S3 M7 Clinical judgement Flashcards
(40 cards)
Prioritization of care
Consider urgency
most critical = highest priority
Malsow hierarchy
Physical needs first, then higher levels
Maslow higherarchy
Physiological (NURSING) safety/security love self esteem self actualization
Priority level of care
LV1 ABCs LV2 Sudden change to V/S and LOC LV3 Unstable metabolic disorders (lytes) LV4 C/O pain, except chest pain LV5 Complex treatments and skills LV6 Discharge teaching and referrals
S/S of internal bleeding
Headaches LOC changes BP drop HR up Breathlessness Pale clammy skin
Stages of shock
stage 1 compensatory
stage 2 progressive
stage 3 irreversible
Stage 1 compensatory
bp normal/hr increase, cold extremities, confusion
Stage 2 progressive
bp down/hr up, resp up, chest pain, kidney injury, worsened mental status, mottled skin
Stage 3 irreversible
multiple organ dysfunction, 60/40bp, mechanical support, anuric, unconscious, acidosis
Shock lead to _ leading to _
organ failure
death
Nursing interventions for hemorrhagic shock
Monitor vitals
Recognize signs
ID and correct blood loss replace fluids, give O2 LOC changes draw labs urinary output
If severe pain disappears
Red flag of Shock
With shock urine should be
CLOSELY MONITORED
volume and color
When Shock progresses
Intubation and mechanical ventilation
ABG monitoring
Support fam members
When to call Dr.
Deterioration + physician orders are not sufficient
Significant BP changes
systolic below 90
systolic drop by 40
MAP greater than 65
Critical thinking
3 parts
Reasoning and judgement
Based on knowledge
Includes analysis
Clinical reasoning
annualize past to think of next steps
Clinical judgement
Interpreting data AND taking action as appropriate
ADPIE
Assessment Diagnosis Plan Implementation Evaluation
Tanner model
Notice
Interpret
Respond
Reflect
Notice
Perception of situation
Interpret
Understanding the situation
Responding
Acting on the situation
Reflecting
In action vs on action
observing pt reaction
in action happens during responding stage
on action happens during reflection
