Nursing Process and CJMM: Key Concepts (Video Notes)

Vocabulary-style flashcards covering the Nursing Process steps, key formats, characteristics, CJMM, and the relationship between CJMM and the Nursing Process.

Nursing Process

A systematic, patient-centered framework that guides nursing care through critical thinking, problem-solving, and clinical judgment.

Assessment (Nursing Process)

Collect data: subjective (symptoms) + objective (signs); sources include patient, family, records, physical exam, labs, and other providers; Types: Initial, Focused, Emergency, Time-Lapsed, Quick Priority, Triage.

Subjective Data

Symptoms reported by the patient.

Objective Data

Signs observed by others; measurable or observable data.

Assessment Data Sources

Patient, family, records, physical exam, labs, and other providers.

Assessment Types

Initial, Focused, Emergency, Time-Lapsed, Quick Priority, Triage.

Diagnosis (Nursing Process)

Identify actual/potential health problems and strengths; Types: Problem-focused (actual), Risk (potential), Health Promotion; Format: PES (Problem–Etiology–Signs/Symptoms).

PES

Problem–Etiology–Signs/Symptoms; a format used in nursing diagnoses.

Planning & Outcomes (Nursing Process)

Set priorities (Maslow, patient preference, future risks); Write SMART outcomes; Outcome categories: Cognitive, Psychomotor, Affective; Types of planning: Initial, Ongoing, Discharge.

SMART Outcomes

Specific, Measurable, Achievable, Relevant, Time-bound.

Outcome Categories

Cognitive (knowledge), Psychomotor (skills), Affective (attitudes/values).

Types of Planning

Initial planning, Ongoing planning, Discharge planning.

Implementation (Nursing Process)

Carry out interventions to meet goals; Types: Independent (nurse-initiated), Dependent (physician-ordered), Collaborative; Examples: teaching, direct care, care bundles, protocols; Alfaro’s Rule: Assess, Reassess, Revise, Record.

Independent Interventions

Nurse-initiated actions that can be performed without a physician’s order.

Dependent Interventions

Interventions requiring physician orders.

Collaborative Interventions

Interventions requiring teamwork with other health professionals.

Alfaro’s Rule

Assess, Reassess, Revise, Record.

Evaluation (Nursing Process)

Determine if outcomes were met; status: Met, Partially Met, Not Met; Revise diagnosis, outcomes, or interventions as needed; Classic 5 elements: set criteria, collect data, interpret findings, document, revise plan.

Classic 5 Elements of Evaluation

Set criteria, collect data, interpret findings, document, revise plan.

Key Characteristics of the Nursing Process

Systematic, Dynamic; Interpersonal, Outcome-Oriented, Universally Applicable.

Systematic

An organized sequence of steps.

Dynamic

Steps overlap and are continuous/overlapping.

Interpersonal

Patient-centered approach focusing on the patient.

Outcome-Oriented

Measurable results guiding care.

Universally Applicable

Applicable in any setting and with any patient.

CJMM

Clinical Judgment Measurement Model developed by the NCSBN to describe and measure how nurses use clinical judgment in practice; foundation of the NGN.

NGN

Next Generation NCLEX; uses CJMM as its foundation.

CJMM – Recognize Cues

Notice relevant data (vital signs, patient statements, labs).

CJMM – Analyze Cues

Organize and link data, compare to norms.

CJMM – Prioritize Hypotheses

Consider possible problems, rank what’s most urgent.

CJMM – Generate Solutions

Identify possible nursing interventions.

CJMM – Take Action

Implement the best solution/intervention.

CJMM – Evaluate Outcomes

Check patient response, decide if goals were met, modify plan.

CJMM & Nursing Process Relationship

Assessment ↔ Recognize & Analyze Cues; Diagnosis ↔ Prioritize Hypotheses; Planning ↔ Generate Solutions; Implementation ↔ Take Action; Evaluation ↔ Evaluate Outcomes.

Nursing Process vs CJMM Analogy

Nursing Process = roadmap of steps; CJMM = GPS for how you notice, interpret, and choose the best path.

NCSBN

National Council of State Boards of Nursing; developed CJMM.

CJMM Data Cues Example

Vital signs, patient statements, labs used to recognize and analyze data.