⚖️ New Lesson 21

Clinical Judgment & Nursing Process

ADPIE, SBAR, prioritization frameworks, recognizing deterioration, and how to think on the NCLEX.

NCSBN Model

NCSBN Clinical Judgment Model

Step	What It Means	Example
1. Recognize Cues	Notice what data is relevant	Patient's BP dropped from 120 to 80 since last hour
2. Analyze Cues	Determine what the data means	Dropping BP + tachycardia = possible hemorrhage or shock
3. Prioritize Hypotheses	Rank most likely explanations	Post-op bleeding is most likely given the setting
4. Generate Solutions	Identify possible actions	Assess incision, check for drainage, call provider
5. Take Actions	Implement the best solution	Assess incision, apply pressure, call provider
6. Evaluate Outcomes	Did your actions work?	BP improving → intervention effective. Not improving → escalate.

Prioritization Frameworks

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ABC Priority: Airway → Breathing → Circulation → Safety → Everything else. A patient with an airway problem ALWAYS goes first.

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Maslow's Hierarchy: Physiological → Safety → Love/Belonging → Esteem → Self-Actualization. Physiological needs (air, circulation, nutrition) ALWAYS take priority over psychological needs.

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Acute vs Chronic rule: NEW, SUDDEN, or WORSENING problems take priority over chronic stable conditions. A patient with new chest pain outranks a patient with chronic back pain rated 5/10.

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Unstable > Stable rule: Any patient showing signs of deterioration (dropping BP, rising HR, decreasing UO, altered LOC) takes priority over stable patients regardless of diagnosis.

Recognizing Deterioration

Recognizing Patient Deterioration — Early Warning Signs

System	Early Warning Signs	Action
Cardiovascular	HR >120 or <50, BP drop >20 from baseline, cool clammy skin	Assess, notify provider, prepare IV access
Respiratory	RR >25 or <10, SpO2 <92%, restlessness/anxiety (early hypoxia)	Oxygen, position, call provider
Neurological	Acute confusion, new slurred speech, facial droop, unequal pupils	FAST stroke protocol, notify immediately
Renal	UO <30 mL/hr for 2 hrs, weight gain, peripheral edema	Assess fluid status, notify provider
GI	Sudden rigid abdomen, absent bowel sounds, guarding	NPO, IV access, surgical consult
Sepsis	Fever or hypothermia + tachycardia + tachypnea + altered LOC	SEPSIS protocol, blood cultures, antibiotics, fluids

Scope of Practice

LPN Scope of Practice Summary

Role	CAN Do	CANNOT Do
LPN	Administer medications (oral/SQ/topical/some IV per state), reinforce teaching, implement care plan, care for STABLE patients, routine wound care, contribute to assessment	Initial nursing assessment, develop care plan, care for UNSTABLE patients, administer blood products (most states), IV push medications (most states), initial patient teaching
RN	All of the above PLUS initial assessment, care planning, IV therapy, blood products, unstable patients, initial teaching, clinical judgment decisions	Prescribe medications, perform surgical procedures (unless APRN)
UAP/CNA	ADL assistance (bathing, dressing), vital signs on stable patients, I&O measurement, routine ambulation, feeding stable patients	Assessment, medication administration, IV management, any clinical judgment

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LPN memory rule: LPN cannot do the FIRST of anything clinical. First assessment → RN. First teaching → RN. First care plan → RN. LPN implements; RN initiates.

📖 Study Notes

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Clinical judgment shortcut: When you see a change in patient condition, the answer is almost always to ASSESS first, then NOTIFY the provider. Very few situations call for immediate independent intervention without notification.

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SBAR for provider calls: Situation → Background → Assessment → Recommendation. Always have the chart, allergies, current meds, and latest vitals in front of you before calling.

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Never harm rule: If an answer choice could harm the patient, eliminate it immediately. NCLEX never rewards shortcuts that compromise patient safety.