CLINICAL JUDGMENT IN

NURSING PRACTICE
 CLIENT ASSESSMENT
• Purpose of the health assessment
• Documentation in nursing
• History taking/physical examination
• Nursing process
• The role of the nurse in admission, transfer
and discharge of patients
 Purpose of the health assessment
• Health assessment is a process of obtaining, analyzing,
evaluating and synthesizing information collected
about the clients in order to determine the client’s
health status and the need for nursing care

• Health Assessment provides a systematic method of

collecting all types of data that identifies client’s
strengths, weakness, physiological status, knowledge,
motivation, support systems and coping ability.
 CONT’D

• Always consider the client’s age, gender, culture,

physical, psychological and social-economic status.
• Objectives of health assessment; to
 Determine strengths which promote health
behaviors.
 Identify needs and clinical problems that form the
basis of nursing care.
 Validate health status.
 Obtain pertinent information to diagnose and treat
health problems.
 History Taking (subjective data)
Medical model health assessment format
• The chief complaint
• History of the present illness
• Past medical/surgical history
• Family health history
• Obs/gyn history or Sexual/reproductive health
history
• Socio-economic history
• Dietary and lifestyle history
• Mental health history
 Physical Examination (objective data)
• Two approaches:
• Review of systems
• Head to toe examination

• Head to toe examination using the four

techniques of physical examination
• Inspection
• Palpation
• Percurssion
• Auscultation
 CONT…
• In addition;
• Nursing assessment focuses on assessing
patients’ needs or wants.
• The Maslow’s hierarchy of needs has been
widely advocated for as a framework for
nursing assessment.
• The hierarchy has five levels and arranged in
the form of a pyramid
The Importance of Nursing Assessment
• It enables one to focus on specific client
characteristics - functional abilities and the ability to
perform activities of daily living.
• It enables one to collect data from several sources
by various methods.
• It enables one to collect data, validate and make
diagnostic judgment.
• It is a systematic, deliberate, and interactive process.
• It is crucial to initiate the nursing process.
 Documentation in nursing
Aim of Documentation
To ensure complete, accurate, concise, current,
factual and organized data.
To communicate in a timely and confidential
manner.
To facilitate care coordination.
To serve as a legal document.
 Documentation guidelines
• Content
• Timing
• Format (use of reported speech other than first
person, highlight of important information)
• Accountability
• Confidentiality
 Purposes of Patient Records
• Communication
• Recording of diagnostic and therapeutic orders
• Care planning
• Quality of care reviewing
• Research
• Decision analysis
• Education
• Legal documentation
• Reimbursement
• Historical documentation
THE ROLE OF THE NURSE IN ADMISSION,
TRANSFER AND DISCHARGE OF PATIENTS
 ADMISSION

• Entering a health care agency for nursing care

and medical/surgical treatment.
 Nursing responsibilities
• Prepare room: provide personal care items, Oxygen,
sunction
• Identify self: Alleviates anxiety/fear, makes pt feel secure
• Orient patient: Location of nurses station, visiting hours
• Gather information: Through history taking and physical
examination
• Completes documents: Admission assessment/interview
documents appropriately
• Provide information about the legal and ethical
components of care
 Types of Admission
• Inpatient :Longer than 24 hours
Can be planned, Emergency, Direct
admission
• Outpatient: Less than 24 hours
Observational: head injury, premature
labor, unstable vital signs, etc
 Valuables
• When documenting valuables, make sure to
use words like: brown belt, black sharp
pointed shoes, ksh.500……..(specific)
• Have a witness
• Have nurse & patient(pt) sign valuables list
• Don’t forget dentures, glasses, etc. when
transferring pt, sign-off with nurse
• Know your facility’s valuables policy
 TRANSFER
• Discharging a patient from one unit or agency
and admitting them to another unit

• A transfer requires a patient to readjust to new

surroundings, new roommates, new routines and
new people providing care all of which may
cause stress and anxiety.
• The nurse is responsible for ensuring that the
comfort, safety and teaching needs of the patient
and family are met.
 Cont…
• Inform the nurse on receiving unit
• The nurse in the original area should give a
complete verbal and written report about the
patient.
• Documents should accompany the patient
• Informs the patient/family
• Complete transfer summary
• Transports patient/belongings/supplies & charts
• checks orders/makes new ones
 DISCHARGE
• Discharge is almost always a welcome event but can
also be stressful.
• Planning for discharge begins on admission
• Discharge planning ensures that the needs of the
patient’s and family needs are consistently met as
the pt moves from the acute care setting to care at
home
• Assess the strengths and limitations of the pt, family
or support person and the environment
• Implement and coordinate the plan of care
considering individual, family and community
resources and evaluating the effectiveness of care
 Cont…
• Termination of care from a health care
agency on medication, health teaching as
an outpatient referral
• Against medical advice: pt leaves prior
to obtaining a written order.
Nurse requests pt to sign form. if refuses,
nurse must let pt leave and note refusal to
sign in a chart.
 Nurses responsibility for discharging a
patient
• Gather belongings/check inventory
• Arrange transportation
• Inform pt of checkout time to avoid being
billed for an extra day
• Facilitate writing of a discharge summary
• Terminal cleaning. bed stripped and
disinfectant used. bedside cabinet
restocked/cleaned.