module 8: nursing process and clinical judgement Flashcards
Tanner’s clinical judgement model
noticing, interpreting, responding, and reflecting
clinical judgement measurement model (CJMM)
focus of the next generation (NG) NCLEX; layers 0-2 and 3-4; coming in 2023
CJMM layers 0-2
how clinical judgement forms clinical decisions; aspect of clinical judgement measurement model
CJMM layers 3-4
expected behaviors of students in specific case scenarios (unfolding case studies); aspect of clinical judgement measurement model
clinical judgement action model (CJAM)
aligns the six cognitive operations from layer 3 of the CJMM with specific situational factors from layer 4
6 clinical judgement functions of layer 3 of CJMM
recognize cues
analyse cues
prioritize hypotheses
generate solutions
take actions
evaluate outcomes
5 nursing processes of layer 4 of CJMM
assessment
analysis
planning
implementation
evaluation
mental model
organized way of thinking that assists in understanding complex aspects of a situation and guides assessments and behaviors
assessment
gather information, identify cues, make inferences, validate data, cluster related data, record data
clinical reasoning
analysis, synthesize (break down), reflect, draw conclusion
etiology
factors causing or maintaining a disease or unhealthy state
health problem
a condition that needs intervention to prevent or resolve disease or illness or to promote coping and wellness
nursing diagnosis
diagnosis of actual or potential health problems that can be prevented/resolved by independent nursing interventions; problem statements; provides basis for selection of appropriate nursing interventions
problem statement
nursing diagnosis and explains the patient’s health problem
medical diagnosis
identifies disease and describe problems for which the physician or advanced practice nurses directs the primary treatment; remains the same for as long as the disease is present
if there is a possible problem,
collect more data to confirm or disprove a suspected problem
if patient denies issue or treatment,
educate them as best as you can
problem-focused nursing diagnosis
clinical judgement concerning an undesirable human response to a health condition for an individual patient, family, or group
risk nursing diagnosis
clinical judgement concerning the vulnerability of an individual, family of group for developing an undesirable human response to health condition
health promotion nursing diagnosis
clinical judgement concerning motivation and desire to increase well-being an to actualize human health potential; promoting a healthy lifestyle
patient outcome
expected conclusion to a pt. health problem or in the event of a wellness diagnosis, an expected conclusion to a pt’s health expectation
expected outcomes
measurable/observable criteria used to evaluate the extent to which a goal has been met
standard care plans
already made plans related to nursing interventions common to a specific issue
discharge planning begins…
at admission
high priority
highest threat to pt. health and wellbeing
medium priority
not life threatening
low priority
not related to issue at hand
maslow’s hierarchy
- physiologic needs
- safety needs
- love and belonging
- self-esteem
- self-actualization
long term goal
more than one week
short term goals
hours, days, a week
SMART goal setting
S- be specific
M- be measurable
A- make attainable
R- be realistic/relevant
T- time bound
