Clinical Judgment Model Concept Map

Title: Post- Op Patient Assessment ___ Name: Gabriella Aguilar Diaz__ Date:__July 2023____

• PMHx
DM2
Depression
Asthma
• Current medication
Metformin 1000mg BID
Zoloft 75mg daily
Ventolin PRN
Atrovent PRN
Recognize Cues • Post op right total knee arthroplasty
Filter information from different sources (eg:
• Serosanguineous draining in drain
signs, symptoms, medical history, etc)
• Dressing to right knee dry and intact
• Vitals
BP 136/75 , P 108, RR 20 , Spo2 97% on
RA, T 36.8
• Pain 7/10
• Receiving morphine via PCA pump
• Nausea
• Red, itchy rash to neck and chest

• Pulse, RR, and BP are elevated from

baseline which could indicate;
Analyze Cues Allergic reaction
Organizing and linking the recognized cues above Post-op infection
to step to the client’s clinical presentation. Poorly managed pain
Candidates should establish probable client needs, • Observed red, raised rash and states
concerns, or problems. itchiness to an area
• c/o nausea (allergic reaction indicator)

Prioritize Hypothesis • Mild allergic reaction to narcotics

Evaluating and ranking hypotheses according to
priority (urgency, likelihood, risk, difficulty, time,
etc.)
Generate Solutions
Identifying expected outcomes and using
hypotheses to define a set of interventions for the
expected outcome
• Urgent not emergent Due to adequate
airway.
• Antihistamines to resolve itch and rash
• Antiemetic to resolve nausea
• Pain management with alternative
analgesic

• Immediately stop administration of pain

Take Action
medication from PCA pump
Implementing the solution(s) that addresses the
highest priorities. Important to recognize that
sometimes no action is an action itself
Evaluate Outcomes
Comparing observed outcomes against expected
outcomes
• Administer an antihistamine and
antiemetic to treat symptoms
• Notify primary physician
• Administer new ordered medication
• Continue to monitor
• Vital signs return to baseline
• Resolve itchiness, rash, and nausea
• Manage pain effectively with new pain
medication and observe reactions.