Clinical Judgment Model and the Nursing Process

The Nursing Process

Clinical Judgment Model NUR 105

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Table of Contents

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Recognize Cues

Analyze Cues

Intro to the CJM

Drug Cards

Generate Solutions

Take Action & Evaluate Outcomes

Form & Prioritize Hypotheses

Clinical Judgement Model - 7 steps

1. Recognize Cues
2. Analyze Cues
3. Form Hypotheses
4. Prioritize Hypotheses
5. Generate Solutions
6. Take Action
7. Evaluate Outcomes

Clinical Judgment Model - Nursing Process

• Nursing is primarily responsible for diagnosing and treating a patient's response to disease and medical treatment.
• We communicate those responses to other heatlhcare providers.

Clinical Judgment Model - Nursing Process

• A systematic, rational method of planning and providing individualized nursing care
• A systematic problem-solving approach
• Used to identify actual and potential problems and promote wellness
• Provides the framework in which nurses use their knowledge and skills to express human caring
• The way one thinks like a NURSE

• Promotes collaboration - working together
• Quality of care
• Avoids omissions: mistake or error
• Universally applicable: any age client, any place in the health care continuum
• Nursing home, hospital, private home, etc.

Skills Needed to Use the Nursing Process

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Care planning is NOT easy - it will take more time than you think it will.

The Clinical Judgment Model

Recognize & Analyze Cues

Form & Prioritize Hypotheses

Generate Solutions

Use your senses:

• Sight: what do you see?
• Hearing: what do you hear?
• Smell: what is that smell?
• Touch: what do you feel?
• Taste: hopefully not this one!

Determine priority problems and rank them.

• Based on data collected

The label of a problem

• Not a medical diagnosis
• Medical diagnosis:
• Pneumonia, asthma, broken hip
• Nursing diagnosis:
• High risk for fall, impaired gas exchange, pain
• These work hand in hand.

Outcomes and Goals

• What do we (nurse and client) want to accomplish with treatment?
• What do we (nurse and client) do about the problem?
• How can the client (with the help of the healthcare team) reach their highest potential?

The Clinical Judgment Model

Take Action

Evaluate Outcomes

Includes:

• Assess: What will we assess to help meet the optimal outcome? This should be a list of assessments
• Do: What can the nurse do (Nursing Interventions)?
• Teach: What can we teach the client that will help them reach their goal?

• Did we meet the goal?
• What needs to be changed?
• The process starts over…

Recognize Cues

Clinical Judgment Model

Recognize Cues

• Information on the patient is identified.
• Sources: the patient, family, medical record, other providers
• Based on accurate and complete data collection.

The nurse must decide:

• What information is relevant or irrelevant
• What information is most important
• What is of immediate concern (most likely to kill or severly harm the patient first, second, third, etc.)

Gathering Clinical Data

Sources of Information

• Observation
• Interview - patient, family, significant other
• Who is the #1 source?
• Medical and surgical history, including medication list and diagnostic labs/studies
• Physical exam - head to toe assessment

Gathering Clinical Data

• Step one: clinical data collection
• Assessment!!
• Sound clinical judgments are based on accurate and complete data collection
• Example: Pale, lethargic, “cold all the time”, no energy, female comes to the doctor’s office – “Just doesn’t feel good”
• Can you diagnose what is wrong from this info?
• NO – you need more information!
• How long has the client had these symptoms? 2 weeks, 6 months, etc.
• Are these symptoms related to anything else?
• like her recent liquid diet to lose weight or extremely heavy periods or her recent exposure to high levels of radiation, etc.

Gathering Clinical Data

• Medical and Surgical History
• Surgical & medical history - HTN, DM, Medications
• Diagnostic Tests
• CBC, Creatinine level, BUN, Potassium, etc.
• X-ray results, EKG results, etc.
• See the WHOLE patient
• A client is not just a diagnosis – they are a human being.

• Where to collect client information:
• Patient, family, significant other (patient is the primary source)
• How to collect client information:
• ASK open ended questions (interviews, conversation)
• LISTEN, sit at eye level, & control the environment
• Physical Examination
• Lung auscultation, abdominal palpation, pulse symmetry, etc.

Our patients are complex...

The whole patient

Roles, relationships, values, beliefs

Stress tolerance, self-perception

Sexuality, reproduction, cognitive, and perceptual pattern

Nutritional, metabolic, and elimination patterns

Health maintenance, activity and exercise

Gathering Clinical Data

• Objective data
• Information that can be measured
• Use of senses to determine
• Subjective data
• Information that cannot be measured
• Perceived and verified only by the patient

Analyze Cues

Clinical Judgment Model

Analyze Cues

• Organizing and linking cues to the client’s clinical presentation and establishing client needs, concerns, and problems.
• Identifying the client’s problem or problems in order to address them.
• Ask yourself…
• What client conditions are consistent with the cues?
• Are there cues that support or contraindicate a certain condition?
• Why is a particular cue or cues a concern for this patient?
• What other information would help establish how significant a cue or cues are?

Analyze Cues

• Nursing actions:
• Analyze both the expected and unexpected findings
• Analyze the client’s needs
• Identify how the pathophysiology of the disease process relates to the client’s presentation
• Identify potential complications
• Identify the cues/data that require immediate attention (prioritization)

Analyze Cues

• Analyze and interpret gathered clinical data
• Determine abnormal data
• Categorize data based on similarities
• Identify problems
• Look at the data and try to determine the BIG PROBLEMS!

Form and Prioritize Hypotheses

Clinical Judgment Model

Form & Prioritize Hypotheses

• Establishing priorities of care based on the client’s health problems.
• Examples:
• Environmental factors
• Risk assessments
• Signs/Symptoms
• Diagnostic tests and lab values
• The nurse identifies client problems and the level of importance of each problem.

Form & Prioritize Hypotheses

• First part of learning to ACT upon what you know!
• Forming hypotheses:
• Generating reasons for the clinical cues that were collected – why does my patient have these abnormal values?
• Prioritizing hypotheses:
• Narrow down your hypotheses to what is the most pressing problem
• Which hypothesis is the priority?
• Which explanations are most/least likely?
• Which possible explanations are the most serious?

Form & Prioritize Hypotheses

• First make sure you have all data needed about your patient.
• Evaluate all the abnormal data for your patient.
• Using your nursing diagnosis book, determine priority problems/hypotheses that fit the abnormal data.
• Rank the problems in order of severity. Always consider what will kill or severely hurt your patient first? Second? Third?

Generate Solutions

Clinical Judgment Model

Generate Solutions

1. Identifying expected outcomes
1. Focus on goals – What needs to be accomplished to achieve a healthier state?
2. Measurable – needs to quantified
2. Define interventions
1. What are the desirable outcomes?
2. What interventions can achieve those outcomes?
3. What should be avoided?
3. Education
1. What does your patient need to know to meet these outcomes?

Generate Solutions

• Use your nursing diagnosis book to help you come up with goals, interventions, and education.
• This step is hard; be prepared to spend some time on this. More time than you think you will need.
• Take advantage of rough draft opportunities! They are your one chance to get comprehensive feedback. You can fail a clinical rotation due to poor care planning. We will help you, but you must do the work.

Generate Solutions

• Nursing Actions:
• Collaborate with members of the healthcare team to develop client outcomes
• Collaborate with client and family to develop client outcomes
• Prioritize the plan of care
• As client condition changes, reprioritize nursing actions
• Determine potential impact of selected interventions

Take Action and Evaluate Outcomes

Clinical Judgment Model

Take Action

• Implementation of appropriate nursing interventions based on:
• Nursing knowledge
• Priorities of care
• Planned outcomes
• The nurse takes action by implementing interventions that address the top priorities.

Take Action

• Take Action
• Implement the solutions that address the highest priorities
• Which intervention or combination of interventions are most appropriate?
• How should these interventions be accomplished?
• Nursing actions:
• Perform nursing actions based on priorities for patient care
• Implement the plan of care in collaboration with the patient, family, and other healthcare team members
• Document patient care accurately
• Provide education
• Monitor responses to interventions

Evaluate Outcomes

• Evaluate client’s response to nursing interventions and determine if outcomes have been met.
• The nurse compares observed outcomes against expected outcomes, reassessing the client’s condition to determine whether expected outcomes have been met.

Evaluate Outcomes

• Compare what you observe with what you expected
• What signs point to improving/declining/unchanged status?
• Were my interventions effective?
• Would other interventions have been more effective?
• Nursing actions:
• Reassess the patient’s condition to determine if the interventions worked
• Modify the nursing interventions based on the patient’s responses
• Update and revise the plan of care

Drug Cards

Important Reminders

• Any drug cards assigned must be handwritten.
• They must be in your own words.

Drug Cards: Info Needed

• Med name: Generic and trade name
• Classification: therapeutic and pharmacologic
• Antidote
• How does it work?
• Side effects
• Food, drug, herbal interactions
• Special administration techniques
• How do you assess if it is working?
• Patient teaching

Name and Class

Antidote

• IMPORTANT: This is not for furosemide. There is no antidote for furosemide.
• The antidote for narcotics is naloxone (Narcan).

How Does It Work?

Side Effects

Food, Drug, and Herbal Interactions

Special Administration Techniques

Assess if it is working

Patient Education