Patient Diagnosis: Hypertension History Diagnosis: history of Deep Vein Thrombosis Patient initials: IM Age:89 Gender: Male Weight/Height: 286lbs/ 5’7 Allergies: Penicillin Patient

To be sure your clinical judgement statements written below are accurate. You need to review the defining characteristics and related factors associated with and see how your patient data match. Do you have an accurate match or are additional data required, or does another cue from abnormal assessment findings need to be investigated?

Take Action

Sorts the actions (based on their evaluation in various dimensions) and carries out the action(s) to address the hypothesis/hypotheses with highest priority first.

Prioritize Hypotheses

Evaluates the probable client needs/concerns and problems generated previously in various dimensions and organize them into an ordered list where the priority hypotheses are on the top. (ABCs, Maslow, safety, acute v chronic, unstable v stable, urgent v non-urgent)

Reflecting

Evaluate

Recognize Cues

Obtain information from different sources (e.g., the environment, the pt., the family, another nurse, EHR) in different formats (e.g., visual observation, audio perception, lab results, text description, etc.).

Evaluation

Compare and contrast what happened with your plan of care against what was expected/anticipated (disease progression, unique client response) and decide whether additional clinical decisions are needed.

Clinical Judgement (The expected/anticipated outcomes or SMART GOALS)

These should be written in a SMART format for patient goals.

For examples:

The patient will have decreased pain by verbalizing pain score 3/10 or below by the end of the shift.

The patient will maintain clear airway by effectively coughing by the end of the shift.

Generate Solutions

Develops a list of actions to address the hypotheses. Give rationales for each solution.

Responding

Interpreting

Observation

Implement

Planning

Analysis

Assessment

Analyze Cues

Interprets cues from their existing knowledge base and nursing perspective, evaluate cues in terms of relevancy, importance, and interrelationship among other cues, organize cues in the mental representation of the scenario (e.g., organize cues in clusters), and then develops a group of probable client needs/concerns and problems

References

Use APA format and hanging indents for all references.

If you have any questions, please consult the APA 7th Edition.

SK/DW 2/22 pg. 1

Final Version 3/10/22 DW/ss & MS Team