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Clinical judgment in nursing:
The cognitive process is where nurses use reasoning, critical thinking, and decision-making to solve problems.
Clinical judgment outcomes: Incorporate prior knowledge, current research, and clinical experience in decision-making
1.) Begin to use the steps of the nursing process to provide care and promote health
2.) Identify the role of evidence and appropriate sources in guiding decision-making
Clinical judgment is an essential concept in nursing. It allows nurses to use their prior knowledge and apply it in real-world situations. I personally feel that I have increased my clinical judgment throughout this course. While it is still something I am actively working to improve, I feel I have progressed from having a general thought process (non-nursing) without focusing on details to developing nursing clinical judgment that incorporates understanding and applying the Assessment, Diagnosis, Planning, Implementation, Evaluation, nursing process.
Key concepts like evaluation and planning tied into priority concept activities have helped me apply what I have learned to potential real-life scenarios. For example, on the activity sheets, we developed SMART goals, which stand for Specific, Measurable, Attainable, Relevant, and Timely. This portion of the priority concept activity is very relevant to health promotion because it guides us in setting realistic goals to improve a patient’s health. These SMART goals can be written either for the nurse’s interventions and care plans or directly for the patient, as we help them set goals for their own well-being.
As I provided treatment for actual patients for the first time this semester, I had several chances to improve my clinical judgment. Being present in the clinical context allowed me to apply what I learned in class to actual scenarios, which helped me understand on how clinical judgment takes place in every single situation in clinical expriences. I learned how to examine patients more carefully, notice when things are wrong, and decide when I needed to seek help from my teacher or the registered nurse. My confidence in setting priorities and predicting my patient's needs has increased as a result of these experiences. It was very helpful to see the registered nurses; I saw how they made choices, expressed concerns, and calmly adjusted to patient changes. I feel like I was able to develop my own decision-making process by observing their train of thoughts in action. I feel like I started to comprehend not immediate needs but also why specific -detailed acts which are important for patient comfort, safety, and overall results.
Trajecsys Care Clincal Jugement Journal Assignment
Category: Clinical Judgement
How did you use the nursing process?
I used the nursing process in my patient during my head-to-toe assessment when taking her vitals. My patient's heart rate and blood pressure dropped significantly (59 P and 129/47 BP). Because of this, we were able to think of a nursing diagnosis of decreased cardiac output related to low blood pressure and low heart rate. We were able to set a plan to continuously monitor vital signs. We intervened by withholding Carvedilol, a beta blocker that lowers blood pressure and heart rate. We evaluated the state of this client by seeing that her vitals her not lowering even more into more dangerous states.
Category: Clinical Judgement
Describe anything that interrupted your plan and how you revised to move on.
Something that may have interrupted the plan, the patient is feeling fatigued and napping. We didn’t want to wake her up and saw she wasn’t in any type of critical condition and most likely needed rest. We revised this by walking by her door every hour and seeing if she was awake or not to see her vitals.
Category: Clinical Judgement
How did you use your knowledge and concepts to develop the plan of care?
My knowledge and concepts were used to develop a plan of care by knowing what normal levels of electrolytes and vitals are. At the moment, my patient’s electrolytes were low ( especially Na), and their vitals were also lower, which allowed me to critically think about what to ask and assess. I asked questions like headache, nausea and vomiting, muscle cramps, and hallucinations. I was able to assess her LOC and listen to their lungs for any signs of respiratory distress.
Category: Clinical Judgement
Your strengths:
My strengths included knowing my lab and vital values, which allowed me to apply my learning. Another one of my strengths was being able to prioritize which assessments and questions should be asked first.
Category: Clinical Judgement
Your areas for improvement and remedy to improve:
My areas for improvement include being more blunt in the questions I ask during my assessment, rather than shying away from the question. With the psychosocial/emotional aspect of nursing care, I struggle because I feel like I become emotionally invasive, but I notice it is part of the assessment. To critically think and judge things, I must know all prior information, so I need to be less shy with those questions.
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