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UNIT 1 How Nurses Think
Table 2-2 ➤ National Council of State Boards of Nursing (NCSBN) Clinical Judgment Model (CJM) Application—cont’d
NCSBN CJM LAYER 3
KNOWLEDGE AND CONTEXT FACTORS ■ Requires theoretical knowledge—care of general postoperative client and client with abdominal surgery, shock, diabetes symptoms, abnormal vital signs ■ Requires practical knowledge (skill levels, management of drains, prior experiences) ■ Explain observations, data collected ■ Fluid and electrolyte imbalances ■ Pain ■ Loss of blood volume ■ Expected postoperative presentation ■ Expected presentation with dementia diagnoses
EXPECTED BEHAVIORS/ACTIONS ■ Relate client observations to potential postoperative complications ■ Describe patterns in data ■ Explore gaps in evidence (present; needed) to form and prioritize hypotheses ■ Prioritize the most life-threatening— loss of blood volume
Analyze cues
Prioritize hypotheses
■ Blood glucose alterations ■ Oxygen saturation values
Generate solutions
■ Requires knowledge of life-threatening nature of shock ■ Requires knowledge of shock management ■ Requires knowledge of provider’s role ■ Fluid resuscitation ■ Obtain oxygen saturation value ■ Determine patency of drainage tubes ■ Determine intake and output ■ Determine amount of blood loss (nasogastric drainage) ■ Determine renal status (output in relation to intake) ■ Collaborate with providers ■ Educate family member on situation ■ Establish another IV site with large-gauge needle ■ Type and crossmatch for blood administration ■ Delegate responsibilities for care of other clients
■ Fluid replacement ■ Obtain additional assistance
■ Client needs care beyond what is available on the medical-surgical unit ■ Administer IV fluids at specified rate ■ Administer oxygen at prescribed rate ■ Transfer to a higher level of care
Take action
Evaluate outcomes
■ Status of client at time of transfer
■ Stability in vital signs ■ Urinary output present ■ Level of conscious ■ Skin color, temperature, turgor
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