KTI week 3 notes

Clinical Judgment Measurement Model (CJMM) & Trauma Informed Care

Introduction

  • Presenters: Dr. Sue Coffey, Dr. Crystal Garvey

  • Copyright Notice: Do not reproduce content without authors' permission.

Need for the CJMM

  • Historical Context:

    • Previously utilized nursing processes consisted of 4, 5, or 6 steps:

    • Assessment

    • Diagnosis

    • Outcome Identification

    • Planning

    • Implementation

    • Evaluation

    • This approach has been in use for more than 50 years and has undergone modifications.

    • Serious errors in practice have persisted, notably failures to rescue patients in critical conditions.

    • For over 15 years, nursing scholars have highlighted the paramount importance of clinical decision-making over a conventional problem-solving approach.

    • This has led to the conclusion that there is a need to expand the nursing process with a greater emphasis on clinical judgment.

Clinical Judgment Measurement Model (CJMM)

  • Framework: An evidence-based methodology designed to enhance the cognitive processes essential for sound clinical judgments.

  • Cognitive Skills Identified by CJMM:

    1. Recognize cues

    2. Analyze cues

    3. Prioritize hypotheses

    4. Generate solutions

    5. Take action

    6. Evaluate outcomes

Recognizing Cues

  • Questions to consider:

    • What cues did you recognize?

    • What are the most significant findings?

    • What information might be less important or distracting?

Unfolding Case Study - Recognizing Cues

  • Case: A 78-year-old female patient in the Emergency Department (ED).

  • Client Findings (1000):

    • Brought in due to increased shortness of breath.

    • Reported fever lasting several days, cough producing greenish mucous, and general body soreness.

    • Recent hospitalization (6 days ago) for atrial fibrillation.

    • Medical history includes hypertension.

    • Vital Signs:

    • Temperature: 101.1°F (38.4°C)

    • Pulse: 92

    • Respiratory Rate: 22

    • Blood Pressure: 152/86

    • Oxygen Saturation: 94% on oxygen at 2 L/min via nasal cannula.

    • Assessment:

    • Breathing slightly labored; coarse crackles in bilateral lung bases noted.

    • Skin is cool and pale; pulse irregular and +3; capillary refill of 3 seconds.

    • Patient is alert and oriented but daughter reports occasional confusion.

    • Vital Signs to Follow-up:

    • Vital Signs

    • Lung Sounds

    • Capillary Refill

    • Client Orientation

Analyzing Cues

  • Questions to ask:

    • What findings were expected based on the diagnosis?

    • Are there contradictory findings?

    • What additional information is needed for significance?

    • Which cue sets are most concerning?

Unfolding Case Study - Analyzing Cues

  • Same 78-year-old patient context.

  • Client Findings should be analyzed for:

    • Pneumonia, UTI, or Influenza: Determine associations with each.

    • Specific symptoms to assess for each condition:

    • Fever

    • Confusion

    • Body soreness

    • Cough and sputum

    • Shortness of breath

Generating Hypotheses

  • Questions to consider:

    • What condition is most likely affecting the patient?

    • What supports this hypothesis?

    • What are the consequences if untreated?

    • What other possibilities exist?

    • Which hypothesis should be prioritized for nursing intervention?

    • What are the risks of ignoring other hypotheses?

Unfolding Case Study - Generating Hypotheses

  • Case continued with the 78-year-old patient scenario.

  • Completing responses based on observed cues and gathered data.

Generating Solutions

  • Questions to reflect on:

    • What are the desired outcomes linked to the hypothesis? (At least 2 needed)

    • Which interventions are necessary?

    • Which interventions are to be avoided?

Unfolding Case Study - Generating Solutions

  • Review of nursing notes and planning interventions for patient care based on vital signs and assessment at different time points (1000, 1200):

    • Assessing treatment indications:

    • Prepare for potential defibrillation.

    • Positioning client in semi-Fowler's.

    • Request orders for increased oxygen.

    • Evaluate necessity of additional peripheral venous access.

    • Administer IV fluid bolus as ordered by physician.

Taking Action

  • Key considerations:

    • Which interventions must be executed immediately?

    • What can be delegated, and to whom?

    • What are the mechanisms of action for prescribed medication, and what major nursing considerations exist?

    • What education will be provided to the patient?

    • What needs to be included in SBAR for handoff and referrals?

Unfolding Case Study - Taking Action

  • Selection of top 3 interventions that should be executed immediately:

    • Inserting an indwelling urinary catheter.

    • Administering Vancomycin 1 g IV every 12 hours.

    • Performing a CT scan of the chest.

    • Infusing 500 mL of normal saline IV.

    • Conducting relevant laboratory tests (blood culture, CBC, ABG).

Evaluating Outcomes

  • Questions to guide evaluation:

    • What follow-up data are necessary?

    • What indicators suggest that an intervention is working or failing?

    • Are there critical values to monitor?

Unfolding Case Study - Evaluating Outcomes

  • Review patient assessment findings to indicate improvements or declines:

    • Assessment to be repeated at different times and findings categorized accordingly.

Clinical Judgment Development

  • Clinical judgment is cultivated through practice and exposure to progressively complex scenarios.

  • The CJMM cultivates essential skills that empower practitioners to notice deteriorating patients and act swiftly to enhance clinical outcomes and save lives.

Trauma Informed Care Overview

  • Purpose: A framework regarding individuals experiencing trauma.

  • Focus: Understanding the respective behavioral responses influenced by personal narratives of trauma.

Trauma Understanding

  • Definition of Trauma: Individualized experiences with potentially varying manifestations.

  • Types of Trauma:

    • Short Term Trauma:

    • Events that resolve without major emotional, mental, or physical impact.

    • Long Term Trauma:

    • Major events that resolve but can have significant enduring effects and lead to emotional or physical triggers.

    • Generational Trauma:

    • Trauma transmitted across generations without explicit acknowledgment, often systemic (e.g., racism, poverty).

    • Historical Trauma:

    • Trauma associated with large-scale events affecting communities or populations.

Trauma Informed Care Approach

  • Recognizes and acknowledges trauma.

  • Understanding the impact of trauma on individuals.

  • Responding appropriately to support recovery.

Hildegard Peplau's Influence on Nursing

  • Historical Context:

    • Reflected societal gender roles and limited career paths for women in the mid-20th century.

    • Advocated for nurses to shift from a servile role under physicians to one that embraces patient autonomy and therapeutic relationships.

Metaparadigm of Peplau (Fill in the Blank)

  • Components include:

    • Person

    • Health

    • Nurse

    • Environment

Phases of the Nurse-Patient Relationship

  1. Orientation Phase:

    • Recognition of need and seeking professional help; developing trust in the nurse-patient dynamic.

  2. Working Phase:

    • Patient identifies with helpers and seeks to fully utilize resources; exploration of feelings and promoting patient's well-being by activating nurse roles.

  3. Resolution Phase:

    • Gradual transition from dependence towards independence as old goals are supplanted by new ones.

Activity and Class Reminders

  • Group Activity: Discuss the metaparadigm concepts of Peplau's theory with practical examples in relation to Trauma Informed Care (TIC).

  • Class Format Reminder: In-person attendance required. Prepare readings and also begin reviewing for an upcoming week 5 quiz covering content from weeks 1 to 4.