NR 226 Exam 1

Student Name

Chamberlain University

NR-226: Fundamentals – Patient Care

Prof. Name

Date

NR 226 – Exam 1 Comprehensive Review

Clinical Judgment and Clinical Decision-Making

Clinical judgment refers to the process of interpreting and making conclusions about a patient’s needs, determining the appropriate interventions, and evaluating the outcomes. It is rooted in critical thinking, experience, and patient-centered care.

Clinical decision-making involves establishing and weighing criteria to determine the most appropriate therapeutic approach for a specific patient. This includes the ability to:

• Weigh risks and benefits of each possible intervention.
• Anticipate potential complications.
• Integrate patient preferences with evidence-based practices.

The Nursing Process

The nursing process serves as the universal, systematic method for organizing and delivering care in nursing practice. It ensures the delivery of personalized, evidence-based care as part of an interdisciplinary healthcare team.

NR 226 Exam 1

Step	Description	Clinical Focus
Assessment	Systematic collection of subjective and objective data	Patient interview, history, physical exam
Diagnosis	Interpretation of data to identify health problems or risks	NANDA-I classification
Planning	Development of patient-centered goals and interventions	SMART goal format
Implementation	Execution of planned interventions	Direct and indirect care
Evaluation	Determining effectiveness of interventions	Modify or continue plan as needed

ADPIE Overview

1. Assess – Collect subjective and objective data from the patient, family, and healthcare records.
2. Diagnose – Interpret and cluster the data to identify problems or potential risks.
3. Plan – Create measurable, realistic, and patient-centered goals with corresponding interventions.
4. Implement – Carry out interventions as planned.
5. Evaluate – Compare patient outcomes to goals and adjust care as needed.

Six Functions of Clinical Judgment

1. Recognize Cues – Identify relevant data from the patient’s signs, symptoms, history, and environment.
2. Analyze Cues – Link recognized cues to a clinical picture, identifying needs or problems.
3. Prioritize Hypotheses – Rank patient problems based on urgency and risk, using assessment findings, labs, and diagnostics.
4. Generate Solutions – Propose interventions that align with the patient’s needs and desired outcomes.
5. Take Action – Implement chosen interventions promptly and safely.
6. Evaluate Outcomes – Determine whether interventions were effective and revise care as necessary.

Assessment

Q: What is subjective data?
A: Subjective data refers to information the patient reports about their health, such as pain, fatigue, or emotional distress, gathered through interviews.

Q: What is objective data?
A: Objective data consists of measurable, observable findings obtained through physical examination techniques such as inspection, palpation, percussion, auscultation, or diagnostic testing.

Keywords indicating assessment is needed: ascertain, assess, check, collect, determine, find out, identify, monitor, observe, obtain information, recognize.

Nursing Diagnosis

A nursing diagnosis is a clinical judgment concerning a human response to health conditions or life processes. It is based on the careful interpretation of assessment data and directs the selection of nursing interventions to achieve outcomes.

Diagnostic Label – Nursing Diagnosis

Q: What is a nursing diagnosis based on?
A: It is based on the selection of cues from assessment findings and analysis of how those cues relate to the patient’s clinical presentation.

Types of Nursing Problems

Type	Components	Example
Actual Problem	Diagnostic label + related-to statement + defining characteristics	Impaired physical mobility related to decreased muscle control as evidenced by inability to control lower extremities
Potential Problem (Risk For)	Diagnostic label + risk factors	Risk for infection related to compromised host defenses
Health Promotion	Diagnostic label only	Readiness for enhanced resilience

Three-Part Nursing Diagnosis (PES Format)

Component	Definition	Example
P – Problem	NANDA-I nursing diagnosis label	Impaired physical mobility
E – Etiology	Related-to cause or contributing factor	Related to decreased muscle control
S – Symptoms	Defining characteristics	As evidenced by inability to control lower extremities

Health Promotion

The role of the nurse extends beyond illness management to health promotion—helping patients enhance well-being through activities like exercise, nutrition counseling, smoking cessation, and preventive screening.

Planning

Planning transforms diagnoses into actionable goals and interventions. Goals are broad statements of desired improvement, while outcomes are specific, measurable indicators of progress.

SMART Goal Criteria

SMART Element	Nursing Example
Specific	Patient will walk 50 feet using a walker
Measurable	Nurse will measure and record walking distance
Attainable	Within the patient’s physical limits
Realistic	Considers current energy and mobility
Time-bound	Within 3 days of initiating mobility plan

Types of Interventions

Type	Definition	Examples
Nurse-Initiated (Independent)	Actions performed without provider orders	Health teaching, ADL assistance
Provider-Initiated (Dependent)	Requires provider orders	Administering medications, pre-op prep
Collaborative (Interdependent)	Involves multidisciplinary coordination	Rehab with PT/OT

Implementation

Implementation is the active phase of nursing, beginning after the care plan is complete. It involves both direct care (e.g., wound care, patient counseling) and indirect care (e.g., documentation, delegating tasks, infection prevention).

Selecting Interventions:

• Match interventions to patient’s goals.
• Ensure cultural acceptability and patient agreement.
• Verify feasibility with available resources.

Evaluation

Evaluation determines whether nursing care achieved desired patient outcomes.

Q: Was the goal attained?

• Yes: Continue or adjust plan to maintain improvement.
• No: Identify barriers, reassess needs, and modify interventions.
• Condition worsened: Reassess and escalate interventions.

Revising the Plan of Care

The nurse revises the care plan when:

• New problems arise.
• Patient’s status changes.
• Updated evidence-based practices suggest a new approach.

Managing Patient Care

Priority Setting

Nurses prioritize based on urgency using Maslow’s Hierarchy and clinical judgment:

Priority Level	Examples
First-Level	Airway, breathing, circulation, vital signs, life-threatening lab values
Second-Level	Acute pain, changes in mental status, elimination problems
Third-Level	Long-term management, rest, family coping

Organizational Skills

• Cluster care to minimize patient disruption.
• Integrate communication, teaching, and assessment during routine tasks.
• Use a to-do list and delegate effectively.

Delegation

Delegation is assigning specific tasks to qualified individuals while retaining accountability.

Five Rights of Delegation:

1. Right task
2. Right circumstance
3. Right person
4. Right direction/communication
5. Right supervision/evaluation

Illinois Standards of Delegation

Task	RN	LPN	UAP
Admission assessment	✓
Ambulation	✓	✓	✓
Foley catheter insertion	✓	✓
Discharge teaching	✓
Vital signs (stable patient)	✓	✓	✓
Oral medications	✓	✓
Bed bath	✓	✓	✓

Ethical and Legal Responsibilities

ANA Code of Ethics

Guides nurses in ethical decision-making, emphasizing:

• Advocacy
• Responsibility
• Accountability
• Confidentiality

Principles of Healthcare Ethics

• Autonomy – Patient’s right to self-determination.
• Beneficence – Promote good.
• Nonmaleficence – Avoid harm.
• Justice – Fair care and resource use.
• Fidelity – Keep promises.
• Veracity – Tell the truth.

Resolving Ethical Dilemmas

Steps:

1. Determine if it is an ethical dilemma.
2. Gather relevant information.
3. Clarify values.
4. Name the problem.
5. Identify possible actions.
6. Implement an action plan.
7. Evaluate results.

Legal Concerns

• Negligence – Failure to act as a reasonably prudent nurse.
• Malpractice – Professional negligence resulting in harm.
• Intentional torts – Assault, battery, false imprisonment.
• Unintentional torts – Errors causing harm without intent.

Aging and Older Adult Care

Common Physiological Changes

System	Age-Related Changes
Integumentary	Skin thinning, loss of elasticity, gray hair
Cardiovascular	Decreased cardiac output, stiffened vessels
Musculoskeletal	Decreased muscle mass, bone loss
Neurological	Slower nerve conduction, reduced reflexes
Sensory	Presbyopia, presbycusis, reduced taste/smell

Cognitive Impairment

• Delirium – Sudden, reversible.
• Dementia – Progressive, irreversible.
• Depression – Often overlooked, treatable.

Older Adults in Acute Care

Risks: infection, delirium, falls, incontinence, malnutrition, skin breakdown.
Prevention: frequent orientation, fall precautions, proper nutrition, repositioning.

End-of-Life Care

Hospice vs. Palliative Care

Hospice	Palliative
Life expectancy ≤ 6 months	Can be at any stage of illness
Focus on comfort, not cure	Focus on quality of life
No curative treatments	May continue treatments

Physical Changes Before Death

• Increased sleep
• Cool extremities
• Irregular breathing (Cheyne–Stokes)
• Decreased intake
• Loss of bladder/bowel control

Grief and Bereavement

Kübler-Ross Stages:

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. ANA.

Berman, A., Snyder, S., & Frandsen, G. (2021). Kozier & Erb’s fundamentals of nursing (11th ed.). Pearson.

NR 226 Exam 1

National Council of State Boards of Nursing. (2019). Clinical Judgment Measurement Model. NCSBN.

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2023). Fundamentals of nursing (11th ed.). Elsevier.