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Scholarly Capstone Paper

Clinical Nursing Judgement

Kayla Boyer

Youngstown State University

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Clinical decision making, and judgement is a vital component of the nursing profession.

Clinical judgment can be defined as the process by which the nurse decides on data to be

collected about a client, makes an interpretation of the data, arrives at a nursing diagnosis, and

identifies appropriate nursing actions: this involves problem solving, decision making, and

critical thinking (Saunders 2003). The process of critical judgement is becoming even more vital

with an increasing complex health care environment and ever-changing technology. It is

important for a nurse to be able to build on his or her clinical judgment skills and be able to care

for patients at optimal level.

Victor-Chmil (2013) described three levels of thinking and knowing. The first is critical

thinking, a mental process. The second is clinical reasoning, which starts to take into

consideration the contextual concepts of patients, their family members, and the practice

situation. The third level is clinical judgment, which encompasses the mental and contextual

influences and extends to the embodied and affective aspect of nursing care. Nursing is

frequently viewed as a physical task to keep the patient safe, clean, nourished and comfortable; a

doctor assisting in completing orders; however, nursing goes beyond that. Nursing care lies in

the clinical judgment skills obtained by assessment, diagnosis, planning, implementation, and

evaluation (Graan, Williams, Koen 2016). Furthermore, Clinical judgment extends to being able

to properly delegate task to other staff, and it is important for proper, sound patient care.

Critical thinking and clinical judgment are key components of nursing and assist in the

provision of safe, effective patient care (Victor-Chmil, 2013). Estimates vary but nurses make

lots of decisions: acute care nurses facing a decision or judgement “task” every 10 min, and

critical care nurses every 30 s (Bucknall, 2000).

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“Worldwide, 19 million nurses (WHO, 2011) will exercise their clinical judgement

before making choices with, for and on behalf of patients. These patients trust nurses to

make decisions that do more good than harm. Nurses have a key role to play in

overcoming the major challenges facing developed healthcare systems: ageing

populations; rising healthcare costs; promoting population health through preventative

healthcare; reducing health inequalities; and employing evidence-based practice to

produce the biggest health gains in the most efficient and acceptable manner possible.

Health systems require nurses whose clinical judgements and decisions contribute to, not

detract from, the quality of health systems (Thompson, Aitken, Doran, and Dowding

2013).”

Throughout the day, nurses make a lot of decisions that affect the patient they are caring for. It is

important to obtain the appropriate skills and knowledge base to affect patient care in a positive

way, while also learning to apply them to a real-life situation. Clinical nursing judgment

fundamentals begins in classroom and expands with experience while in the work place.

Fundamentals are expanded upon via help from an experienced nurse and instructors guiding you

into making judgment decisions. During my short career as a nursing student, I have seen clinical

judgment, experience, and a knowledge basics utilized several times to positively influence

patient care and outcomes.

To conclude my final year of nursing school, I precepted in the Surgical Intensive Care

Unit (SICU) at Mercy Youngstown. One patient stands on in my mind for needing strong clinical

judgment skills. I was caring for a gentleman in the SICU who was in the hospital for falling at

the nursing home from the bed. Due to the fall, the patient sustained a scalp laceration. The
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patient had a CT scan, which showed an old subdural bleed. The doctor admitted the patient to

the unit for observation in fear of a re-bleed.

On the patients first day of admission, I was caring for the patient during the night shift.

The patient was noted to be an 85-year-old male, having no known allergies and was a full code.

Upon assessment, the patient had a Normal Saline running at 25 mL/hr. in a peripheral line and

had TPN running at 35 mL/hr. I concluded one of my highest priorities was patient’s

neurological assessments. When assessing the patient noted there was a left sided head

laceration, which was covered by a dressing and no drainage noted. Patient’s eye assessment

noted to be having a pupil size of 3 bilaterally and were equally reactive round to light. Patient

had a difficult time talking due to his history of ALS, but was able to state name, year, location,

and reason for admission. Patient was able to squeeze hands, wiggle toes, and put both thumbs

up. Patient reported no numbness or tingling and had strength to be noted equally strong

throughout all four extremities. The patient was receiving 2L nasal cannula of oxygen and his

lung sounds were clear and diminished. Cardiac assessment noted that the patient was in normal

sinus rhythm, having normal heart sounds of S1 and S2. Noted in patient’s abdominal

assessment, he had active bowel sounds, was flat, and non-distended, having no bowel

movements during current admission thus far. Patient had adequate urine output of at least 30

mL an hour, yellow and clear in color. Patient’s pulses were +2 bilaterally, having no edema, and

capillary refill less than three seconds was noted.

In the SICU, vitals need to be check every hour. The patient’s heart rate stayed between

60-70 bpm, RR 14-16, SpO2 95-97%, Temperature 97.1-97.2 and BP 110/60-100/57 mmHg.

Additionally, patient has no reports of pain. Patient assessment was stable and neurologically
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intact. Personally, I felt the blood pressure was to be the only concerning finding during the

initial assessment. I decided to keep a close eye on it to make sure it stayed stable.

Moreover, the patient’s blood pressure continued to stay above 100/57 mmHg until

around 0300. Around 0300, the patient started to display hypotension and bradycardia. I reported

my findings to the doctor and waited for my new order, which was to administer a fluid bolus.

With the patient’s blood pressure and heart rate dropping, and I begin to closely monitor vitals

and urine output, to indicate if the patient was potentially at risk for decreased organ perfusion.

Urine output stayed above 30 mL/hr, and with the fluid bolus, the patient’s blood pressure and

heart rate stabilized.

Upon a reassessment at 0400, the patient was noted to be difficult to awaken, blood

pressure dropping again, and heart rate slowing down. The urine output remained above 30

mL/hr. I reported my findings to the doctor and awaited the next instruction. The doctor ordered

another fluid bolus and attempted a sternal rub to wake the patient. He then decided to give him

some time to see if the patient would wake up, and he also discussed another CT scan if he did

not improve neurologically within an hour.

Despite our efforts, the fluid bolus did not work. Again, I called the doctor and notified

him of this, as well as the noted hypotension with the bolus having been completed. I further

discussed with the doctor about the possibility of running a vasopressin medication to stabilize

the blood pressure, and we also discussed potentially needing a central line to have more access

in an emergency. The patient was also noted to be having a difficult time breathing, requiring

further increase to 3L of oxygen and elevation of the head of the bed. I notified the physician of

that as well, and additionally asked if she wanted me to run lab work and ABG’s. The physician

agreed with the need for the increase in oxygen supply, as well as the initiation of a vasopressin
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medication. She further ordered the supplies to be gathered for her insertion of a central line and

items to obtain lab work and ABG’s upon the completion of the insertion of the central line.

When the lab work came back, the patient’s CO2 was 132 and sodium levels dropping.

The doctor called the family to give an update and obtain consent to intubate the patient. The

family discussed and decided they wanted to change his code status to a DNR-CC, as they did

not want him to be intubated. They wanted to come to the hospital and see him before any

decisions were made, only wanting him to be comfortable.

While waiting for the family to arrive, I monitored respiratory status and blood pressure.

The patients blood pressure was not stabilizing, and I had to increase the norepinephrine

bitartrate. I noticed that the nasal cannula was no longer providing adequate oxygenation for the

patient and discussed with the doctor about supplying patient with a more beneficial oxygenation

intake, like using the Bi-Pap machine. The doctor put in an order for the patient to begin on the

Bi-Pap machine, to ease the patient’s breathing. The patient was still hard to awaken, and he was

noting to be requiring higher oxygenation concentration levels, but I finally got the

norepinephrine bitartrate to stabilize the blood pressure until the family could arrive.

Once the family arrived, I explained what was going on with the patient and the steps

that were taking to stabilize him. The doctor came in and explained the patient’s status and

prognosis. After discussing the options, the family stood firm on their decision to make the

patient comfortable and remove all equipment. The family was able to stay with the patient and

say their goodbyes. Therefore, my use of critical judgment allowed staff to stabilize the patient

long enough to give the family time to say goodbye and allow the patient to pass comfortably.

In some, clinical judgment is a key component to taking care of patients. It takes time and

experience for one to develop the knowledge and skills needed. Nurses are faced with making
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thousands of difficult decisions that impact their patients daily. The health care world is forever

changing and increasing in the difficulty level. As medicine expands so does the need for nursing

with good clinical judgment skills. Moving forward with my career it is an area I feel must be a

focal point in my continuing education. I hope to improve on the skills I started obtaining in

school and be able to care for my patients on an optimal level.

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References

Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing & Allied Health -- Revised
Reprint. (2005, February 23). Retrieved March 01, 2018, from
https://www.us.elsevierhealth.com/miller-keane-encyclopedia-dictionary-of-medicine-
nursing-allied-health-revised-reprint-9781416026044.html

Professional nurses' understanding of clinical judgement: A contextual inquiry. (2016, August

08). Retrieved March 01, 2018, from
https://www.sciencedirect.com/science/article/pii/S1025984816300047

Thompson, C., Dowding, D., Doran, D., & Aitken, L. (2013, December). An agenda for clinical
decision making and judgement in nursing research and education. Retrieved March 01,
2018, from http://www.journalofnursingstudies.com/article/S0020-7489(13)00144-
2/fulltext

Victor-Chmil, J. (2013). Critical thinking versus clinical reasoning versus clinical judgment.
Nurse Educator, 38(1), 34–36. doi: 10.1097/NNE.0b013e318276dfbe