Clinical Judgment And Interpreting Nursing Interventions

A nurse utilizes his or her clinical judgement when interpreting patient data and implementing nursing interventions. In the clinical setting, clinical judgement is defined as "an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response” (Giddens, 2017). When narrowing down this comprehensive definition, it remains evident that clinical judgement stands as the process that determines how, when, and why a nurse performs a set of actions. Clinical judgement stands greater than simply making a choice; clinical judgement requires assessing the patient, interpreting data,
When completing my OB rotation at Honor Health, I provided patient education and discharge teaching to a mother and her newborn. In this experience, I used clinical judgement to provide the new mother with valuable information that would make her transition from the hospital setting to her home easier. Rather than throwing a great deal of information at the new mother, I first gathered information and assessed the mom’s desire to learn. Information I obtained included safety risks in the home environment, previous pregnancies and child care experiences, mother and newborn needs, requests for supplies (Diapers, formula, etc.), social support, cultural values/beliefs, and a baseline for what the mother already knew regarding the care of herself and her newborn. Upon gathering data, I was able to interpret what information that new mother still needed, ask open ended questions, and come up with a plan to provide effective discharge teaching. Through verbal, written, and visual instructions, I was able to effectively perform a postpartum discharge teaching plan, which focused on newborn feeding cues, appropriate times to call the provider, proper car seat placement and fitting, breastfeeding, SIDS prevention, umbilical cord care, and signs of postpartum depression. Throughout the education process, the new mother voiced
Patients tend to place their trust in their nurses, seeking out guidance and clarification on their health care concerns. During the discharge process, a great deal of information is thrown at patients, which can cause them to become confused and overwhelmed. Upon leaving the hospital, the overwhelmed patient stands more likely to experience poor medication and treatment adherence, readmissions, and adverse outcomes. To enhance patient outcomes, while decreasing readmission and adverse event rates, improvements must unfold in patient education, care coordination, and communication (Hesselink et al., 2014). By directly involving the patient in their education and discharge planning, open communication can occur, which increases patient adherence and understanding of discharge information. While a condition, medication, or treatment may stand routine to health care professionals, it is often a new and frightening experience for patients. For this reason, in my future practice I will ensure to properly assess my patient’s motivation and ability to learn, values and beliefs, and preferred learning style prior to providing education. As a nursing professional, I stand responsible for interpreting my patient’s needs and concerns, adjusting my care to fit these needs, and evaluating the