching Rationale Helps client make smart food choices when shopping.Intervention #2 Recommend increasing intake of fresh fruits and vegetables. Matching Rationale Fresh fruits and vegetables contribute vitamins and antioxidants to the diet.Nursing Application for Clinical Judgement Prepare: Nursing Application: Clinical Judgement Symptoms of Urinary Tract Infection Using your knowledge of the urinary tract, infection, and inflammation, along with textbook and library resources, match the assessment findings below to the type of urinary tract infection (UTI) with which it is associated.

NOTE: Assessment findings may be associated with more than one type of UTI.

Risk for Complications Although anyone who experiences an infection, is at risk for sepsis individuals most at risk include those over the age of 65 and those who are immunocompromised.Order of Nursing Care Order the list of actions in which the nurse will complete them for a newly admitted client, with the first action at the top.

1.Introduce self.

2.Verify client identity.

3.Assess current level of comfort.

4.Complete admission assessment.

5.Obtain prescribed blood and urine cultures.

6.Administer prescribed antibiotics.

Self-Check: Maggie's Nursing Diagnosis

Identifying Nursing Diagnosis Components: Margaret (Maggie) Conner

What evidence is present in Maggie’s admission assessment to support a nursing diagnosis related to infection?Select the assessment data, or cues, that contribute to the Related to Statement and Defining Characteristics by This study source was downloaded by 100000857336479 from CourseHero.com on 03-28-2023 08:52:02 GMT -05:00 https://www.coursehero.com/file/167211410/NR-226-Fundamentals-Patient-Care-Week-1-Conceptsdocx/