clinical judgement measurement model (cjmm) and safety

what are the components of cjmm (6)

1. recognize cues

2. analyze cues

3. prioritize hypotheses

4. generate solutions

5. take action

6. evaluate outcomes

what should be considered during the general survey of cjmm (5)

appearance, behavior, mobility, body structure, and safety considerations (distress, fall risk, level of consciousness changes)

what are the five components of a vital signs interview

BP, pulse, respirations, temperature, and BMI

what are the methods of measuring temperature

oral, tympanic (ear), and temporal (forehead)

what are the values for tachycardia and bradycardia

tachycardia: over 100bpm

bradycardia: under 60bpm

normal bp range of values

90-120 systolic pressure

60-80 diastolic pressure

ranges for hypertension (elevated bp)

130-139 systolic pressure

What are the ranges for a hypertensive crisis (extreme high bp)What are

>180/120

what is orthostatic hypotension

if their bp drops when they stand, which can lead to dizziness, momentary vision loss, nausea, and vertigo

what might a weak pulse indicate

perfusion issues

what is assessed in a pulse assessment (3)

rate, rhythm, and strength

normal pulse value range

60-100 beats per min

what is assessed in respirations (3)

rate, depth, effort (labored or nah)

normal respiration value range

12-20 breaths/min

normal temperature ranges, and what being above/below it indicates

96.4-99.1 degrees fahrenheit

high temp: fever or infection

low temp: hypothermia, which is an emergency

alert and oriented x4 components

person (aware of their identity)

place: recognizing their environment and where they are

time: knowing date, year, time currently

situation: understanding why they are there

get 1 point for their score for each of the components they understand

normal o2 sats range

95-100% on room air

3 measures of infection control

hand hygiene, ppe, equipment cleaning

how many identifiers necessary for patient identification, and what are they

name and DOB

what is a pain goal

a goal of how much they want their pain to improve, help create a realistic goal

What is a functional goal?

what functions they want to be able to do with their pain level (perform adls, sit, climb, stand, shop, etc.)

what does sbar stand for

situation, background, assessment, reccomendation