Clinical Assessment Presentation

What data are RELEVANT and must be interpreted as clinically significant by the nurse?

Step 1: Recognize Clues

NCSBN Clinical Judgement

Interpreting relevant clinical data, identify the most likely problem(s). Is additional data needed to confirm the significance of clinical cues collected so far?

Step2:Analyze Clues

• Utilize the information from your comprehensive assessment and monitoring of your patient to work through Layer 3 of the NCSBN Clinical Judgement Model. • Layer 3 outlines the cognitive aspects of clinical decision making that are directly measurable.

Rank the most likely problems by urgency.

Step 3: Prioritize hypotheses

Which problem is most likely present? What problem is most concerning? Why?

Step 3: Prioritize hypotheses

Based on the most pressing problem, what are the priority actions?

Step 4: Generate solutions

Step 5: Take action

Evaluate the patient’s response. Recognizing relevant clinical data, has the patient status improved, declined, or remained unchanged?

Step 6: Evaluate outcomes

• Answer the questions in the provided boxes on the table.

If the patient status has not improved, what problem may be present? What additional interventions need to be considered?

Step 6: Evaluate outcomes

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