Proactive Nursing ENG 2022 INKIJK-2

Marc Bakker
Nurses are closely involved in their patient’s current state of health and are often the first to
ProActive Nursing: Clinical Judgement

witness (sometimes acute) changes in it. Good clinical judgement is therefore an essential
professional skill. Three competences play a key role in clinical judgement: observing,
analysing and communication.
ProActive Nursing: Clinical Judgement helps nurses to make a professional assessment

of ‘how the patient is doing’ and to clarify their patient’s clinical condition. The book
combines the eighteen health care topics of the World Health Organization’s International
Classification of Functions (ICF) with the three focal points of patient-centred care:
wellbeing, bodily functions, and patient functioning. It clarifies what is going well and what
is not, what the clinical problems, disorders and limitations of the patient are and what
interaction there is between the different problems. All of the eighteen healthcare topics
covered in this book are summarized in a practical mind map showing the clinical focus
points. There is also a section on the ‘Time-out practice model’ which helps nurses in a
structured way how to apply their clinical judgement skills into practice.
Marc Bakker is a nurse and educator at heart and has worked in intensive care, emergency
care, cardiac care, anaesthesia, recovery care, paediatrics, internal medicine, oncology,
neurology, orthopaedics, surgery, psychogeriatrics and psychiatry, among others. He is
the founder of ProActive Nursing within the VUmc Academy and has been giving lectures,
courses, workshops and master classes at colleges, universities and healthcare institutions
in the Netherlands, Belgium, and the Caribbean for over 30 years. He is a pioneer and
authority in the field of clinical judgement.
Marc Bakker
ProActive Nursing:
Clinical Judgement
www.boomstudent.nl
www.boomhogeronderwijs.nl
18785-10-ProActive Nursing-ENG.indd 2-3 10-11-2022 12:24

ProActive Nursing:
Clinical Judgement
MARC BAKKER
Disclaimer
Although this book has been compiled with the greatest of care, we are not responsible for any errors
that may be contained within the text. The author and publisher disclaim all liability and responsibility
for any medical and/or nursing errors resulting from these texts.
Cover design: Haagsblauw, The Hague

Layout: Textcetera, The Hague
Drawings: Karin Creemers
Design of mind maps and Law of Eight: Marc Bakker
Educational Design Time-out practice model: Marc Bakker
© VUmc Academie, Marc Bakker & Boom publishers Amsterdam, 2023
Subject to the exceptions in or under the Copyright Act of 1912, no part of this publication may be reproduced, stored
in a database or retrieval system or published in any form or by any means—electronic, mechanical, photocopying,
recording or otherwise—without the prior written permission of the publisher.
Insofar as the creation of reprographic simplifications from this publication is permitted on the grounds of Article 16h
of the Copyright Act of 1912, the statutory fees due for such purposes must be paid to the Reprographic Reproduction
Rights Foundation (Stichting Reprorecht): PO Box 3051, 2130 KB Hoofddorp, www.reprorecht.nl. For the reproduction
of any part or parts of this publication in anthologies, readers or other compilation works (Art. 16 of the Copyright Act
of 1912), please contact the PRO Foundation (Stichting Publicatie- en Reproductierechten Organisatie, PO Box 3060,
2130 KB Hoofddorp, www.stichting-pro.nl).
No part of this book may be reproduced in any form, by print, photoprint, microfilm or any other means without written
permission from the publisher.
ISBN 9789024456413 (e-book)

EAN 3009010006559
NUR 183
www.clinicaljudgement.nl
TABLE OF CONTENTS
Introduction11
Part I Time-out for clinical judgement 13
Table of Contents Part I 15
1 What is clinical judgement? 17
2 Patient-centred care 21
3 Time-out practice model 25
4 Three basic professional skills 29
Sources consulted 41
Part II Insight into clinical problems 45
Insight into clinical problems 49
18 Healthcare topics 51
Mind maps 57
Healthcare topic 1 Well-being59

1 Clinical focuspoints 62
2 Clinical problems 67
3 Clinical observations 70
4 A few clinical situations 75
Healthcare topic 2 Mental functions 79

1 Clinical focus points 85
5
Healthcare topic 3 Sensory functions and pain 123
Healthcare topic 4 Voice and speech 145

ABC Vital functions
Healthcare topic 5 Respiratory tract 159

Healthcare topic 6 Respiration175

3A Highlight: Pulse oximetry 198
Healthcare topic 7 Circulation209

3A Highlight: Arterial blood pressure 253
3B Highlight: Cardiac rhythm monitoring 259
6 ProActive Nursing: Clinical Judgement

3C Highlight: Invasively measured blood pressure 267
3D Highlight: Haemodynamic profiles 269
3E Highlight: Blood pressure curves 277
Healthcare topic 8 Oxygen supply to the heart 285

Healthcare topic 9 Urinary system 305

Healthcare topic 10 Blood333

3A Highlight: Haematology 362
3B Highlight: Clinical chemistry 370
3C Highlight: Arterial blood gases 381
Disability functions
Healthcare topic 11 Nervous system 389

Table of Contents 7
Healthcare topic 12 Musculoskeletal system 429
Healthcare topic 13 Endocrine system 451

Exposure functions
Healthcare topic 14 Thermoregulation 481

Healthcare topic 15 Skin and immune system 503

Healthcare topic 16 Digestive functions 541


Healthcare topic 17 Reproductive functions 573
3A Highlight: CTG 614
4A The pregnant body 618
4B The newborn 627
4C Apgar score and the PEWS 638
Healthcare topic 18 Functioning and self-reliance 641

Index661
Table of Contents 9
‘PROUD TO BE A NURSE’
INTRODUCTION
This book on clinical judgement is intended primarily for students, but it is also suitable for nurses
interested in further developing their clinical judgement skills. For some years now ‘clinical
judgement’ has been an importance subject in educational institutions and in clinical instruction.
Although it is not long ago that ‘clinical judgement’ was a new term for many, it is now profes-
sionally recognised and included in both the formal and extra-curricular components of training
programmes.
Clinical judgement without a solid base of (biomedical) knowledge is impossible and potentially
harmful to the patient. You need to be able to apply your biomedical knowledge daily while caring for
patients. This requires a lifetime of study, repetition and maintenance of one’s clinical knowledge
base. This book aims to be a helpful partner in that process.
The first edition of the original Dutch version was published in 2013, under the title of Klinische
problematiek inzichtelijk (Insight into clinical problems). The second edition was published in 2017,
followed by the third edition in 2022. And now the third edition is translated in English.
Part I: Time-out for clinical judgement

Part I focuses on clinical judgement, based on the ‘Time-out’ practice model. This model is designed
specifically for teaching clinical judgement in practice. In the past five years, this model has been
used, tested and adjusted within a number of educational pilot projects. These projects were
conducted in a general hospital (twice), as well as in a large care institution for people with mental
disabilities and within the setting of a nursing home.
Part II: Insight into clinical problems

The second part contains the 18 ICF healthcare topics, arranged according to the ABCDE method.
Each healthcare topic is summarized in a useful mind map.
I would like to thank the nurses, teachers, educators and other experts on clinical judgement I have
worked with. As a nurse, founder, teacher and author of ProActive Nursing, I am proud of what we
have accomplished, but we will continue our mission.
I wish you the greatest success in learning or further developing clinical judgement skills.
Marc Bakker
11
The question…
How is it going?
Hoe giet it? (Frisian)
Hoe-is-ie? (Bargoens)
Kon ta bai? (Papiamento)
Comment ça va? (French)
How you doing? (English slang)
Cómo estás? (Spanish)
Wie geht’s? (German)
Come está? (Portuguese)
Hvordan går det? (Danish)
Hur mår du? (Swedish)
O genki desu ka? (Japanese)
Ni hao? (Chinese)
Habari gani? (Swahili)
Jak sie? masz? (Polish)
Ma sjlomchech? (Hebrew)
TI kAnis? (Greek)
Ce faci? (Romanian)
Mitä kuuluu? (Finnish/Suomi)
Kak si? (Bulgarian)
Kak dyela? (Russian)
Kayf Halek? (Moroccan)
Bagaimana kabarnya? (Javanese)
Come stai? (Italian)
Nasilsin? (Turkish)
Hoe gaan dit met jou? (South-Afrikaans)
Otto-sjim-nikka? (Korean)
Jak se dar’i? (Czech)
Kako ste? (Croatian)
Hale shoma chetor ast? (Farsi)
Kiel vi fartas? (Esperanto)
Hvordan går det? (Norwegian)
Apa kabar? (Malay)
Izzayyik (Egyptian)
Aap kaiseh hai? (Hindi)
Hoe gaat het? (Dutch)
Wie geit ut? (Limburgish)
…is often difficult to answer

PART I
TIME-OUT
FOR CLINICAL
JUDGEMENT
TABLE OF CONTENTS PART I

4.1 Observation 29
4.2 Analysis 36
4.3 Communication 38
15
1 WHAT IS CLINICAL
JUDGEMENT?
Clinical judgement is a specific, professionally oriented form of associative and critical thinking. In
daily practice, we are not always conscious of this. Thinking is a particularly rapid process and, for
the most part, it is done more or less subconsciously (automatically). We quickly link what we see
(observations) to our biomedical knowledge, and we immediately know what to do and what to say.
Clinical judgement is a high-level cognitive skill, and all healthcare professionals obviously possess
optimal skills in this regard.
Clinical judgement cannot be learnt overnight, however, nor is it a simple task to acquire a solid
professional biomedical knowledge base. Clinical judgement is not easy to learn or teach for any of
the professionals involved (e.g. nursing specialists, nurses, students, educators).
In international literature on clinical reasoning, the terms ‘clinical judgement’, ‘clinical reasoning’,
‘problem-solving mentality’, ‘clinical decision-making’ and ‘critical thinking’ are often used synony-
mously.
‘Clinical judgment refers to the cognitive processes involved in making judgments, which includes
making sense of data and cues and is defined as an interpretation about “a patient’s needs,
concerns, or health problems,” followed by a determined course of action.’ (Tanner, 2006, p. 204).
We regard clinical judgement as an important professional skill, not only in nurses. A wide variety of
healthcare professionals currently receive training in some form of clinical judgement. Although all
of these professional practitioners use the term clinical judgement, there are both similarities and
differences in the clinical judgement applied within the various disciplines of healthcare. The most
important similarity is that the clinical judgement of all healthcare professionals is aimed at the
health problems of the patient.1 The greatest difference is their primary focus.
1. Clinical judgement is directed towards the disease/condition of the patient

The primary focus of clinical judgement is to diagnose a disease/condition and to set up the appro-
priate medical (or other) treatment plan. The (end-)authority and responsibility of this rests with
the physician.
Physicians diagnose diseases/conditions using a variety of tools, including medical history, physical
examination, laboratory analysis and medical imaging. The International Classification of Diseases
(ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) are used as guides for
the diagnosis of physical and mental diseases and conditions.
2. Clinical judgement is directed towards the clinical state of the patient

The focus of clinical judgement is to monitor and diagnose the clinical condition (state) of the patient
who must endure, learn to live with, and/or possibly die from the illness in question, along with the
accompanying medical treatment and possible complications, discomforts and woes.
1 For the sake of readability, we use the term ‘patient’ in this book instead of other similar terms (e.g. ‘client’, ‘care
recipient’).

A patient’s clinical state is monitored and diagnosed according to symptoms, worrisome signs, clini-
metrics, scoring systems, blood values and specific monitoring. The International Classification
of Functioning, Disability and Health (ICF) can be used to diagnose the clinical state of patients. In
acute and/or life-threatening situations, the ABCDE method is used. Both of these methods are
inter-professional, and are used by nurses, physicians and many other healthcare professionals.
For further details, see chapter 4.
Well-being ICF International Classification of Functioning

Functioning, Disability and Health
Feeling well/comfortable Mental functions Learning and the application of
Coping Sensory functions and pain knowledge
Quality of life Voice and speech General tasks and requirements
ABC Vital functions Communication
Respiratory tract Mobility
Respiration Self-care
Circulation Housekeeping
Oxygen supply to the heart Interpersonal interaction and
Urinary system (and fluid and electrolyte relationships
balance) Important domains of life
Blood Societal, social and civic life
Disability
Nervous system
Musculoskeletal system
Endocrine system
Exposure
Skin and immune system (+skin wounds)
Thermoregulation
Digestion (+nutritional status)
Reproduction
Table 1 The ICF is a classification used to provide insight into clinical problems; all these healthcare
topics are described in Part II of this book.
Several important ICF concepts:

• Functions: physical and mental characteristics of the human organism.
• Dysfunctions: abnormalities in or loss of functions and anatomical characteristics.
• Disabilities: difficulties that an individual experiences with regard to performing activities.
• Participation problems: a problem with an individual’s functioning or participation in social life.
• External factors: the physical and social surroundings that serve to impede or support an
individual’s functioning.
• Personal factors: a person’s individual background (e.g. age, sex, social status, cultural
background, life experience).
In practice: inter-professional clinical judgement

It is important to realise that the aforementioned types of clinical judgement are functionally related
to each other. Each is an extension of the other, and they are complementary. In terms of the safety
and effectiveness of patient care, it is highly important for physicians and nurses to share, discuss,
and coordinate each other’s findings, opinions, and diagnoses through the inter-professional clinical
consultation.

Clinical consultation
Clinical consultation can take many forms. It can take place by telephone (particularly during
emergencies) or in a variety of other contexts (e.g. grand rounds, shift changes, multidisciplinary
consultation or emergency intervention team calls). The patient is the focus for all of these forms
of inter-professional clinical consultation. The goal of clinical consultation is to make clear agree-
ments concerning the patient’s care. It is obviously quite important for healthcare professionals
who consult with each other about a patient’s clinical state to speak the same language and use
the same observations, methodologies and scoring systems. Particularly in acute situations,
inter-professional clinical consultation is often conducted according to the SBAR method (situation,
background, assessment, recommendation).
How is it going?
Clinical consultation
Physician Nurse
‘How is it going with regard to the ‘How is it going with my patiënt
disease and my treatment of this patiënt?’ in terms of this disease and this treatment?’
Patiënt-centred
CARE

Figure 1 Clinical consultation between physician and nurse. Both of these practitioners have a specific
way of looking at the patient. Good professional communication is of vital importance to the patient.
Florence Nightingale, the founder of modern nursing, wrote

the manual Notes on Nursing in 1859. Amongst other propo-
sitions in this manual, she argued that ‘[t]he most important
practical lesson that can be given to nurses is to teach them
what to observe’.
Nurses should observe and know:

• which signals indicate improvement and which indicate
the opposite;
• which signals are important and which are not;
• which signals provide evidence of problems and what type
of problems.

Three basic professional skills of clinical judgement
Florence Nightingale’s vision is still in force today, more than 150 years later. A well-trained nurse
possesses well-trained basic professional skills: observation (clinical view), analysis (problem
insight) and How is it going?
communication (clinical leadership). We address these basic clinical-judgement skills in
Your vision on the clinical situation of the patient
How is it going?
greater detail in Chapter 4.
Observation
Observation
your clinical view
your clinical view
Nurses are How
expectedis itto:going?
Yourcontinuously
• be Analysis
vision on the clinical
alert situation of the patient
and vigilant to changes in the clinical state of the patient;
• identify and Analysis
interpret
your insight relevant
into problems clinical observations, taking into account the patient’s medical
background, illness/conditions, medication and treatments, as well as any desires and limits with
your insight into problems
regard toObservation
treatment;
Threefold focus of care
• be able to arrive at and substantiate a diagnosis of the complete clinical state of the patient,
your clinicalofview
of care
including any Threefold

risk focus
of death.care
of care
Evaluation
Well-being
Analysis
Evaluation
Well-being
Functions
Functions
Functioning
Functioning
Nurses are expected to be able to analyse:
Evaluation of care
• what is going well, what is at risk and what is not going well with regard to the ICF healthcare
topics and/or the ABCDE vital functions;
• any clinical problems (disorders, dysfunctions, disabilities, participation problems and inter
actions). Well-being
© ProActive Nursing
Functions
Communication
Functioning
Communication
your clinical leadership
Patient-centred
CARE
Nurses are expected to demonstrate clinical leadership and to:
Patient-centred
CARE
• share their findings in a timely manner with the relevant physician, other nurses and the patient;
• inform those involved of the patient’s clinical state, complaints and problems (using the SBAR
Communication
method); Reflection
• engageyour clinical leadership
in proactive, patient-centred thinking with regard to the actions and care that are needed
Reflection
Knowledge and skills
for specific patients and situations.
Patient-centred
CARE
Reflection

2 PATIENT-CENTRED CARE
Healthcare professionals engage in clinical judgement in order to understand the patient’s clinical
problems and provide appropriate care. This is nothing new. Healthcare is constantly developing,
however, due in part to a number of important social developments that are now widely known:
• people are becoming increasingly older (ageing and increasing frailty);
• chronic diseases are increasing (curative care is shifting towards palliative care);
• multiple morbidities (e.g. hypertension, heart failure, COPD, diabetes, dementia) are becoming
more common;
• people are working and living at home for longer (self-sufficiency in health and daily functioning);
• patient-centred care is becoming more common.
We address the latter point in greater detail in this chapter. Care is no longer considered good unless
it is ‘patient-centred’, with the patient being the ‘central focus’. In recent years, studies have inves-
tigated the opinions of patients (with conditions including heart failure, hernia’s, breast cancer,
arthritis and hip/knee surgery) with regard to healthcare. One assumption was that patients with
acute symptoms would assign less importance to patient-centred care. Such is not the case. All of
the patient groups investigated considered patient-centred care to be of above-average importance.
Patient-centred care
The patient is the starting point; a unique person with a unique history, future and goals. Getting
to know the patient and providing care customised to the patient’s wishes, involving relatives and
loved ones, maintaining control—even with regard to palliative care—and setting care goals are all
criteria for providing care that is customised to the individual wishes, needs and personal charac-
teristics of the patient.
Four areas of focus:
1. compassion: the patient experiences closeness, trust, attention and understanding.
2. uniqueness: the patient is seen as a unique person with a personal context that matters and
an individual identity that should be allowed to flourish.
3. autonomy: the patient has the possibility to exercise individual control over life and well-being,
including with regard to palliative care.
4. healthcare objectives: the patient has clear agreements with regard to objectives and
outcomes in relation to care.
Protocols and standards of care

Healthcare professionals are expected to act according to the standards of quality (guidelines,
diagnosis-treatment combinations [DTC], standards of care and protocols). These standards should
ideally be evidence-based or corroborated as best practices. In itself, the protocolisation of care in
recent decades is regarded as an important quality improvement. At the same time, however, the
realisation has emerged that, by definition, such guidelines and protocols cannot be patient-centred.
It is also important for the patient to know that protocols are not sacred. Protocols exist in order to
ensure the provision of proper, safe care. They are not intended to hinder people. Fortunately, devia-
tions from guidelines and standards are allowed, but they must be justifiable.
Context of the patient
Patient-centred or person-centred care requires care providers to do more than study the medical
history, the current disease situation, the treatment and its prognosis. They must also investigate the
various personal characteristics, personality traits, life experiences and lifestyles of their patients.
What is their outlook on life? What do these chronic (or acute) diseases and the experience of being
ill mean to their patients? What are their patients’ life goals? In which ways are their patients limited
in their functioning? Healthcare professionals combine all of this information and, most importantly,
consider what the diseases and experience of being ill mean for their patients’ well-being and quality
of life.
Desires and limits with regard to treatment

Nowadays, patients are invited to devote careful consideration to what they want in treatment and
where their limits lie. The subject of ‘limits to treatment’ can be difficult for both patients and their
care providers. It is therefore important and wise to start thinking about possible limits to treatment
as soon as possible. When people suddenly become ill and end up in the emergency room, with
unfamiliar doctors and nurses, it can be difficult for them to make clear what their desires and limits
are.
It is of the utmost importance for desires and limits with regard to treatment to be discussed,
recorded in patient files, and made known to other parties involved, including nurses and relatives.
In the event of an acute change in the patient’s clinical state, those who are responsible for the care
at that time should be aware of the patient’s desires and limits with regard to treatment.
The most important limits to treatment are listed below:

• Do not resuscitate (DNR). The question of whether or not to resuscitate is often asked when
individuals are admitted to hospitals or nursing homes. Any agreements that are made are then
documented.
• Do not intubate (DNI): do not artificially take over breathing with a respirator.
• No intensive care: no admission to the intensive care unit (ICU, e.g. for the support of blood
pressure or artificial ventilation).
• No coronary care (cardiac monitoring): no admission to the coronary care unit (CCU) for cardiac
rhythm monitoring.
• No dialysis: no renal function replacement.
• No surgery.
• No blood products: no administration of erythrocytes or platelets.
• No antibiotics: no treatment of bacterial infections.
• No tube feeding: no administration of artificial nutrition through a gastric (or other) tube.
• No invasive diagnostic procedures: no new examinations that could be burdensome.
• No hospitalisation.
• No further treatment: termination of treatment, with the exception of treatments aimed at
comfort (counteracting pain and shortness of breath). Such directives do not concern the active
termination of life (euthanasia).
Futile treatment
The discussion above might seem to imply that patients have full freedom of choice in healthcare
at all times. This is obviously relative. One important principle in the provision of care is that care
should be neither withheld nor imposed. For patients, healthcare is a right, but it cannot simply be
enforced. Any medical (or other) treatment or intervention should always be able to be justified. Such
justification should be positioned within a specific interest of the patient. Treatments that are not

(or that are no longer) in the interest of the patient are known as medically futile treatment. Unnec-
essary medical intervention is not permitted.
The following considerations can be used to assess whether treatment would be medically futile:
1. the effectiveness of the treatment: to what extent does the treatment have a positive effect on
the underlying disease?
2. the proportionality: to what extent is the severity of the treatment in reasonable proportion to the
goal that can be achieved with it?
3. will the patient be able to achieve a minimum level of functioning as a result of the treatment?
For example, a patient who is in an irreversible coma is unlikely to achieve this level.
In such cases, treatment could be medically futile. Whether an intervention is or is not medically
futile is up to the judgement of healthcare professionals. In many cases, however, there is a grey
area in which discussion with the patient or family may arise concerning the issue of medically futile
treatment.
Communication
Patient-centred care is characterised by good communication with the various care providers and
shared decision-making concerning the treatment. It is thus characterised by inter-professional
working methods. Patients consider this extremely important with regard to all treatments.
The multidisciplinary approach centres on approaching a topic or problem from a variety of

perspectives, without integrating the disciplines/fields involved. In the interdisciplinary approach,
the various fields/disciplines need each other in order to solve a problem or investigate a question.
Inter-professional cooperation takes place from within a single vision and care plan. This is in
contrast to multidisciplinary cooperation, in which the various professions work together but are
also able to work alongside each other in an organised manner.
Important: Nurses DO NOT make their own medical diagnoses, and they NEVER make their own
decisions concerning treatment plans. They nevertheless contribute critical input in considering
‘How it’s going’ with the patient and which care is needed for that specific patient.
Friendliness and participation in deliberations and decision-making

A researcher once proposed the following: ‘It apparently does not matter which health problems
patients have. They are well aware of what they consider important.’ Patients usually have a clear
image of patient-centred care, and this is always high on their list of priorities. This is not necessarily
surprising, as patients are often in a state of uncertainty and need good information in order to cope
with their health problems. Patient-centred communication contributes in this regard: healthcare
professionals should be friendly and provide a listening ear. Patients also want to feel that decisions
are not being taken behind their backs, but that they are able to participate in decision-making
concerning the treatment. Shared decision-making is a right. Physicians and nurses must therefore
allow patients space for this.
Healthcare is teamwork
Healthcare is teamwork, and clinical judgement is as well. In daily practice, physicians and nurses
collaborate very closely in the care of the patient. Medical care and nursing care should be coordi-
nated. Clinical consultation provides the foundation for teamwork in the care of the patient. It is here
that the clinical-judgement skills of the various professionals meet. Physicians and nurses engage
in intensive consultation with each other with regard to the patient’s clinical state, and they listen
carefully to each other’s substantive findings, concerns and recommendations. The goal is always to
optimise the care to be provided to the patient.
Figure 2 Healthcare is teamwork; clinical judgement is too!
Central role of nurses

Nurses play a central role in relation to a wide range of healthcare professionals. Nurses are
often very close—both literally and figuratively—to patients, with their pain, tightness of the chest,
nausea and countless other discomforts and emotions that accompany the disease, the illness
and the associated treatment or operation. Nurses are constantly (night and day; 24/7) occupied
with a wide range of care duties, administering medication, taking care of equipment lines and
wounds, performing nursing procedures and caring for, mobilising and assisting patients (who are
sometimes very ill) and their relatives. For this reason, nurses are in an ideal position to monitor the
patient’s clinical state, to engage in problem-centred thinking and to participate actively in the care
that is appropriate for the patient in question. Your clinical judgement and clinical leadership are
at the very heart of our nursing profession: safeguarding the interests of the patient and providing
patient-centred care.
Advocate for the patient

Nurses can act as ‘advocates’ for patients, particularly in situations in which they are temporarily
or permanently incapable of indicating what is or is not going well. Nurses actively consider what
is best for their patients. They apply empathic ability, professional knowledge, professional and life
experience, and clinical leadership in the interest of the patient.
Threefold focus
Every nurse has the desire to know: ‘How is my patient doing?’ Nurses approach their patients in
order to ascertain their problems and needs for care with regard to their personal well-being, bodily
functions and functioning. They do this by using patient-centred clinical judgement.

3 TIME-OUT PRACTICE
MODEL
In their daily professional practice, nurses come into contact with a wide variety of people and care
situations. This requires a great deal of flexibility. Each individual reacts to illness in a different way.
The contact between nurses and their patients is often intense and frequent. Nurses are expected
always to be able to assess ‘how things are going’ with their patients, as well as to respond appropri-
ately. This is actually the major utility of clinical judgement in professional nursing practice.
How is it going?
All types of people constantly ask each other this seemingly simple question. In ordinary inter-
action, the reaction is often likely to be, ‘Fine’, ‘Things are great’ or something else to that effect. The
question is often answered with a ‘socially desirable’ response. It is sometimes little more than a
common way to start a conversation.
In the field of healthcare, however, the question has another goal. This is because care providers
seek to obtain insight into a patient’s health status before actually providing care. Within the context
of nursing, the question ‘How is it going?’ is of the utmost importance to the course of the healthcare
process. Nurses often act as ‘patient advocates’, particularly in situations in which patients are
temporarily or permanently incapable of indicating what is or is not going well. They are in an
ideal position to fulfil this role, as they are often so close to their patients, so familiar with their
healthcare situations and trusted by patients. The ability to judge ‘how it’s going’ is at the heart of
our profession.
Clinical state
In addition to providing nursing care for the patient, nurses always have a very important moral (and
legal) responsibility to monitor the patient’s clinical state at all times. Every patient is different, and
every patient is likely to have a different reaction (both mental and physical) to the disease, as well
as to the illness and/or treatment. For this reason, nurses must always be alert and attentive to
‘how it’s going’ with their patients. Are things going well? Are things not going well? What might be
happening? What is the problem? What needs to happen? If these questions seem familiar to you, it
indicates that you are engaged in vocational clinical judgement and that you are actively putting your
professional knowledge into practice.
Time-out practice model

The Time-out2 practice model was developed for teaching and practising clinical judgement. The
development of the model was based on years of educational experimentation (field labs) and
practical experience with professional clinical judgement. The model links the basic professional
skills (observation, analysis and communication) to the threefold professional focus of healthcare:
2 ‘Time-out’ is a term used in team sports to refer to an interruption of the game for the purpose of tactical consultation.
Professional nursing practice is often characterised by hard work. Although this is fine in itself, it unfortunately often
leaves little time for bedside education and learning in general. In this book, we use the term ‘Time-out’ to indicate
that it is precisely for such teaching and learning that we should stop time. It can be highly educational and wise to
take a Time-out for thinking about the patient.

the well-being, functions and functioning of the patient. As a whole, it provides a guide for practising
with realistic case studies in order to ‘master’ clinical judgement.
Definition
Time-out is a practical tool for teaching and/or practising clinical judgement in a clear, structured
and professionally focused manner at school and/or in professional nursing practice. It is a practical
teaching tool for school-based instructors, practical instructors and students. The Time-out practice
model can be used both at school and in the workplace to discuss and learn from patient case
studies.
Objective
The Time-out practice model is a clear, structured guide for use when learning clinical judgement,
and it was developed specifically for nurses and for clinical instruction. Nurses teach clinical
judgement to each other: learning together through clinical judgement. The objective of the Time-out
practice model is to help all parties expand and strengthen their:
• Three basic professional skills: observation, analysis, communication
• Biomedical knowledge base (physiology, anatomy, pathophysiology, pharmacology, psychology)
• Healthcare insight: patient-centred care
Clinical state of the patiënt

How is it going?
Your findings as a healthcare professional
Figure 3 Time-out for clinical judgement regarding the clinical state of the patient.

How is it going?
Observation
your clinical view
Analysis
Well-being Evaluation of care

Functions
Functioning
Communication
Patient-centred
CARE
Reflection
Figure 4 Time-out is a model for teaching clinical judgement in a clear, structured and professionally
focused manner at school and/or in professional nursing practice.
Reflection
The Time-out practice model is a clear, structured guide for use when learning clinical judgement.
No learning process is complete without reflection. This is the fourth skill to be applied within
the Time-out practice model. Reflection consists primarily of asking oneself critical questions.
For this reason, it is important to ask the following after each case: what have I learned from this
situation? What should you do if you have teaching questions of your own? It is important to recall
that it may require some time to answer these questions in a self-critical and functional manner.

New knowledge can be added through reflection. The learning process is self-guided with regard to
clinical judgement. Professionalism in nursing includes the ability to discuss one’s actions in various
forms of consultation (e.g. patient meetings) or learning situations (e.g. supervision or peer review).
Reflection can help to add breadth and depth to knowledge and basic skills.
Figure 5 Reflection is looking ‘in the mirror’. Reflection is considering a healthcare situation in order to
learn from it. Give careful consideration to what you have learned, and share it with others.

4 THREE BASIC
PROFESSIONAL SKILLS
In this chapter, we provide a deeper discussion of the three basic professional skills involved in
clinical judgement: observation, analysis and communication.
How is it going?
Observation
Clinical view
Analysis
Insight into problems
Communication
Clinical leadership
Figure 6 Three basic professional skills: observation, analysis and communication in practice. Nurses
continually observe and analyse the clinical state of the patient, and they share their findings with the
patient, the physician and other nurses who are involved. The goal is always to provide well-considered
and optimised patient-centred care.
4.1 Obser vation
Nurses are expected to:

• be continuously alert and vigilant to changes in the clinical state of the patient;
• identify and interpret relevant clinical observations, taking into account the patient’s medical
background, illness/conditions, medication and treatments, as well as any desires and limits with
regard to treatment;
• be able to arrive at and substantiate a diagnosis of the patient’s complete clinical condition,
including any risk of death.
Nurses are actually engaged in professional observation during any patient contact. This is not
something that can be turned off or not done. The objective of such observation is to monitor and
diagnose the clinical state of the patient. Observation is an important foundation for describing the
clinical picture and the differential diagnoses. The clinical picture is a description of how a disease/
condition is manifested in a patient. The clinical picture can be made concrete through ‘observations
and measurements’. Many healthcare professionals refer to this as their ‘clinical view’. The trick is to
be able to express this clinical view into words clearly, correctly and unambiguously.

We have a strong tendency to interpret the question ‘How is it going?’ with one or two words. For
example, ‘...fine’ or ‘...not so great’. It can be very difficult to indicate ‘how it’s going’ with the patient
in only one or two words. The answer can sometimes be clear at first glance, but this is often not the
case. Our conclusions regarding ‘how it’s going’ refers to our own opinion of the patient’s current
situation. To this end, we should ideally use clear, unambiguous gradations, such as:
• Well
• Reasonably well
• Moderately well
• Not well
Support your findings

It is important to realise that simply noting that ‘it’s not going well’ or statements of that nature are
of little use. In most cases, very little attention is paid to such observations. Simply making such a
statement is regarded as speculative and unprofessional. Healthcare professionals are expected to
be able to formulate and provide clear argumentation for what is not going well and why. The reverse
applies as well: if someone else suspects something is wrong, you want to receive clear information
on what, how and why.
It is always best to accompany our opinions with facts, particularly within the context of healthcare.
Opinions should be supported by substantive knowledge, as well as with concrete, verifiable facts
(e.g. clinimetrics, validated scoring systems). One extremely important principle in this regard (as
expressed in an old Dutch saying) is that ‘to measure is to know’. We should speak in plain, clear
language and not lapse into assumptions or vagueness.
The following apply in practice

• Always be alert or vigilant to complaints and unfavourable signals.
• Use appropriate medical history taking methods to elicit further complaints or unfavourable signals:
SCEBS, ALTIS.
• ‘To measure is to know’: collect basic clinimetric data, if possible: respiratory rate, HR, BP, saturation and
temperature.
• If possible, assess whether there is a major difference from previous measurements.
• Use the (M)EWS score to determine whether the patient is at risk of death.
• If possible, collect recent blood values and/or data relating to specific monitoring.
• Document your findings.
Interpretation
• Interpret all clinical observations as a whole and from a patient-centred perspective. Are the observations
consistent with the patient (given the specific medical background), with the disease/condition and with
the medication used?
• Be attentive to logical and illogical combinations of outcomes (e.g. high cardiac frequency is consistent
with a high temperature).
• Reason out what might be happening: consider the differential diagnoses and a working diagnosis.
Clinical observations at five levels

‘Clinical observations’ is a collective term for a wide range of complaints, worrisome signs,
symptoms, measurements and other descriptions. There are many different observations, each with
its own specific use and value. Although some are relatively subjective, they are valuable because
of the simplicity with which they can be performed. For example, the observation of ‘colour’ is quite
subjective. At the same time, however, the colour of the skin (e.g. red, yellow, pale grey, bluish
purple) can provide a large amount of diagnostic input. Other observations are much more objective,
albeit also more invasive. The key, however, is always to interpret them as a whole and within the
context of the patient.

Clinical observations
Complaints, worrisome sings
Clinimetrics
Scoring systems
Blood values
Specific monitoring
HOW IS IT GOING?  General clinical state
Figure 7 A patient’s complete clinical state is monitored and diagnosed according to symptoms,
worrisome signs, clinimetrics, scoring systems, blood values and specific monitoring.
1. Complaints and worrisome signs

Complaints and worrisome signs are often the first noticeable expressions that ‘something’ is not
going well. Worrisome signs are not easy to measure and express in figures. Although they are often
regarded as subjective, they may be early signals of an undiagnosed underlying disease/condition,
a complication, clinical deterioration or similar factor. They are therefore important indicators that
should be taken seriously. Specific medical history taking methods are available for eliciting further
details about complaints and unfavourable signals. General medical history taking methods include
SCEBS (psychosocial interview) and ALTIS (exploration of pain complaints). These methods are
described in Part II of this book.
Worrisome somatic signs Worrisome mental signs

Audible respiration Itching Gloominess Histrionic attitude
Inability to speak in full Oedema Listlessness Rejection of assistance
sentences Abdominal swelling Apathy Complaining
Shortness of breath/ Decreased appetite Anxiety Self-absorption
tightness in the chest Weight loss Anger Dependence
Use of accessory Vomiting Threatening attitude Inhibition
respiratory muscles Diarrhoea Overstrained attitude Compulsivity
Coughing; productive Constipation Desperation Monotonous attitude
Cyanosis Stroke symptoms Agitation Activity
Chest pain Chills Confusion Regression
Pale grey colour Fever Tormented attitude Withdrawn attitude
Dizziness Cold extremities Insensitivity Delirium
Fainting Petechiae Suspicion Grogginess, sleepiness,
Bruising Dry skin turgor Lack of inhibition sluggishness
Easily fatigued; exhausted Dark urine Euphoria Forgetfulness
Perspiration/clammy skin Malodorous urine Dysphoria Eccentricity
Congested cervical veins Urinary incontinence
Increased bleeding Jaundice
tendency
Muscle cramps
Pain
Table 2 Examples of worrisome somatic and mental signs.

Worrisome signs from the environment
A large amount of information can also be ‘read’ from the patient’s immediate surroundings.
Examples could include neglect of housekeeping (food scraps, unwashed dishes, odour, garbage,
dirty clothes) and maintenance to the home and garden; excessive supply of a specific item and not
enough of the rest (hoarding); and an environment that is stressful, too cold, too warm, unhealthy,
hazardous or threatening. All of these types of signals could indicate underlying clinical problems.
2. Basic clinimetrics
Clinimetrics are observations that serve as objective measurements/findings to which numerical
values can be assigned. To measure is to know. We understand basic clinimetrics as the standard
measurements that provide a relatively simple way to chart the state of the vital bodily functions.
These clinimetrics are described in detail in Part II of this book.
Basic clinimetrics What do we want to see?

AVPU reaction pattern Alert
Respiratory frequency 12–14/minute
Saturation – SpO2% >95%
Arterial blood pressure (BP) 120/80 mmHg
Systolic pressure 110–140 mmHg
Diastolic pressure 70–85 mmHg
Average pressure (MAP) 60–90 mmHg
Pulse pressure 40–50 mmHg
Cardiac frequency 60–100/minute
Pulsations Regular
Cardiac rhythm Sinus rhythm
Diuresis 1 ml/kg/hour
Capillary refill time 2–3 seconds
Core temperature 36.5–37.5°C
Table 3 Basic clinimetrics.
3. Scoring systems
Scoring systems are usually extremely useful instruments for assessing and quantifying highly
specific observations in a clear, methodical manner. Some apply to highly specific situations, while
others are intended for more general use. Inter-professional validation is nevertheless always
important. A large number of these scoring systems are described in Part II of this book.

(M)EWS Early Warning Score
Score 3 2 1 0 1 2 3
Respiratory frequency <9 9-14 15-20 21-30 >30
Cardiac frequency <40 40-50 51-100 101-110 111-130 >130
Systolic pressure < 70 70-80 81-100 101-120 >200
Consciousness 😵 A V P U
Temperature <35.1 35.1-36.5 36.6-37.5 >37.5
😵
A = Alert V = Responds to verbal stimulus P = Responds to pain stimulus U = Unresponsive to verbal or
pain stimulus
= Acute confusion or agitation
If saturation < 90% despite therapy: 3 points

If urine production < 75 ml in the past 4 hours: 1 point
If worried about the clinical state: 1 point
> 3 POINTS INDICATES A VITALLY THREATENED PATIENT
Figure 8 The (M)EWS score is used to determine the degree of illness based on vital signs.
A few examples of specific scoring systems:

• Numeric Rating Scale (NRS) or Visual Analogue Scale (VAS; pain score)
• (M)EWS Early Warning Signs for patients at risk of death
• (Modified) Early Obstetric Warning System ([M]EOWS)
• Glasgow Coma Scale (GCS)
• Systematic inflammatory response system (SIRS) criteria (sepsis)
• qSOFA and SOFA (sepsis prognosis)
• Delirium Observation Scale (DOS) score
• Short Nutritional Assessment Questionnaire (SNAQ) score (nutritional state)
• APGAR score (newborns)
• Paediatric Early Warning Signals (PEWS)
• Modified Aldrete score (Post Anaesthetic Care Unit/PACU discharge criteria)
• Richmond Agitation and Sedation Scale (RASS; ICU)
• Confusion Assessment Method (CAM-ICU)
4. Blood values
Blood values are the outcomes of a blood test. In a blood test, a sample of blood is taken, usually by
venepuncture or finger prick, and analysed in a laboratory. The results are of important diagnostic
value. Blood values are often divided into three categories: haematology, clinical chemistry and the
arterial blood gas analysis. All of these blood values are described in Part II of this book.

Haematology Reference value Description
Haemoglobin (male) 8.5 – 11.0 mmol/L Protein in erythrocytes, oxygen transport
Haemoglobin (female) 7.5 – 10.0 mmol/L Protein in erythrocytes, oxygen transport
Haematocrit 0.40 – 0.50 Percentage of cells in plasma
HbA1c < 53 mmol/mol (< 7%) Hb saccharification
Erythrocyte count (male) 4.5 – 6.0 x 10-12/L Red blood cells, oxygen transport
Erythrocyte count (female) 3.9 – 5.4 x 10-12/L Red blood cells, oxygen transport
MCV 80 – 100 fl Average cell volume of erythrocytes
Reticulocyte count 25 – 110/nl New erythrocytes
Leukocyte count 4.0 – 10.0 x 109/L White blood cells, defence function
Thrombocyte count 150 – 400 x 109/L Platelets, coagulation
INR/ PT 0.8 – 1.2 Coagulation test, coumarin use
APTT 22 – 33 seconds Coagulation test
Fibrinogen 2 – 4 g/L Coagulation test
D-dimer < 500 µg/L Coagulation test
CRP < 10 mg/L Acute phase protein, infection parameter
BSE < 15 mm/hour Sedimentation rate, infection parameter
Arterial blood gases Reference value
pH 7.35 – 7.45 Acidity
pCO2 35 – 45 mmHg Carbon dioxide tension
Bicarbonate 22.0 – 26.0 mmol/L Electrolyte and acid buffer
pO2 75 – 100 mmHg Oxygen tension
SaO2 > 95% Arterial oxygen saturation Hb
Clinical chemistry Reference value
Sodium 135 – 145 mmol/L Electrolyte, positive ion
Potassium 3.6 – 5.1 mmol/L Electrolyte, positive ion
Calcium 2.20 – 2.60 mmol/L Electrolyte, positive ion
Chloride 98 – 108 mmol/L Electrolyte, negative ion
Bicarbonate 22.0 – 26.0 mmol/L Electrolyte, negative ion, acid buffer
Fasting glucose 3.0 – 6.0 mmol/L Carbohydrate, energy source
Glucose after meal 4.0 – 10.0 mmol/L Carbohydrate, energy source
Osmolarity 280 – 300 mOsmol/kg Crystalline osmotic pressure
Albumin 35 – 50 g/L Blood protein, colloidal osmotic pressure
Total protein 65 – 80 g/L Total volume of plasma proteins
Creatinine (male) 65 – 110 µmol/L Muscle metabolism degradation product
Creatinine (female) 50 – 100 µmol/L Muscle metabolism degradation product
Urea 3.0 – 7.0 µmol/L Protein metabolism degradation product
eGFR > 90 ml/minute/1.73m2 Glomerular filtration rate
ASAT < 40 U/L Non-specific enzyme
ALAT < 45 U/L Hepatic enzyme
Gamma GT < 50 U/L Hepatic enzyme, bile ducts
Alkaline phosphatase < 35 – 120 U/L Hepatic enzyme, bile ducts, bone
Amylase < 100 U/L Pancreatic enzyme
LDH < 250 U/L Hepatic enzyme
CPK < 200 U/L General enzyme, non-specific
CKmb < 10.0 µg/L Cardiac muscle enzyme
Bilirubin < 20 µmol/L Bile pigment, Hb degradation product
Troponin (1 of T) < 0.1 (I)/ < 0.3 (T) µg/L Cardiac muscle marker
NTproBNP < 740pg/ml Cardiac muscle hormone
Lactate < 2.2 mmol/L Acid residue
Table 4 Important blood values and their reference values used in the Netherlands.

5. Detailed and specific monitoring
A patient monitor is used for the intensive and continual monitoring of patients. For example, it can
be used to monitor vital signs in patients during and after surgery or in the medium care or intensive
care unit, but it is increasingly being used in common care and outpatient settings as well. The
patient monitor can be used to determine multiple functions and values at the same time, with their
values appearing on a colour display. To obtain these vital functions, the patient is connected to the
monitor by sensors and meters (e.g. a blood pressure cuff, ECG cable or SpO2 finger sensor). In an
intensive care unit, the patient’s blood pressure can also be monitored in an invasive manner using
an ‘arterial line’. The settings on the monitor are customised for each patient. The device issues an
alarm if the heart rate, blood pressure or oxygen level exceeds or falls below the set value. Many of
these forms of monitoring are described in Part II of this book.
Figure 9 Detailed invasive monitoring of the vital functions: in figures and along a curve.
Some specialisations have their own specific observations. A few examples:

• neurological observations;
• dialysis observations;
• obstetric observations;
• cardiological observations (cardiac rhythm monitoring);
• haemodynamic profiles (invasive blood pressures, ICU);
• ventilation parameters (ICU);
• NIDCAP parameters (NICU).

4.2 Analysis
Nurses are expected to be able to analyse:

• what is going well, what is at risk and what is not going well with regard to the ICF healthcare
topics and/or the ABCDE vital functions;
• any clinical problems (disorders, dysfunctions, disabilities, participation problems and interac-
tions).
Seeing a problem is the first step towards resolving it. For patient problems, although it is tempting
to start considering possible solutions immediately, it is much better to start by considering the
problem itself. What is actually happening? Which interactions can be observed? Suitable, patient-
centred solutions cannot be proposed until after a thorough problem analysis.
Problem overview
The International Classification of Functions (ICF) developed by the WHO is used to provide clear
insight into the clinical state of patients. The ABCDE method is used for patients who are at risk
of death. The bodily functions are listed in the ABCDE order in figure 10. Taken together, it forms a
dashboard for the clinical state of the patient in question. What is going well, what is not going well
and what is in danger? Where are the clinical problems, disorders and disabilities situated? How are
the problems interacting favourably or unfavourably with each other?
Figure 10 The clinical state dashboard; the traffic light system provides a simple way to create an
overview of problems.

The clinical state dashboard is divided into the three focal points of patient-centred care: well-being,
bodily functions and patient functioning. We refer to this as the ‘threefold focus of care’. The specific
healthcare topics are listed beneath each column. All of these healthcare topics are obviously not
independent. A large amount of interdependence is involved in proper functioning, as well as in
dysfunctions (interactions) within these healthcare topics.
Interactions
A proper, thorough analysis can sometimes provide surprising insights into the interrelatedness
of the problems, disorders, dysfunctions, limitations and participation problems. Such insight
can ultimately lead to care that is customised to specific individuals. Interactions can be either
favourable (compensation mechanisms) or unfavourable (problem-reinforcing). The interactions are
often dynamic, specific, and not always in a predictable one-to-one relationship. Interactions can
take place in all directions (cross-links). The clinical problems that are present should therefore be
analysed within the context of their inter-relationships whenever possible, as well as with regard to
their potentially favourable or unfavourable effects.
How is it going?
With the patient
Given the patient’s unique history,
future and objectives
Personal What are the problems Bodily What are the problems
Functioning
well-being What are the interactions functions What are the interactions
Patiënt-centred
CARE
Figure 11 The three focal points in healthcare together form a trinity, and they should be approached as
such. A clinical problem within a given healthcare topic will eventually have an effect on another problem.
Insight into the mutual interactions is of major importance to patient-centred care.
The following apply in practice:

• Use the ICF healthcare topics to create an overview. This is done by reviewing all of the healthcare topics
and indicating where problems can be observed (or predicted).
• Thereafter, formulate what the problem, disorder, functional problem or disability is.
• Carefully consider the picture as a whole and any mutual interactions amongst the problems.
• Make a note of your findings.
What is the problem?

It is not enough simply to state what is going well and what is at risk or not going well. Nurses are
expected to be able to provide insight into the problem. In other words, they should be able to provide
a clear, concise formulation of ‘what’ the problem or danger is.
The patient problems associated with these healthcare topics can be formulated in several different
ways. The goal is to arrive at a short, concise statement of the problem. It should be able to be
understood by others. Avoid jargon and a multitude of unnecessary abbreviations. The inventory and

formulation should ideally be based on available knowledge. This book can also be consulted for
inspiration. In Part II of this book, all of the ICF healthcare topics are accompanied by descriptions of
a large number of problems, disorders, dysfunctions, disabilities and diseases that could be helpful
in the process.
The following sources could also be used:

• Carpenito’s Handbook of Nursing Diagnosis. One disadvantage of this resource is that the
diagnoses are arranged alphabetically and not according to healthcare topic. Another disad-
vantage is that the diagnoses are not formulated in an inter-professional manner.
• Nationale Kernset Patiëntproblemen [National Core Set of Patient Problems] (in Dutch).3
4.3 Communication
Nurses are expected to demonstrate clinical leadership and to:

• share their findings in a timely manner with the relevant physician, other nurses and the patient;
• inform those involved with regard to the patient’s clinical state, complaints and problems (using
the SBAR method);
• engage in proactive, patient-centred thinking with regard to the actions and care that are needed
for specific patients and situations.
In daily practice, nurses regularly engage in consultation concerning the clinical state of the patient.
Clinical consultation can take many forms. It can take place by telephone (particularly during
emergencies) or in a variety of other contexts (e.g. grand rounds, shift change, multidisciplinary
consultation, emergency intervention team calls). The patient is the focus for all of these forms of
inter-professional clinical consultation. The goal of clinical consultation is to make clear agreements
concerning the patient’s care.
Inform and inspire each other

Think carefully in advance. Good communication also involves thinking carefully about who, when
and where, as well as how to provide others with concise, concrete and respectful information about
‘how it’s going with the patient’ and ‘what the problem is (or might be)’. In acute situations, inter-pro-
fessional clinical consultation in acute situations is often conducted in the form of the SBAR method
(situation, background, assessment, recommendation). Consultation moments often proceed much
more clearly, pleasantly and efficiently when both the sender and receiver are familiar with the
situation.
Think together proactively

As nurses, we are often close to the patient, and we are therefore in an ideal position to monitor
the clinical state, to engage in problem-centred thinking and to participate actively in the care that
is appropriate for the patient in question. Your clinical judgement and clinical leadership are at the
very heart of our nursing profession: providing patient-centred care. Nurses act as ‘advocates’
for patients, particularly in situations in which they are temporarily or permanently incapable of
indicating what is or is not going well. Nurses actively consider what is best for their patients.
They apply empathic ability, professional knowledge, professional and life experience, and clinical
leadership in the interest of the patient.
3 The Nationale Kernset Patientproblemen [National Core Set of Patient Problems] is intended to provide a single
language within the nursing and healthcare sectors in the Netherlands. This core set consists of patient problems,
interventions, healthcare results, observations and measurement tools. It is available (in Dutch) at www.nictiz.nl.

The following applies in practice:
• Consider what you would like to discuss with whom, when and where.
• Consider whether this discussion can take place by telephone (particularly during emergencies) or in any
of a variety of other contexts (e.g. grand rounds, shift change, multidisciplinary consultation, emergency
intervention team calls).
• Inform other healthcare professionals using the SBAR method.
• Think together. Ask concrete questions and make concrete proposals.
• Document the consultation and any agreements that have been made.
Five categories of recommendation

The fact that you have identified problems in a patient does not mean that you must or can solve all
of these problems personally. Thinking together with others also involves the ability to propose the
expertise of other healthcare professionals. For purposes of inspiration, the proposals—recommen-
dations—that can be made are divided into five categories: supplementary testing, interventions,
consultation, counselling and relating to self-reliance.
1. Think together and make recommendations relating to supplementary testing

Examples could include:
• asking supplementary medical history questions (e.g. based on ALTIS, SCEBS or AMPLE);
• performing physical examination/observation (e.g. looking, measuring, listening, feeling the head,
neck, thorax, abdomen, back or extremities);
• maintaining specific scoring lists (e.g. SNAQ, DOS, Lastmeter, ADL, EMV, Ramsey);
• laboratory tests (e.g. blood, sputum, cerebrospinal fluid, mucus, faeces, urine, wounds);
• imaging tests (e.g. X-ray, ultrasound, CT scan);
• physical-diagnostic tests (e.g. ECG, EEG, endoscopy, Doppler, scans).
2. Think together and make recommendations relating to interventions

Indicate the specific form of intervention and whether the action in question should be started,
stopped, adjusted or continued.
• airway management/resuscitation techniques;
• ventilation;
• oxygen therapy;
• intravenous therapy;
• pharmacotherapy;
• pain medication or pain treatment;
• posture/position;
• catheters/tubes/drains;
• nutrition/diet/fluid policy;
• wound policy/bandages;
• bed sores policy;
• mobilisation (or immobilisation) policy with/without assistive devices;
• heat/cold management;
• insulation/barrier/reverse insulation;
• blood products (erythrocytes/plasma/thrombocytes);
• renal function replacement therapy;
• extensive controls every ... minutes or every ... hours;
• admission/transfer/discharge;
• sedation or palliative sedation;
• psychotherapy;
• other.

3. Think together and make recommendations relating to consultation with other healthcare
professionals
• physician, medical specialist;
• rapid response team;
• pain team;
• nursing specialist;
• specialised nurse;
• medical social worker;
• midwife;
• lactation consultant;
• physiotherapist;
• occupational therapist;
• dietician;
• hygienist;
• educational specialist;
• interpreter;
• spiritual advisor (e.g. pastor, imam, counsellor, priest, rabbi);
• other.
4. Think together and make recommendations relating to well-being

• psychosocial guidance/empathic support;
• medication;
• tender loving care (TLC);
• other.
5. Think together and make proposals relating to self-reliance and functioning

• information/advice/instructions;
• encouragement (e.g. by making recommendations, indicating, giving advice);
• support (e.g. through treatment, techniques, therapy, assistive devices, pain medication);
• involving informal carers;
• other.

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International Classification of Functioning, Disability and Health
The titles, terminology and substantive information used in this book are applied largely in
accordance with the ICF, the Dutch translation of the International Classification of Functioning,
Disability and Health. Bilthoven: WHO-FIC Collaborating Centre/RIVM.
Internet
In addition to literature, we made frequent and grateful use of the internet. Despite many reserva-
tions concerning the reliability of the information, when used critically, the internet has time and
again proven to be a fantastic, inexhaustible source of information. Google and Wikipedia were
particularly indispensable in the preparation of this book. Despite copyrights, it will not be long
before the contents of this book appear on the internet, thereby closing the circle.
The Time-out practice model was developed based on:

Problem-based training, Experiential learning, Reflection, Korthagen, 70-20-10, Entrustable Profes-
sional Activity (EPA)-based education, Inter-professional Education (IPE), Team-based learning
(TBL), The will to know, Socratic dialogue, Social constructivism, Self-determination theory (SDT),
Beroepscode Verpleegkundigen [Code of Conduct for Nurses], Beroepsopleidingsprofiel verpleeg-
kundigen [Job-training profile for nurses] and Notes on Nursing by Florence Nightingale.
PART II
INSIGHT INTO
CLINICAL
PROBLEMS
Well-being
Functions
Functioning
TABLE OF CONTENTS PART II

Mind maps 57
Healthcare topic 1 Well-being59
Healthcare topic 2 Mental functions 79
Healthcare topic 3 Sensory functions and pain 123
Healthcare topic 4 Voice and speech 145
ABC Vital functions

Healthcare topic 5 Respiratory tract 159
Healthcare topic 6 Respiration175
Healthcare topic 7 Circulation209
Healthcare topic 8 Oxygen supply to the heart 285
Healthcare topic 9 Urinary system 305
Healthcare topic 10 Blood333
Disability functions
Healthcare topic 11 Nervous system 389
Healthcare topic 12 Musculoskeletal system 429
Healthcare topic 13 Endocrine system 451
Exposure functions
Healthcare topic 14 Thermoregulation 481
Healthcare topic 15 Skin and immune system 503
Healthcare topic 16 Digestive functions 541
Healthcare topic 17 Reproductive functions 573
Healthcare topic 18 Functioning and self-reliance 641

Index661
INSIGHT INTO CLINICAL
PROBLEMS
Clinical problems constitute the whole of mental, social and/or physical dysfunctions, disabilities,
interactions, complications, discomforts and hardships that a patient may experience, be required
to learn to live with and/or might potentially die from. Clinical problems can emerge from a disease/
condition, as well as from the associated medical policy or the individual person.
Insight into problems: a basic professional skill
The ability to properly identify and analyse a patient’s clinical problems is an important basic profes-
sional skill for nurses. The International Classification of Functions (ICF) developed by the World
Health Organisation (WHO) is used to provide clear insight into the clinical problems of patients.
The ABCDE method is used for patients who are in vital danger. The bodily functions are listed in
the ABCDE order in the figure below. Taken together, it forms a dashboard for the clinical state of
the patient. What is going well, what is not going well and what is at risk? Where can the problems,
disorders and disabilities be predicted? How are the problems interacting favourably or unfavourably
with each other?
Dashboard of the clinical state of Kim (25). This example provides an overview of Kim’s clinical problems.
The healthcare topics with red dots are those that she sees as problematic areas in her life with cystic
fibrosis, the PEG tube and the oxygen tank.

International Classification of Func tions (ICF)
The International Classification of Functioning, Disability and Health (ICF) is an inter-professional

classification that makes it possible to describe human functioning and any problems that people
may experience in this regard. The ICF is accepted in 192 countries, including the Netherlands.
It is managed by the World Health Organization (WHO). The ICF provides an international, inter-
professional classification and standard language for describing an individual’s functioning from
three different perspectives:
1. The human being as an organism: for describing the bodily functions, anatomical characteristics
and disorders of the various parts of the body.
2. Human functioning: for describing what individuals do or can (still) do themselves, which activities
they perform and which limitations they encounter in doing so.
3. Participation: for describing whether individuals are able to participate in all areas of social life,
their actual participation and any problems that they encounter in this regard.
A few concepts for use with the ICF:

• Functions: physiological and mental characteristics of the human organism.
• Disorders: clinical problems in the form of abnormalities in or loss of functions and anatomical
characteristics.
• Disabilities: difficulties that an individual has with regard to functioning and performing
activities.
• Participation problem: a problem with an individual’s functioning or participation in social life.
ProActive Nursing uses the ICF as a guide for clinical judgement aimed at obtaining insight into
the clinical state and problems of our patients. The following dashboard is based on the ICF
classification. Several bodily functions are presented in the order of the ABCDE method.
The dashboard is divided into the three focal points of care: well-being, bodily functions and patient
functioning. We refer to this as the ‘threefold focus of care’. The specific healthcare topics are listed
beneath each column. All of these ICF healthcare topics are obviously not independent. A large
amount of interdependence is involved in proper functioning, as well as in dysfunctions (inter-
actions) within these healthcare topics. In vulnerable people with disruptions, well-being, bodily
functions and functioning will eventually become compromised. Diseases, conditions and/or injuries,
whether acute or chronic, usually have many negative consequences. It is of critical importance
for both caregivers and patients to see ‘how’, ‘where’, ‘when’ and ‘why’ these problems, dysfunc-
tions, disorders and impairments may occur. Only then can they be prevented or approached from
a patient-centred perspective.

18 HEALTHCARE TOPICS
In Part II of this book, the eighteen healthcare topics are described: what they entail and what the
Clinical focus points or problem areas are.
WELL-BEING Healthcare topic 1

Well-being refers to the extent to which an individual feels well
mentally, physically and socially. In addition to feeling good about
oneself, well-being involves being healthy and satisfied with
one’s life. Well-being is the personal, subjective measure of the
quality of life.
Clinical focus points:
1. feeling well/comfortable;
2. coping;
3. quality of life.
MENTAL FUNCTIONS Healthcare topic 2

The mental functions are located in the brain. They include
general mental functions (e.g. consciousness, sleep, energy
and drives), as well as specific mental functions (e.g. memory,
language, arithmetic and higher cognitive functions).
1. general mental functions;
2. specific mental functions.
SENSORY FUNCTIONS Healthcare topic 3

The sensory functions exist for the purpose of registering a wide
AND PAIN
range of stimuli in the environment. If they are strong enough,
these stimuli proceed to the nervous system, where they are
processed and assigned meaning. The sensory organs, nervous
system and muscles thus cooperate to ensure proper control,
movement or communication.
1. sensory functions;
2. pain.
VOICE AND SPEECH Healthcare topic 4
The voice is the sound that is made with the vocal folds. Inhaled
air flowing into the throat first passes the larynx, with the vocal
folds. The air moves through the larynx and makes the vocal
folds vibrate. This results in sound, making it possible to speak
and sing. What and how something is said or sung is captured
with the sense of hearing. The voice could also be regarded as
the ‘transport vessel of the mind’.
1. speech production;
2. speech muscles;
3. larynx;
4. vocal usage;
5. speech perception.
ABC vital func tions
The ABC vital functions consist of the primary life functions, including the following: airways,
breathing and circulation. Secondarily, it also involves the oxygen supply to the heart, the urogenital
functions (including the fluid and electrolyte balance) and the blood.
RESPIRATORY TRACT Healthcare topic 5

The respiratory tract is the continuously open connection
between the external air and the alveoli. Inhaled air flows in and
out through the upper respiratory tract: the nasal cavity or the
oral cavity, the pharynx, the larynx and the trachea. The trachea
splits into the lower respiratory tract: the main bronchi, many
smaller bronchi and the bronchioli. These structures transport
air from and to the alveoli.
1. upper respiratory tract;
2. lower respiratory tract.
RESPIRATION Healthcare topic 6

Breathing is the active inhalation and passive exhalation of air
through the working of muscles. Oxygen is taken up as required
by the metabolism, and the carbon dioxide that has been
produced is excreted. Respiration adapts continuously to three
variables: the activity factor, the stress factor (infection, trauma,
disease) and body temperature.
1. respiratory stimulus;
2. respiratory activity;
3. gas exchange;
4. pulmonary blood supply.

CIRCULATION Healthcare topic 7
Circulation is the active pumping and distribution of blood
through the work of the cardiac muscles. It consists of the heart
and an extremely dense network of blood vessels, venules and
major veins. The left heart pumps blood through the aorta,
arteries and arterioles towards the capillary networks of the
organs, providing the cells with food and oxygen, in addition
to transporting waste (e.g. carbon dioxide) as venous return
through the right heart and to the lungs.
1. venous supply;
2. cardiac rhythm;
3. pump function;
4. arterial vascular system;
5. microcirculation.
OXYGEN SUPPLY TO Healthcare topic 8

The cardiac muscle continuously needs a large amount of
THE HEART
oxygen in order to perform. The supply of oxygen and the amount
of oxygen that the cardiac muscle (myocardium) needs must
therefore be constantly in balance. The blood supply to the
myocardium is provided by the three major coronary arteries: 1)
LAD, 2) RCA and 3) LCX.
1. oxygen supply;
2. demand for oxygen.
URINARY SYSTEM Healthcare topic 9

The body has a continual need for water, along with the
substances that are dissolved in it (e.g. electrolytes). The body
is composed predominantly of water, which must constantly be
refreshed. The body’s water-salt balance is intended to maintain
a constant level in the total volume of water, the total volume of
electrolytes and the ratio between them.
1. intake and requirement;
2. osmolarity;
3. total water mass;
4. renal functions;
5. micturition.
BLOOD Healthcare topic 10
Blood is a liquid organ that is found everywhere in the body and
that serves a particularly important function in transporting
oxygen, nutritional substances, hormones, carbon dioxide, heat
and other substances. Blood consists of two main components:
water and cells.
1. blood volume;
2. acid-base balance;
3. oxygen transport;
4. coagulation;
5. blood values.
Disabilit y func tions
NERVOUS SYSTEM Healthcare topic 11

The nervous system has a coordinating role in the processing of
external and internal sensory stimuli, as well as in the general
and specific mental processes, the control of the skeletal
muscles, the coordination of movement and the control of the
internal organs.
1. central nervous system;
2. peripheral nervous system.
MUSCULOSKELETAL Healthcare topic 12

The locomotor system is the entirety of bones, joints, muscles
SYSTEM
and tendons. The skeletal muscles are controlled by the nervous
system through peripheral nerves. With regard to movement, a
distinction is made between voluntary movement and reflexive
movement.
1. neuromuscular control;
2. skeletal muscles;
3. bones, tendons and joints;
4. motor functions.
ENDOCRINE SYSTEM Healthcare topic 13

Hormones are chemical substances that have widespread
effects on organs and tissues. For example, they can either
stimulate or inhibit organ function. Hormones are transported
by the blood and broken down in the liver and/or excreted in the
urine. They play a major role in the long-term and slow mainte-
nance of homeostasis.
1. central regulation;
2. lower endocrine organs;
3. target organs.

E xposure func tions
THERMOREGULATION Healthcare topic 14

Maintaining a constant body temperature is of vital importance.
In the metabolic process, the production of energy results in the
release of a large amount of heat into the body cells, and this
heat must subsequently be dissipated. A wide range of bodily
processes (e.g. enzyme processes, coagulation, oxygen binding,
muscle contraction) are optimised at a temperature of 37°C.
1. heat production;
2. heat release.
SKIN AND IMMUNE Healthcare topic 15

The immune system is the body’s defence system, which is
SYSTEM
intended to fight invaders, as well as the body’s own cells if
they have been altered (e.g. cancer cells). The skin and mucous
membranes (mucosa) form physical barriers against pathogenic
micro-organisms. These pathogens contain antigens, which can
be recognised by leukocytes, which can subsequently disable
pathogens.
1. skin and mucous membranes (1st line);
2. innate immune system (2nd line);
3. adaptive immune system (3rd line).
DIGESTION Healthcare topic 16

Digestion is a complex process that starts in the mouth and
ends in the rectum. The duration of digestion varies from 24 to
72 hours, depending on what has been eaten. During digestion,
food is converted into carbohydrates, proteins and fats. The other
substances that remain are broken down and eliminated.
1. intake and requirement; 4. absorption;
2. breakdown and digestion; 5. processing;
3. transport; 6. defaecation.
REPRODUCTION Healthcare topic 17

The reproductive system consists of the genital organs and
the reproductive hormones, which cooperate for purposes
of reproduction. Sexual intercourse between a man and a
woman can result in the fertilisation of an egg cell, which can
subsequently result in a pregnancy. After a full-term pregnancy
of approximately 40 weeks, the mother and the child are ready
for childbirth.
1. sexuality; 4. childbirth;
2. becoming pregnant; 5. recovery.
3. pregnancy;
FUNCTIONING > Healthcare topic 18
‘Activities and participation’ provide a reflection of functioning
ACTIVITIES AND
in daily life. Activities are elements of a person’s actions,
PARTICIPATION and participation consists of taking part in life within society.
Self-reliance literally means ‘the ability to rely on oneself’ in
daily life. There are nine categories of human functioning.
Clinical categories:
1. learning and the application of knowledge;
2. general tasks and requirements;
3. communication;
4. mobility;
5. self-care;
6. housekeeping;
7. interpersonal interactions and relationships;
8. important domains of life;
9. societal, social and civic life.

MIND MAPS
Mind maps containing the appropriate clinical focus points have been created for each of the ICF/
ABCDE healthcare topics. These maps can be used to help provide insight into clinical problems.
Mind maps
The mind maps are actually summaries of clinical knowledge concerning the relevant healthcare
topics. A mind map is constructed of the clinical focus points that reflect each of the main points.
These clinical focus points should be regarded as checkpoints in determining ‘how it’s going’
with the patient with regard to a specific healthcare topic. The clinical focus points are numbered
and presented from top to bottom in a specific physiological order. Important comments on that
specific point of interest are presented to the right. The mind maps do not provide any exact choices,
answers or ready-made diagnoses. It is always necessary to be able to understand the problem and
articulate it well, using the correct terminology. This requires a lot of practise and mental energy. Do
not be discouraged. People learn by doing.
Breathing is the active inhalation and passive exhalation of air through muscle activity. Oxygen is taken up
to the needs of the metabolism, and the carbon dioxide that has been produced is excreted. Respiration
Respiration adapts continuously to three variables: the activity factor, the stress factor (infection, trauma, disease) and
body temperature.
How is it going → what is going well, what is at risk and what is not going well?
Brainstem → Sensitive to pCO2 - pH - pO2 and emotions

Medulla oblongata → Regulates respiratory frequency and depth
1. Respiratory stimulus Phrenic nerve → The spinal cord nerve (C2–C4) controls the diaphragm
Diaphragm → Accounts for 70% of alveolar ventilation

2. Respiratory activity Intercostal muscles → Increases alveolar ventilation during exertion
Accessory respiration → Increases alveolar ventilation during respiratory distress
3. Gas exchange Alveolocapillary → Diffusion of CO2 > from blood to alveoli

membrane → Diffusion of O2 > from alveoli to blood
Pulmonary circulation → Heart > blood through lungs to left heart Alveolar
4. Pulmonary blood supply → V/Q ratio = 1:1 > saturation >95% ventilation
Ventilation-perfusion
V/Q mismatch → Shunting or dead space ventilation
Alveolar gas exchange

Diffusion > CO2 first out of blood and then O2 into blood
The mind map is a tool for assessing ‘how it’s going’ in terms of respiration. The four clinical focus
points for respiration are displayed on the far left. The relevant blocks contain further important
details, and the grey blocks explain why these details are so important.
Mind maps 57
Chapter 1 Clinical focus points
In Chapter 1, the mind map is used to explain the physiological issues relating to ‘respiration’, as well
as how they operate (or how they are supposed to operate). In this case, the issues are as follows:
1. Respiratory stimulus
2. Respiratory activity
3. Gas exchange
4. Perfusion
Chapter 2 Clinical problems
This chapter provides an inventory of possible clinical problem situations associated with respi-
ration. The problem is ordered according to the six Clinical focus points of the mind map. Note: The
issues are merely overviews of problems, disorders, dysfunctions and/or disabilities. These lists can
never be exhaustive. The possible causes (aetiology) of these clinical problem situations or dysfunc-
tions are presented as much as possible.
Chapter 3 Clinical obser vations
Chapter 3 provides an overview of clinical observations—signals that are relevant to diagnosing

the situation (in this case, with regard to respiration). For a few healthcare topics (e.g. respiration),
specific parameters are highlighted. In the case of respiration, this applies to saturation.
Chapter 4 A few clinical situations
Chapter 4 contains examples of commonly occurring and/or relevant situations with severe dysfunc-
tions (in this case, with regard to respiration).

1
HEALTHCARE
TOPIC
WELL-BEING

HEALTHCARE TOPIC 1
WELL-BEING
Well-being refers to the extent to which an individual feels mentally, physically and socially well, fine,
pleasant or comfortable. In addition to feeling good about oneself, well-being involves being healthy and
Personal
Well-being
satisfied with one’s life. Well-being is also a personal, subjective measure of the quality of life.
How is it going → what is going well, what is at risk and what is not going well?
A number of important aspects of ‘feeling well, fine, pleasant or comfortable’:
• Absence of complaints: no pain, cramping, itch, chills, hunger, thirst, shortness of breath, dizziness, nausea etc.
• Security: feeling secure, safe, welcome
• Eating/drinking: feeling satisfied, satiated; savouring food
• Personal hygiene: feeling clean, dry and content
• Mobility: able to move and get around smoothly
• Rest/sleep: feeling well-rested, fit, energetic
• Mood: feeling happy, cheerful, not stressed
• Cognitive: clear-minded, not confused; feeling heard and understood
1. Feeling well/comfortable • Company: not feeling lonely; experiencing friendship; having contact; experiencing family ties
• Identity: being able to express who one is: gender, spirituality, culture
• Treatment: dignified, respectful, equal
• Intimacy: able to share one’s deepest thoughts and feelings
• Autonomy: being in control, independent and self-sufficient
Coping is the manner in which individuals manage situations, problems, events, thoughts and feelings. There is
2. Coping no right or wrong manner of coping. People often apply a combination of coping styles.
Coping styles: 1. active problem solving; 2. seeking social support; 3. avoidance and passive expectancy; 4.
palliative/distractive responses; 5. depressive reaction patterns; 6. expressing emotions; 7. wishful thinking
and comforting cognitions.
Quality of life is a subjective concept. It concerns how people experience their physical, psychological and social
functioning. It may also include objective aspects (e.g. the limitations experienced as a result of illness).
3. Quality of life ‘Satisfaction’ is an indicator of the quality of life. It consists of three components: satisfaction with life,
satisfaction with physical health and satisfaction with psychological health.
Other commonly used indicators of the quality of life include the perception of health and disabilities (functional
problems) and control over one’s own life.
This mind map provides insight into the healthcare topic of ‘the personal well-being of the patient’.
Well-being literally means ‘feeling good, well or comfortable’. Well-being refers to the extent to
which an individual feels well mentally and socially. In addition to ‘feeling good about oneself’,
well-being involves the perception of feeling healthy and satisfied with life. Good or poor well-being
can be of major influence on the quality of a person’s life.
Well-being 61
1 CLINICAL FOCUS
POINTS
Patients regard personal well-being as an important entity. People want to feel good, to experience
no health complaints or discomforts and to be satisfied with life, there is nothing wrong with that.
Everyone wants to feel good, including sick and vulnerable people and those who cannot express
themselves in these terms.
In practice, however, different terminology is often used for the concept of well-being. Patients do
this as well. A patient would never say, ‘I am experiencing such negative well-being today.’ Patients
use very different terms than healthcare professionals do to describe these kinds of feelings and
experiences. Sincere interest, good observation, empathy and good interviewing techniques are
helpful in this regard.
Well-being as a focus of care

Healthcare professionals obviously regard well-being as an important focus of care as well. In
professional practice and in the workplace, however, the concept of ‘well-being’ (as terminology)
is not in common usage as such. In recent years, however, awareness and attention have been
increasing with regard to this concept as a focus of care in its own right.
1. Feeling well or comfor table
Exactly what constitutes well-being is difficult to define, and differs from one person to another.
What is clear is that illness usually has a major negative impact on well-being. Illness (whether
acute or chronic) and, in some cases, the treatment that is associated with it (which can sometimes
be painful) can pose a severe disruption to personal well-being. It is not only physical discom-
forts (e.g. pain, shortness of breath, hunger, thirst, nausea) that play a role in whether or not an
individual ‘feels well’, but this is also influenced by mental aspects. How do people cope with illness,
prognoses and treatment? What do they worry about?
In practice, well-being, welfare and ‘being comfortable’ are often used synonymously. When people
say that they ‘feel good’ or that they are ‘fit as a fiddle’, they are usually referring to their personal
well-being.
How can we see how someone is feeling? Although it can sometimes be obvious, this is not always
the case. In daily practice, it can often seem as if we are able to see at a glance how things are
going with patients. Are they feeling well, or not? Some patients might express complaints, thereby
indicating that things are not going so well. A patient’s state of mind is often reflected in facial
expressions and body posture.
It’s not always so clear, however, and it is sometimes necessary to rely only on a certain feeling
or impression about the patient’s well-being. Some patients prefer to conceal their misery or the
fact that they are feeling bad, possibly in order to appear tough or to avoid complaining. A sense of
well-being is highly personal and complex, which can be even more complex in times of (severe)
illness. These are feelings that everyone can recognise.

‘Well-being’ is regarded as an all-encompassing term for everything related to another, also difficult
to define, concept: quality of life. Although the term ‘well-being’ may sound somewhat strange,
care and attention to well-being have always been highly important to healthcare professionals.
There has obviously always been great concern and respect for the well-being of people who are
vulnerable, ill, pregnant, newborn, lonely, traumatised, exhausted, injured, manic, drugged, in
mortal danger and/or dying, and those who have recently undergone surgery.
An individual’s well-being is obviously highly personal. One person’s experience of ‘feeling well’ is
not the same as that of someone else. This also applies to the opposite: when does someone not feel
well/comfortable? Nevertheless, it is possible to identify several general factors that contribute to a
patient’s well-being. Below a list of positive factors can be found.
What makes people feel ‘well’ or ‘comfortable’?

People often have a complex mix of experiences and feelings. Emotions and feelings can also shift
rapidly, consider the proverbial ‘emotional roller coaster’. The following list provides an overview of
factors that make a positive contribution to the sense of well-being. Many other, less general factors
are obviously conceivable. The list is intended to help interpret the concept of well-being.
• Symptom free not feeling sick, short of breath, not experiencing pain, itching, cramping, not
feeling dizzy or nauseous
• Safety to feel cared for, to feel welcome
• Eating and drinking feeling satisfied, eating with taste
• Personal hygiene to feel clean, dry and continent
• Mobility being able to move smoothly and without pain
• Rest and sleep to feel well rested, to feel fit and energetic
• Mood feeling happy, cheerful and not stressed
• Cognitive functions a clear mind, to feel acknowledged
• Companionship not feeling lonely, having family ties, experiencing friendship
• Identity being able to fully express who one is (gender, spiritual and cultural)
• Treatment being treated with dignity, respect, equal treatment
• Intimacy able to share deepest thoughts and feelings
• Autonomy being in control, independent and self-reliant
Table 1.1 Factors that make a positive contribution to the sense of well-being.
The list is definitely not complete, nor does it focus on any particular individuals or groups of
individuals. The factors that are mentioned are also not arranged in any order, none of them is more
important than the others. Most of these items are self-explanatory. There is also an opposite list
of factors that make people feel ‘not well’ (i.e. ‘uncomfortable’) and experience stress (see the next
chapter).
2. Coping: the abilit y to deal with problems
Coping is the manner in which an individual deals with the stress and discomfort associated with
illness. Stressful situations are usually handled in three steps:
Step 1: Identifying the problem.
Step 2: Assessing the problem. How severe is it?
Step 3: Reacting to the problem (i.e. coping). How is it being dealt with?
Developing a way in which to deal with the state of illness

Most people develop a preference for one or more styles from a very young age. For example,
children have different ways of coping with boredom. Some may cry, others may go to sleep and yet
Well-being 63
others may start looking for something interesting. Depending on their effects, children will use
these strategies more often or not at all. The reactions of people in the immediate surroundings
play an important role in this regard. As they mature, children develop their own ways of coping with
stressful situations.
Coping mechanisms
Coping mechanisms can be described in a variety of ways. One instrument that is in common use
in the Netherlands is the ‘Utrecht Coping List’, which describes seven coping styles. Some of these
mechanisms are regarded as less appropriate ways of coping with stress; they are used primarily
by people with more emotionally oriented coping strategies. This classification can be used to
determine how patients and their relatives are reacting to stressful situations and what types of
support would be appropriate.
1. Active problem solving

People who adopt this mechanism approach problems head-on. They go on the offensive and are
highly rational in this regard. They break the problem down into pieces and seek a solution for each
piece. This is one of the most effective coping styles.
2. Seeking social support

People who adopt this mechanism seek comfort, a listening ear, understanding and support from
others. They would like to work with others to conceive of different ways of resolving the problem.
This is one of the most effective coping styles.
3. Avoidance and passive expectancy

People who adopt this mechanism run away from the problem mentally. Instead of addressing the
problem, they avoid or deny it. If this does not work, they adopt a wait-and-see attitude with regard to
the consequences.
4. Palliative/distractive responses
People who adopt this mechanism run away from the problem emotionally. They focus on other
things in the attempt not to think about the problem. If this does not work, they may seek refuge in
nicotine, drugs and alcohol abuse.
5. Depressive reaction patterns

People who adopt this mechanism are overwhelmed by the problem, and they are incapable of
resolving it. These people worry, doubt themselves, blame themselves and may become depressed.
This passive coping style is not effective; the problem is not resolved.
6. Expressing emotions
People who adopt this mechanism become frustrated, tense and angry as a result of the problem.
They take these emotions out on those in their immediate surroundings. Aggression and anti-social
behaviour may occur. This coping style is not effective; the problem is not resolved.
7. Wishful thinking and comforting cognitions

People who adopt this mechanism convince themselves that every cloud has a silver lining or that
the problem is not as bad as it seems; after all, others are facing even worse problems. No matter
how much courage they give themselves, the problem is not solved. This coping style is thus not
effective.
Combination of mechanisms
People are usually don’t have only one clear coping style, but several. The ways in which people
react to problems obviously depends largely on the specific problems that they are facing. In most
cases, however, there is a common thread in the approach, consisting of one or more preferred
coping styles.

3. Qualit y of life
Although the concepts of personal well-being and quality of life are closely related, they are not
identical. In reality, they are extensions of each other. If a patient ‘is not feeling well’ and has a wide
range of complaints and concerns (mental, physical and social), we can say that the patient is not
experiencing well-being at that time. There is discomfort, and no one enjoys that. As healthcare
professionals, we notice this and try to obtain insight into what the exact complaints and feelings are,
so that we can address them appropriately. We offer practical help (e.g. in the form of medication)
and counsel the patient in coping with all the unpleasantness that can go with the disease and its
treatment.
Quality of life concerns how people experience their physical, psychological and social func-
tioning. It may also include such aspects as the limitations experienced as a result of illness.
‘Satisfaction’ is used as an indicator of quality of life. It consists of three elements:
• Satisfaction with life;
• Satisfaction with physical health;
• Satisfaction with psychological health.
Other commonly used indicators of quality of life include:

• Perception of own health;
• Perception of disabilities (problems in functioning);
• Having control over one’s own life.
Even if a patient has demonstrable physical disabilities or is barely able to function (if at all), this
does not always mean that the person’s quality of life is also very poor. The experience of quality of
life is
Even if a patient has demonstrable physical disabilities or is barely able to function (if at all), this
does not always mean that the person’s quality of life is also very poor. The experience of quality
of life is strongly influenced by individual expectations about health, ambitions that can no longer
be fulfilled (or that can still be fulfilled), mental capacity to cope with limitations, tolerance for
discomfort and the ability to cope with chronic illness. For example, two different people with similar
health conditions and limitations in functioning may experience their lives completely differently.
Despite their equal health status, therefore, their quality of life need not be the same at all.
Consequences for the quality of life

Quality of life is always subjective, and is strongly influenced by an individual’s personality, emotional
stability, ability to express oneself, social support (or lack thereof) and the number of stressful
events.
Physical consequences
Physical consequences in quality of life include the patient’s discomfort with physical complaints and
the extent to which the patient is limited in the ability to cope with everyday tasks.
Mental consequences
Mental consequences in quality of life include psychological complaints (e.g. anger, fear and
depression), which also have a negative impact on personal well-being. They also include complaints
that the patient experiences in connection with cognitive dysfunctions (e.g. concentration and
memory problems). Loss of autonomy is regarded as a very important factor in decreased quality of
life.
Well-being 65
Social consequences
Social consequences in quality of life may include possible changes or limitations in personal
relationships, social activities and participation in society.
Quality and quantity of life

In addition to the pursuit of long life, the quality of life is becoming an increasingly important consid-
eration. This is particularly true for chronically ill people, as well as for the frail elderly and people in
hopeless situations, which are often accompanied by highly disagreeable physical discomforts (e.g.
pain, nausea, shortness of breath, itching). Personality factors (especially anxiety) also appear to
play an important role in quality of life. Quality of life nevertheless involves more than that. It encom-
passes the extent to which people are satisfied with a wide array of aspects of life.
For patients who are experiencing problems that are more frequent, more prolonged and, perhaps,
more hopeless (i.e. there is no hope that the situation will improve), it will eventually be necessary to
address the issue of quality of life (both in the present, as well as what can be expected in the future).
It is likely that patients or their relatives will start asking questions about expectations regarding
quality of life. Healthcare professionals (physicians or nurses) might, however, still draw the line on
certain treatments which could improve quality of life that in the long term may be futile. In contrast,
there are also situations in which physicians opt to continue treatment, even against their better
judgement, thereby losing sight of issues relating to quality of life. In such cases, it is often nurses
who start to question whether the patient is still experiencing quality of life. This is almost always a
fraught subject, which should be approached with the utmost care.
In order to improve care, it is important for healthcare professionals and patients to have a timely
dialogue about what is important to the patient. This should be done even when curative treatment
is still being applied. What are the patient’s wishes if this treatment does not work? Discussing what
quality of life means to the patient can make it possible to provide more suitable care. The patient
must be well informed about the circumstances, prognosis, treatment options and their conse-
quences for their personal well-being and quality of life, both now and in the future.
Treatment limitations
Based on this information, the patient may choose to refrain from further treatment and/or opt to
limit treatment. The reasons for deciding on such treatment limitations are highly personal and
related to specific circumstances. Ideology or religion can play a role in this as well.
Several examples:
• Seriously ill patients who are at an advanced age and who have very little chance of curation may
decide that they no longer wish to be resuscitated.
• For seriously ill patients, the physician may sometimes indicate that mechanical ventilation
(or its continuation) is not advisable, as it will not improve the chances of recovery. Starting
or continuing ventilation would only exacerbate the patient’s suffering without increasing the
likelihood of survival. In this case, the treatment limitation ‘no mechanical ventilation’ may be
agreed upon.
• For patients with extensively metastasised malignant disease who are no longer responding to
treatment, it may no longer make sense to treat new problems (e.g. infections).
• For very elderly, physically fragile patients, new burdensome treatments (e.g. admission to an
ICU or dialysis) may be excessively aggressive and not very useful.
Having a disease and undergoing treatment can often have a major impact on the daily life of a
patient. Following the WHO definition of health, the term ‘quality of life’ refers to the entirety of
physical, psychological and social consequences of an illness and/or treatment, as experienced by
the patient.

Marc Bakker
Nurses are closely involved in their patient’s current state of health and are often the first to

witness (sometimes acute) changes in it. Good clinical judgement is therefore an essential
professional skill. Three competences play a key role in clinical judgement: observing,
analysing and communication.
ProActive Nursing: Clinical Judgement helps nurses to make a professional assessment

of ‘how the patient is doing’ and to clarify their patient’s clinical condition. The book
combines the eighteen health care topics of the World Health Organization’s International
Classification of Functions (ICF) with the three focal points of patient-centred care:
wellbeing, bodily functions, and patient functioning. It clarifies what is going well and what
is not, what the clinical problems, disorders and limitations of the patient are and what
interaction there is between the different problems. All of the eighteen healthcare topics
covered in this book are summarized in a practical mind map showing the clinical focus
points. There is also a section on the ‘Time-out practice model’ which helps nurses in a
structured way how to apply their clinical judgement skills into practice.
Marc Bakker is a nurse and educator at heart and has worked in intensive care, emergency
care, cardiac care, anaesthesia, recovery care, paediatrics, internal medicine, oncology,
neurology, orthopaedics, surgery, psychogeriatrics and psychiatry, among others. He is
the founder of ProActive Nursing within the VUmc Academy and has been giving lectures,
courses, workshops and master classes at colleges, universities and healthcare institutions
in the Netherlands, Belgium, and the Caribbean for over 30 years. He is a pioneer and
authority in the field of clinical judgement.
Marc Bakker
ProActive Nursing:
Clinical Judgement
www.boomstudent.nl
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Marc Bakker

ProActive Nursing: Clinical Judgement

ProActive Nursing: Clinical Judgement helps nurses to make a professional assessment

18785-10-ProActive Nursing-ENG.indd 2-3 10-11-2022 12:24

Cover design: Haagsblauw, The Hague

© VUmc Academie, Marc Bakker & Boom publishers Amsterdam, 2023

ISBN 9789024456413 (e-book)

Part I Time-out for clinical judgement 13

Table of Contents Part I 15

1 What is clinical judgement? 17

3 Time-out practice model 25

4 Three basic professional skills 29

Part II Insight into clinical problems 45

Insight into clinical problems 49

Healthcare topic 1 Well-being59

4 A few clinical situations 75

Healthcare topic 2 Mental functions 79

2 Clinical observations 110

3 A few clinical situations 115

2 Clinical problems 135

3 Clinical observations 140

4 A few clinical situations 142

Healthcare topic 4 Voice and speech 145

2 Clinical problems 152

3 Clinical observations 155

4 A few clinical situations 156

ABC Vital functions

Healthcare topic 5 Respiratory tract 159

2 Clinical problems 167

3 Clinical observations 170

4 A few clinical situations 172

Healthcare topic 6 Respiration175

2 Clinical problems 189

3 Clinical observations 193

3A Highlight: Pulse oximetry 198

4 A few clinical situations 202

Healthcare topic 7 Circulation209

2 Clinical problems 236

3 Clinical observations 242

3A Highlight: Arterial blood pressure 253

3B Highlight: Cardiac rhythm monitoring 259

6 ProActive Nursing: Clinical Judgement

3D Highlight: Haemodynamic profiles 269

3E Highlight: Blood pressure curves 277

4 A few clinical situations 279

Healthcare topic 8 Oxygen supply to the heart 285

2 Clinical problems 293

3 Clinical observations 295

4 A few clinical situations 302

Healthcare topic 9 Urinary system 305

2 Clinical problems 320

3 Clinical observations 325

4 A few clinical situations 329

Healthcare topic 10 Blood333

2 Clinical problems 353

3 Clinical observations 358

3A Highlight: Haematology 362

3B Highlight: Clinical chemistry 370

Part I Time-out for clinical judgement 13

Table of Contents Part I 15

1 What is clinical judgement? 17

3 Time-out practice model 25

4 Three basic professional skills 29

Part II Insight into clinical problems 45

Insight into clinical problems 49

Healthcare topic 1 Well-being59

4 A few clinical situations 75

Healthcare topic 2 Mental functions 79

2 Clinical observations 110

3 A few clinical situations 115

2 Clinical problems 135

3 Clinical observations 140

4 A few clinical situations 142

Healthcare topic 4 Voice and speech 145

2 Clinical problems 152

3 Clinical observations 155

4 A few clinical situations 156

Healthcare topic 5 Respiratory tract 159

2 Clinical problems 167

3 Clinical observations 170

4 A few clinical situations 172

Healthcare topic 6 Respiration175

2 Clinical problems 189

3 Clinical observations 193

3A Highlight: Pulse oximetry 198

4 A few clinical situations 202

Healthcare topic 7 Circulation209

2 Clinical problems 236

3 Clinical observations 242

3A Highlight: Arterial blood pressure 253

3B Highlight: Cardiac rhythm monitoring 259

3D Highlight: Haemodynamic profiles 269

3E Highlight: Blood pressure curves 277

4 A few clinical situations 279

Healthcare topic 8 Oxygen supply to the heart 285

2 Clinical problems 293

3 Clinical observations 295

4 A few clinical situations 302

Healthcare topic 9 Urinary system 305

2 Clinical problems 320

3 Clinical observations 325

4 A few clinical situations 329

Healthcare topic 10 Blood333

2 Clinical problems 353

3 Clinical observations 358

3A Highlight: Haematology 362

3B Highlight: Clinical chemistry 370

3C Highlight: Arterial blood gases 381

4 A few clinical situations 385

Healthcare topic 11 Nervous system 389

2 Clinical problems 411

3 Clinical observations 417

4 A few clinical situations 423

2 Clinical problems 441

3 Clinical observations 445

4 A few clinical situations 448

Healthcare topic 13 Endocrine system 451

2 Clinical problems 468

3 Clinical observations 472

4 A few clinical situations 477

Healthcare topic 14 Thermoregulation 481

2 Clinical problems 492

3 Clinical observations 494

4 A few clinical situations 497

Healthcare topic 15 Skin and immune system 503

2 Clinical problems 519

3 Clinical observations 523

4 A few clinical situations 527

Healthcare topic 16 Digestive functions 541

2 Clinical problems 560

3 Clinical observations 566

4 A few clinical situations 570

2 Clinical problems 599

3 Clinical observations 606

3A Highlight: CTG 614

4A The pregnant body 618

4B The newborn 627

4C Apgar score and the PEWS 638