Clinical Judgment Process and Nursing Process

Flashcards cover the Nursing Process, CJMM steps, critical thinking, clinical reasoning, clinical judgment, and delegation responsibilities as described in the notes.

Who developed the Nursing Process in 1958 and what is its purpose?

Ida Jean Orlando; it guides direct nursing care using critical thinking, experience, and evidence-based practice guidelines.

What are the major components of the Nursing Process as described in the notes?

Assessment, Analysis, Planning, Implementation (including Delegation & supervision), Evaluation.

What does Assessment involve in the Nursing Process?

Collect, organize, validate, and document objective and subjective data pertinent to the client.

What does Analysis involve in the Nursing Process?

Determine the client problems by analyzing the data collected.

What does Planning involve in the Nursing Process?

Create a plan to address client problems—make decisions and problem solve.

What does Implementation involve in the Nursing Process?

Take action to provide care as outlined in planning using nursing knowledge.

What does Delegation & supervision refer to in the Nursing Process?

Delegation and supervision of care; nurses are still responsible for delegated activities.

What is Evaluation in the Nursing Process?

Evaluate the effectiveness of interventions and document the client’s response.

What are the steps of the Clinical Judgment Model (CJMM)?

Recognize Cues; Analyze Cues & Prioritize Hypotheses; Generate Solutions; Take Actions; Evaluate.

What does Recognize Cues involve in CJMM?

Filter information from different sources (signs/symptoms, health history, environment).

What does Analyze Cues & Prioritize Hypotheses entail?

Link recognized cues to the patient’s presentation, establish problems/concerns/needs, and prioritize care based on hypotheses.

What does Generate Solutions involve in CJMM?

Identify related nursing interventions and expected outcomes.

What does Take Actions mean in CJMM?

Implement appropriate interventions based on the above information.

What is Evaluated in CJMM?

Evaluate the CJMM steps by assessing the effectiveness of interventions and outcomes.

What is Critical Thinking?

The skill of analyzing and interpreting data to solve a problem to achieve a desired outcome; includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity.

What is Clinical Reasoning?

The mental process used when analyzing all the data of a clinical situation to decide on a solution; involves assessing and compiling data, selecting/discarding information based on relevance, and making decisions; applies critical thinking to practice.

What is Clinical Judgment?

The visible outcome of critical thinking and decision making that considers nursing knowledge, client situations, and prioritization, while utilizing evidence-based practice; improves with practice.

Can delegation affect accountability for care?

No; nurses remain responsible for delegated activities, and clinical reasoning and judgment cannot be delegated.

What are key rules about delegation in nursing practice?

Delegation involves assigning an activity to someone with appropriate training; communication of the delegated activity must be clear and concise; nurses are still responsible for delegated tasks.