Caputi Clinical judgemental framework

Question 1

Step 1: Getting the information

Answer 1

The “Getting the Information” step involves collecting data about the Patient or
a healthcare situation. The nurse uses assessment techniques such as observation
and auscultation to collect data. Information is collected from all sources such
as the patient, the medical history in the Patient’s medical record, trends in vital)
signs, etc. This aligns with the NCSBN’s “Recognize Cues” step.

Question 2

Step 2: Making meaning of the Information

Answer 2

The second step, Making
Meaning of the Information.”The nurse analyzes the data to determine just what
the data mean. An overall term for all the thinking of this step is data analysis
Nurses analyze the data to make sense of the data to determine issues, problems,

Or concerns. This iS the NCSBN’s CJMM “Analyze Cues step in which the infor-
mation is organized and linked to the patient’s individual situation or context

Question 3

Step 3: Determining actions to take

Answer 3

in the “Making Meaning of the Information step identifies
Pztient care nceds or problerns in the healthcare environment. With the issues
identified in the “Making Meaning of the Information” step, the nurse must
now determine what actions to take and which actions take priority. The nurse
considers what Patient concerns are the most urgent, most likely to cause com-
plcations if not addressed, or at highest risk for developing into bigger con-
cerns, These are cxamples of ways nurses rank patient care needs to determine which are the highest priority

Question 4

Step 4: Taking Action

Answer 4

In the “Taking Action step the nurse carries out the nursing interventions
planned during the “Determining Actions to Take” step. Those actions that
were designated as the highest priority are implemented first. Actions are not
just nursing interventions or psychomotor skills, but can also be delegating
nursing actions for others to implement; communicating with healthcare team
members; teaching patients and others; and documenting various aspects of
care. How the actions are implemented are, once again, dependent on the indi-
vidual patient’s situation or the unique care environment.

Question 5

Step 5: Evaluating Outcomes (1st part of step)

Answer 5

1. Collects data (evaluation data) related to the effects of the
   nursing actions implemented for the patient. When collecting
   data, the nurse incorporates feedback from the patient to
   determine satisfaction with a specific nursing action and overall
   satisfaction with care delivered.
2. Compares the data collected prior to the nursing action with the
   data collected after implementing the nursing action. Based on
   this comparison, the nurse determines if the patient’s condition is
   improving, declining, or remaining unchanged.
3. Plans further care depending on the results of #2. The nurse also
   considers the possibility that other nursing actions would have
   been more effective.

Question 6

Step 5: Your Thinking (2nd part of step)

Answer 6

In this step you reflect on the thinking used
was accurate or if there are areas of thinking that need improvement This step
throughout the entire clinical judgment process to determine if your thinking
involves learning from your experiences by reflecting on those experiences. To improve thinking the nurse reflects on the thinking that was used throughout
the clinical judgment process. Reflective thinking is tantamount to learning
and growing as a nurse.
Reviewing your thinking and its effectiveness
encour-
ages deeper understanding of your ability to think, supports self-evaluation,
and, with honest reflection, fosters growth in your ability tO use clinical judg-
ment.