Running Head: SCHOLARLY CAPSTONE PAPER 1

Scholarly Capstone Paper

Clinical Nursing Judgment

Augusta Fronzaglio

Youngstown State University

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The way nurses come to understand the problems; issues or concerns of patients

who need the presence of care with critical information leading to the nurses reaction to

the situation is known as clinical judgment. Nurses don’t work alone when it comes to

applying clinical judgment in a complex scenario working with other professional teams

to guarantee health care quality and safety. According to Benner, Sutphen, Leonard and

Day (2014), “the critical components include: changes in patient status, uncertainty

about the most appropriate course of action, accounting for context, and the nurse’s

practical experience”. A vital skill such as clinical judgment allows nurses to decide the

appropriate nursing interventions when planning patient care, especially the ability to

manage rapidly deteriorating patients (Graan, Williams, & Koen, 2016).

Educators and employers acknowledge that novice nurses do not meet the

expectations for entry-level clinical decision-making and judgment that having further

education and experience will improve this skill. Nurses especially novice nurses that

follow the process in the same order every shift just like reading off a piece of paper or

going down a checklist and not expanding their clinical decision making cannot assure a

good clinical judgment that will solve the patients problem. Educators are held

accountable to find adequate clinical experience for students that go along with the

health care environment but there is minimal exposure to real life patients where

students are able to have the critical judgment be put to use (Graan, Williams, & Koen,

2016). A nursing student should have the opportunity to be able to use scientific

knowledge, experiences and clinical judgment in certain situations. When nursing

students have the chance to do this they can take past experiences and use them as a

foundation for future clinical decision-making and apply their knowledge throughout
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their nursing career. Another environment where student nurses can apply clinical

decision-making and judgment can be done in the stimulation room. A stimulation room

is an excellent environment where the students can use clinical judgment in life-

threatening scenario’s without the risk of killing a patient literally and be able to learn

from there experience and gain knowledge on what to do if the scenario where to

happen again (Hallin, Haggstrom, Backstrom, & Kristiansen, 2015). Eventually these

student nurses will turn into nurse teaching the students, so the novice nurse becomes

more experienced the patient will be less likely to recognized interventions being done

to them because it will become natural to the nurse.

When it comes to the health care system nurses are significant decisions makers.

According to Thompson, Aitken, Doran, and Dowding, (2013) “Worldwide, 19 million

nurses will exercise their clinical judgment before making choices with, for and on

behalf of patients. These patients trust nurses to make decisions that do more good than

harm”(p. 1721). The number of nurses making clinical judgments everyday is

outstanding but the number that nurses make every minute is mind blowing. Nurses

facing a decision or judgment duty every 10 minutes while critical care nurses have to

make a decision or judgment every thirty seconds (Thompson et al., 2013). By reading

these numbers it is an eye opener that we still have a lot more research to do on clinical

decision-making and judgment, by doing so we can better prepare the novice nurse for

basic to critical situations and continue to improve the working nurse with experience.

When thinking about the past five years of nursing school and all the clinical

decision-making I have either saw nurses or my instructors do, and then eventually I

was able to do so leads me into my preceptor experience. I precept at St. Joseph’s

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Hospital in Warren, Ohio on the sixth floor or also know as Intermediate Care Unit. On

February 27, 2018 I had the opportunity to make a clinical decision. My patient whom I

had the opportunity to do so was a male, 56 years old, full code with a diagnosis of upper

GI bleed and Acute kidney injury but what brought the patient in was a fall that occurred

at the nursing home where he fractures C5 and his femur. Some information about his

past medical history is he is legally blind, cirrhosis, vanishing duct syndrome and

possibly mental retardation. Give you a report on the patient is alert to self, sinus

tachycardia, has a Foley, Peg tube running at 30 cc an hour, two IVs 18 in the right AC, 20

left forearm and was also on the BiPap machine 12/8 back up of 8 and 100% FIO2 which

needs to remain on at all times. The patient had a chest x-ray showed worsening,

cardiomegaly, CT of abdomen right side pneumonia and atelectasis, DVT ultrasound

negative and abdominal ultrasound distending gallbladder with slug, and mild extra

hepatic bile duct dilation. When looking up the patients labs I had noticed his potassium

was at 2.7 which is low, BUN at 34 which is high, and an elevation in the WBC 17.9. After

reading the labs I tell my preceptor that I’m going to call the doctor and let him know

about the significant lab values. The doctor then proceeds to order 6 bags of 20 mEq in

50 ml bag of potassium. The patient already has an antibiotic running Flagyl and D5 with

40 K+ at 125 an hour. Before entering the room I knew all the information above and my

nurse said to be prepared to take your time with him because there is a lot going on. So

when entering the room I introduce myself as “Hi, I’m Augusta your YSU nursing student

for the day” then I see that the patient was in a neck brace and leg immobilizer because

his hip would pop out of place when rolling. I looked at the IV sites and the pump to

make sure everything was running correctly and was connected. Then I did my head to
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toe assessment and this is where the patient began to swing his arms, trying to pull out

IVs, the BiPap mask, kicking his leg off the bed. The patient was very agitated and

restless because on the pain he was experience from his fractures. Before getting his

medication ready I calmed him down reassuring him he was okay and who I was. He had

went to the bathroom and it was messy so my nurse came in and we got him cleaned up

and comfortable before administering med and that did help him relax. The shift before

us had his neck brace on wrong so we also adjusted that. I began checking in his

medication hanging the flagyl that was piggyback to the D5 with 40 K and then I hooked

up the new line for the potassium where I hang two and just piggybacked running that at

70 and hour so it was less burning the vein. Then I crushed up his pain medication and

as I’m doing this, my nurse is trying to calm my patient but nothing is working. I

administer his medication through the peg tube. After that we have to rewrap his IVs

with gauze over them because he is ripping them out. As we finish up I tell my nurse that

I think we should call the doctor to see if we can get him something ordered because the

fentanyl given was not helping. As we start to walk out the doctor and his team are

making there rounds and I telling him what’s going on and my nurse backs me up. He

first asks if we would like restraints and we decided no so he ordered Haldol sub-q

injection. We go to med room and get the medication and administer it. It did help the

patient relax and he was calm but I thought it was unsafe for him to be by himself still.

SO we made a room change were a sitter was already sitting because the bed was open.

He was placed under 1:1 visit and as along as his medication was given he remained

calm. But when the medication was wearing off he began to pull and swing arms.

Throughout the shift he had spurts of arm swinging and pulling but the sitter was able to
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assist with that. Overall I felt really good about my experience that day and thought that

I had made good clinical judgment and optimally just wanting my patient to remain safe

and harm free.

Clinical decision-making and judgment is such an essential component in the

nursing profession. So it is evident that the importance to make clinical decisions and

judgment is increasing as we move forward in the health care world. Taking my clinical

experience into use for future encounters on the floor wherever I may be working at will

only improve my decision-making.

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References

Benner, P., Sutphen, M., Leonard, V., Day, L. (2014), Pratical/Vocaional Nursing
Program Outcome:Nursing Judgment. National League for Nursing.

Graan, A. C., Williams, M. J., & Koen, M. P. (2016). Professional nurses understanding of
clinical judgment: A contextual inquiry. Health SA Gesondheid,21.
doi:10.1016/j.hsag.2016.04.001

Hallin, K., Haggstrom, M., Backstrom, B., & Kristiansen, L. (2015). Correlations Between
Clinical Judgment and Learning Style Preferences of Nursing Students in the
Simulation Room. Global Journal of Health Science,8(6). doi:10.5539/gjhs.v8n6p1

Thompson, C., Aitken, L., Doran, D., & Dowding, D. (2013). An agenda for clinical
decision-making and judgment in nursing research and education. International
Journal of Nursing Studies,50(12). doi:10.1016/j.ijnurstu.2013.05.003