Nursing Process – Clinical Judgment (Nursing)

00:00 Welcome back everyone.

00:02 In this video, we are discussing a critical element and fundamental element to clinical judgement, The nursing process.

00:11 The nursing process is the essential core of practice for the registered nurse to deliver holistic, patient-focused care.

00:20 It involves five steps.

00:22 The first step of the nursing process is Assessment.

00:25 It includes subjective data which are verbal statements from the patient or the caregiver.

00:31 It also includes objective data.

00:34 this is measurable, tangible data such as vital signs, intake and output, height and weight.

00:41 Things that you can collect yourself.

00:44 Now, it's important to remember that data may come from the patient directly or from a primary care giver who may or may not be a direct relation family member.

00:55 When thinking of electronic health records, they can be very helpful to the assessment process.

00:59 If a patient has been in the system before, it can prepopulate this information into your assessment record, allowing you the opportunity to review it for it's accuracy.

01:09 Second, it can also assist by having certain questions to remind you to complete a holistic assessment so you don't forget anything.

01:18 The second step of the nursing process is the diagnosis.

01:21 And this is the formulation of a nursing diagnosis really assist in planning and the implementation of patient care.

01:29 Don't forget about the North American Nursing Diagnosis Association.

01:32 This is an organization that maintains an up-to-date list of nursing diagnosis at all times.

01:39 The diagnosis includes clinical judgement about responses to actual or potential health problems on the part of the patient, family or community.

01:48 And it includes Maslow's hierarchy of needs which helps to prioritize and plan care based on the patient-centered outcomes.

01:56 The third step is Planning.

01:58 This includes goals and outcomes, and they directly impact patient care based on evidence-based practice guidelines.

02:05 Now, patient specific goals and attainment do assist in ensuring a positive outcome.

02:11 So when you think about a nursing care plan, they are essential in this phase of goal-setting.

02:16 And they provide a course of direction for personalized care, tailored to an individual's unique needs.

02:22 When you're thinking about setting goals, you want to create SMART goals.

02:27 SMART goals are goals that are Specific, Measurable or Meaningful, they're Attainable or Action-oriented, they're Realistic or Results-oriented, and finally, they are Timely or Time-oriented meaning there is a specific time by which they need to be attained.

02:47 And the fourth step of the nursing process is Implementation.

02:51 And this involves implementing interventions according to the care plan and provides for continuity of care for the patient during hospitalization and in preparation for discharge.

03:01 It involves action and the actual carrying out of the nursing interventions that are outlined in the plan of care.

03:08 It does require nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration and standard treatment protocols.

03:20 And it's really important after you initiate an intervention and you implement it that you document it in the patient's records.

03:27 The fifth step of the nursing process is evaluation and it is vital to a positive patient outcome.

03:34 It stands to reason that whenever a healthcare provider intervenes or implements care, they must re-assess or evaluate to ensure that this desired outcome has been met.

03:44 Now, depending on the overall patient condition, you might need frequent reassessments.

03:51 And finally, you may need to adapt the plan of care based on new assessment data that you received.

03:57 So remember, the utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care.

04:07 So let's review what we've learned today.

04:10 First, the assessment includes both subjective and objective data.

04:15 Meaning you have information that comes from others and information that you collect yourself.

04:20 Second, a nursing diagnosis assist in the planning and implementation of patient care.

04:26 Now, patient-specific goals and attainment actually assist in ensuring a positive outcome.

04:31 Goals should be created using the SMART format.

04:35 Implementation invloves action and the actual carrying out of nursing intervention outlined in the plan of care.

04:42 And finally, whenever a healthcare provider intervenes or implements care, they must reasses or evaluate to ensure the desired outcome has been met.

04:52 I hope you've enjoyed this video on the nursing process.

04:55 Thank you so much for watching.