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.

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.

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.

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.

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 actual problems

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. Which is the priority nursing diagnosis?

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.

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.

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.

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 Diagnosis: Readiness for enhanced nutrition

• 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.

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.

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.

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 clicking on them. Remember “P.E.S” as the data is reviewed and selected. Click the History & Physical and Nurses’ Notes tabs to complete this activity.

Nursing Diagnosis Margaret (Maggie) Conner

• After completing the admission assessment, the nurse identifies and clusters cues, forms a hypothesis concerning nursing Maggie’s priority care needs and selects a nursing diagnosis. Using nursing diagnosis textbook, select the most appropriate diagnosis label and defining characteristics, based on Maggie’s information by selecting the correct words/phrases to complete the Nursing Diagnosis below:

Selecting Expected Outcomes - Margaret (Maggie) Conner

• Based on the nursing diagnosis and information in Maggie’s EHR, select the four (4) most appropriate goals of care and drag them to the Expected Outcomes on the Plan of Care (POC).

Self-Check: Selecting Interventions

Selecting Interventions - Margaret (Maggie) Conner

• Sort potential interventions for Maggie’s care according to priority (high, medium, low, or contraindicated) and necessity (essential or non-essential). Drag all essential interventions into the correct category (high, medium, or low). Not all interventions (those that are non-essential or contraindicated) will be sorted into a category.

Incomplete Interventions - Margaret (Maggie) Conner

• While reviewing Maggie’s plan of care the first night of her admission, the nurse taking over her care adds which high priority, essential intervention?

Reflect: Nursing Application: Clinical Judgement

Evaluating Progress - Margaret (Maggie) Conner

• Maggie has been in the hospital for two days and is starting to feel better. Her urine and and blood cultures both revealed E coli infection and antibiotics were started.

Based on the documentation in Maggie’s EHR, the nurse notes that which expected outcomes have been met? Select all that apply. Click the Nurses’ Notes tab to complete this activity.

Updating Interventions - Margaret (Maggie) Conner

• Based on the documented improvement in Maggie’s state of health, which interventions can be decreased in frequency? Select all that apply.

Readiness for Enhanced Learning - Margaret (Maggie) Conner

• On the fifth day after admission to the hospital Maggie is stable and ready for discharge to home. She will be discharged with a peripherally inserted central catheter (PICC) line to complete the final nine days of her intravenous (IV) antibiotic therapy. Maggie does not have a health care background and has not taken care of a PICC line or selfadministrated IV fluids in the past but expressed that she and her partner are willing and able to learn what needs to be done so she can go home safely. Based on this information, and using a nursing diagnosis text, select the most appropriate nursing diagnosis to prepare Maggie for discharge. Select all that apply.

Completing the Nursing Diagnosis - Margaret (Maggie) Conner

• Use the drop-down menus on the Nurses’ Notes tab to complete the defining characteristics and related to statement for Maggie’s nursing diagnostic statement.

Discharge Teaching Goals - Margaret (Maggie) Conner

• Since both Maggie and her partner have expressed interest in learning about caring for her PICC and IV medications at home the following goals are mutually set. Indicate the importance of meeting these outcomes for each person by dragging their picture to the correct column (Essential, Desirable, or Not Needed) for each outcome.

Discharge Teaching Interventions - Margaret (Maggie) Conner

• Which topics will the nursing include when teaching Maggie and her partner related to ways to protect the PICC site and signs of adverse events? Select all that apply.

Clustering Information for Focused Teaching - Margaret (Maggie) Conner

• Drag the selected interventions to the category into which it fits: information on how to protect the PICC line or how to recognize an adverse effect during treatment.

Evaluation of Learning - Margaret (Maggie) Conner

• The nurse determines that further education is needed after hearing Maggie make which statements? Select all that apply.