Chapter 1 – Introduction to Health Assessment
Clinical Judgment and Nursing
When collecting subjective and objective data, you need to consider clinical judgment. In nursing, the purpose of health assessment is to facilitate clinical judgment, which is defined as:
- A determination about a client’s health and illness status.
- Their health concerns and needs.
- The capacity to engage in their own care.
AND - The decision to intervene/act or not – and if action is required, what action (Tanner, 2006).
The nursing process is the foundation of clinical judgment. However, clinical judgment is more comprehensive, action-oriented, and guided by the philosophy of client safety. Thus, it is important to learn when to act to prevent clinical deterioration, a worsening clinical state related to physiological decompensation (Padilla & Mayo, 2017).
To facilitate clinical judgment, you must determine if the collected data represent or . When findings are abnormal, you must act on these cues as they signal a potential concern and require action. Failing to recognize abnormal findings and act on these cues can lead to negative consequences including sub-optimal health and wellness – and more importantly, clinical deterioration. Some abnormal findings are considered that place the client at further risk if the nurse does not act immediately.
The process leading to clinical judgment is described as clinical reasoning. This process involves:
- Thoughtfully considering all client data as a whole, whether each piece of information is relevant or irrelevant, and how each piece of information is related or not related.
- Recognizing and analyzing . Is the information collected a normal, abnormal, or critical finding? Can the information be clustered to inform your clinical judgment?
- Interpreting problems. What is the priority problem and what are the factors causing it? What else do you need to assess to validate or invalidate your interpretation? What other information do you need to collect to make an accurate clinical judgment?
- Determining, implementing, and then evaluating appropriate actions (Dickison et al., 2019; Tanner, 2006).
The clinical reasoning process is encompassed by critical thinking. This means that when engaging in the process of clinical reasoning, you should systematically analyze your own thinking so that the outcomes are clear, rational, creative, and objective with limited risk of judgment and error.
Clinical Judgement
A client tells you “I have a headache.” As the nurse, you immediately recognize the cue: headache. However, you do not have sufficient information to analyze this cue and identify the significance. Thus, you may ask a series of subjective questions such as “When did the headache start? What were you doing when it started? Have you ever had this type of headache before?” The client’s response will provide you detailed information to facilitate your critical thinking and the process of hypothesizing what is going on, and thereby helping you determine what actions to take.
Clinical judgement is facilitated by cognitive steps that help you determine when and how to act to prevent clinical deterioration; see Table 1.2. Like the nursing process, these steps should be performed in an iterative manner as per the client situation and your clinical reasoning process.
Table 1.2: Clinical judgment steps (developed based on NCSBN, 2020)
|
Steps |
Considerations |
|---|---|
|
Recognize cues |
Recognizing cues involves identifying findings that require action because they are abnormal. This involves what Tanner (2006) calls “noticing” (i.e., recognizing when something is abnormal). You should be asking yourself what matters most? |
|
Analyze cues |
Analyzing cues involves interpreting/making sense of the collected data, what it means, and how it may relate to possible pathophysiological processes. This involves what Tanner (2006) calls “interpreting”, making sense of the collected data. |
|
Prioritize hypotheses |
Prioritizing hypotheses involves figuring out where to start and how to prioritize care. This step involves what Tanner (2006) refers to as “responding” to the collected data |
|
Generate solutions |
Generating solutions involves identifying the various options (e.g., actions/interventions) to address the problem or the abnormal findings/cues. This may involve identifying which solutions are , , , and . |
|
Take actions |
Taking actions involves identifying the action that should be taken. Examples of actions are specific but could be related to notifying the physician or nurse practitioner, calling for help, monitoring the client, collecting further data. |
|
Evaluate outcomes |
Evaluating outcomes involves determining if the action taken was effective. It may include identifying outcomes that are considered improved, unchanged, or worsened. |
Activity: Check Your Understanding
References
Dickison, P., Haerling, K., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03
NCSBN (2020, Spring). Next Generation NCLEX news. https://www.ncsbn.org/NGN_Spring20_Eng_02.pdf
Padilla, R., & Mayo, A. (2017). Clinical deterioration: A concept analysis. Journal of Clinical Nursing, 27, 1360-1368. https://doi.org/10.1111/jocn.14238
Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04
are findings that are not of concern and expected for a client’s age, developmental stage, and sex.
are findings of concern because they are not normal and not consistent with a client’s age, developmental stage, and sex.
are findings that require prompt and immediate action to prevent clinical deterioration or intervene when a client is deteriorating.
are a sign or symptom that prompts an action such as an abnormal finding that signals a potential concern.
, in reference to solutions/interventions, refers to solutions and interventions that are suggested as a desirable or necessary course of action.
in reference to solutions/interventions, refers to solutions and interventions that are not needed and not absolutely necessary.
in reference to solutions/interventions, refers to solutions and interventions that are not connected or related to the problem.
in reference to solutions/interventions, refers to solutions and interventions that should not be used because they may be harmful.
