Department of Nursing
Clinical Judgment Model &
the NCSBN Clinical
Judgment Measurement
Model
e.
Clinical
Judgement
Clinical judgment is defined as the observed outcome of
critical thinking and decision-making.
It is an iterative process that uses nursing knowledge
to observe and access presenting situations, identify a
prioritized client concern, and generate the best
possible evidence-based solutions in order to deliver safe
client care
NCSBN Clinical Judgment Measurement
Model
Case Study-Infection Control
The nurse is caring for a 3-year-old pediatric client who has been admitted to
the hospital for care secondary to respiratory syncytial virus (RSV) infection
and pneumonia. The client is learning to cover their cough and sneeze but
does not do it routinely. The child’s mother is with the client most of the time.
The client demonstrates fear of the nursing staff by crying when they enter
with a mask and gown to provide care for the child, making it difficult to
complete assessments of the client’s condition. The mother has requested that
staff do not wear masks when entering the room to prevent the child from
being fearful. The child demonstrates some respiratory difficulty with mild
intercostal retractions and respiratory rate of 32. Other vital signs include HR
110, Temp 101.2°F. The child is receiving antibiotics intravenously, nebulized
breathing treatments, and antipyretics. This is the child’s first hospitalization.
Recognize cues
Identify relevant a n d important information f r o m
d i ff e r e n t s o u r c e s (e.g., m e d i c a l h i s t o r y, v i t a l signs).
•
What information is relevant/irrelevant?
•
What information is m o s t important?
•
W h a t is o f i m m e d i a t e c o n c e r n ?
D o not c o n n e c t c u e s w i t h h y p o t h e s e s j u s t y e t .
@Pearson
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National Council a / S t a t Boards of
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Recognize
cues
The child is receiving antibiotics intravenously,
nebulized breathing treatments, and antipyretics.
This is the child’s first hospitalization.
The child demonstrates some respiratory difficulty with
mild intercostal retractions and respiratory rate of 32.
Other vital signs include HR 110, Temp 101.2°F.
The client demonstrates fear of the nursing staff by
crying when they enter with a mask and gown to provide
care for the child
Analyze cues
Organizing a n d l i n k i n g t h e recognized cues to the client's
clinical p r e s e n t a t i o n .
•
W h a t c l i e n t c o n d i t i o n s a r e c o n s i s t e n t w i t h t h e cues?
•
Are t h e r e cues t h a t s u p p o r t o r c o n t r a i n d i c a t e a
particular condition?
•
W h y is a p a r t i c u l a r c u e o r s u b s e t of cues of concern?
•
W h a t o t h e r i n f o r m a t i o n w o u l d h e l p establish the
significance of a c u e or set of cues?
Consider m u l t i p l e t h i n g s t h a t c o u l d b e h a p p e n i n g .
N a r r o w i n g t h i n g s d o w n c o m e s at the n e x t s t e p .
@Pearson
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National Council of S t a t Boarch of Nursin,
Analyze
cues
Consistent with:
• RSV
• Child developmental level
• Fever & lack of prior history decrease likelihood
of asthma
Concerns:
• Airway
• Infection-contagion
• Child’s fear/parental request vs infection control
priorities
Prioritize hypotheses
Evaluating a n d r a n k i n g h y p o t h e s e s
a c c o r d i n g to p r i o r i t y (urgency,
l i k e l i h o o d , risk, d i ff i c u l t y, t i m e , etc.).
•
Which explanations are most/least
likely?
•
W h i c h possible e x p l a n a t i o n s a r e
t h e m o s t serious?
Evaluating a h y p o t h e s i s s h o u l d
i n c l u d e j u s t i f i c a t i o n (i.e., the why).
R a n k i n g w i l l typically uses phrases like
" m o s t likely."
@Pearson
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Prioritize hypotheses
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Most likely
RSV with age of child, possibly with time of year/community
prevalence
Strep is possible, but no c/o sore throat, red or swollen tonsils
Covid is possible and symptoms are similar, but the RSV
diagnosis is given
Asthma is possible, but not as likely with no prior history
Most serious
Airway is most pressing concern with RSV
Generate solutions
Identifying expected outcomes and using hypotheses
to d e f i n e a s e t o f i n t e r v e n t i o n s f o r t h e e x p e c t e d
outcomes.
•
What are the desirable outcomes?
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W h a t interventions c a n achieve those outcomes?
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What should be avoided?
Focus on goals a n d m u l t i p l e p o t e n t i a l i n t e r v e n t i o n s n o t j u s t t h e b e s t o n e - t h a t c o n n e c t t o t h o s e goals.
Potential solutions could include collecting additional
information.
@Pearson
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NCSBN
National Council a / S t a t Boards o/Nursi,w
Generate solutions
• Client will maintain an oxygen saturation of 95%
with RR of 30 or less
• Client will not display flaring, retractions, or
respiratory difficulty while at rest.
•
Assess oxygenation; administer nebulizer meds as
ordered
• Client temperature will remain below 100.3°F
•
Antipyretics as ordered, assess temperature q 4h
• Client will adapt to the sight of nursing staff with
masks and gowns
Take action
I m p l e m e n t i n g t h e s o l u t i o n ( s ) t h a t a d d r e s s e s the h i g h e s t p r i o r i t i e s .
•
Which intervention or combination of interventions is m o s t
appropriate?
•
H o w should the intervention(s) b e accomplished (performed,
requested, administered, communicated, taught, documented,
etc.)?
For " h o w " q u e s t i o n s , e n s u r e t h a t specific e l e m e n t s f r o m t h e
s c e n a r i o a r e w h a t d e t e r m i n e s a p p r o a c h . Av o i d m e m o r i z e d o r
"textbook" procedures. The i t e m stem and/or the responses
should include action verbs.
@Pearson
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• • • ■ ■ N C S B N
N'otionol Council of State Boards of Nurdng
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Take
action
Administer antibiotics,
antipyretics, nebulizer meds as
ordered.
• Ongoing assessment of respiratory effort of the client,
including pulmonary assessment for adventitious sounds
and pulse oximetry
• Consult with child life to explore ways to make the
necessary masks less threatening to the child
•
Can assessments be done while the child is held by the mothershort term solution?
• Educate the parent about the reasons for the mask and gown
Evaluate outcomes
C o m p a r i n g o b s e r v e d o u t c o m e s against
expected o u t c o m e s .
•
W h a t signs p o i n t t o i m p r o v i n g / d e c l i n i n g /
u n c h a n g e d status?
•
We r e the i n t e r v e n t i o n s effective?
•
Wo u l d o t h e r i n t e r v e n t i o n s h a v e b e e n m o r e
effective?
I t e m d e v e l o p m e n t s h o u l d focus o n the efficacy
of the i n t e r v e n t i o n ( s ) f r o m t h e p r e v i o u s
items.
@Pearson
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• • • N C S B N
Nolionol Cotzncil of Stqtc Boordsof NiAr,irtg
Evaluate outcomes
• Client maintained an oxygen saturation of 95%
with RR of 30 or less
• Client did not display flaring, retractions, or
respiratory difficulty while at rest.
• Client temperature remained below 100.3°F
• Client was willing to be assessed by nursing staff
wearing masks and gowns
Level 3 & Questions
Recognize
Cues
Assessment
Analyze Cues
AssessmentAnalyze
Prioritize
Hypotheses
AnalyzePlanning
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Settin
gs &
Resource
s
Demo
graphics
&
History
Norm
al &
Abnorma
l
Findings
Speci
al
equipme
nt
Time
pressures
What
impacts data
analysis?
Demographi
cs
-History
•
What
pathophysiol
ogy relates
to the
clinical
presentation
?
•
What are
client needs?
•
Potential
complication
s.
Generate
Solutions
Planning
What
•
What
is the
interventi
priority
ons are
need?
needed to
•
What
address
are the
the
other
client’s
needs of
needs?
the client? •
Any
•
What
inappropr
impacts
iate
the needs
interventi
of the
ons?
client?
•
What
-Resources
impacts
the list of
Demographics
interventi
-History
ons?
-Resources
Demographi
cs
-History
Take
Action
Implemen
tation
•
•
•
Evaluate
OutcomesEvaluate &
Revise
Wh •
at
action
s
should
be
taken?
Is
there a
priorit
y
action
?
Wh
at
impact
s the
chosen
action
s?
-Resources
Demograp
•
•
•
•
What
outcomes
are
expected?
What
outcomes
are
achieved?
Are
resources
needed to
evaluate
the
outcomes?
What
should be
assessed?
What
should be
reassessed
?
BSU Department of Nursing Clinical Judgment Concept Map
Pathophysiology
Risk factors
Signs/symptoms
Diagnosis/Treatment
Medical diagnosis- reason to
seek care
Treatment/Medications
Comorbidities
Patient education
Nursing diagnosis-concept
Three Concepts-One Map
Pathophysiology
Risk factors
Signs/symptoms
Pathophysiology
Risk factors
Diagnosis/Treatment
Signs/symptoms
Diagnosis/Treatment
Medical diagnosis- reason to
Medical diagnosis- reason to
Treatment/Medications
seek care
seek care
Comorbidities
Treatment/Medications
Comorbidities
Nursing diagnosis-concept
Nursing diagnosis-concept
Patient education
Pathophysiology
Risk factors
Signs/symptoms
Diagnosis/Treatment
Medical diagnosis- reason to seek
care
Treatment/Medications
Comorbidities
Nursing diagnosis-concept
Patient education
Patient education