CJM-Table

Recognize Cues Analyze Cues Prioritize Hypotheses Generate Solutions Take Action Evaluate Outcomes
What clinical Based on your From Analyze Cues What potential What interventions What findings would
manifestations, labs, or identified clinical column what is the interventions are need to be performed indicate an
diagnostics are manifestations, what priority diagnosis or needed for this patient? immediately? List the improvement? What
abnormal for this possible disease problem? Why is this What are the top 3 interventions finding would decline?
patient? Consider Risk processes or problems the priority problem or contradictions if any? need for this patient
Factors and history exist? List the problem diagnosis? (if you need This should be an all- right now for priority
and the clinical or use a resource for inclusive list of what problem.
manifestations that the why please cite it interventions or
support the and reference it) treatments are needed
problem/diagnosis. to care for this patient.
Dx Hypovolemia Dehydration: • Administer IV • Administer IV Improvement:
Hypovolemia poses a fluids to correct fluids to correct Increased urine output.
• Inguinal Hernia significant threat to Dehydration could dehydration. dehydration. • Improved
• Herniorrhaphy hemodynamic stability exacerbate Parkinson’s • Monitor fluid • Implement fall cognitive
• Small bowel and organ perfusion, symptoms, impair intake and precautions and function and
resection increasing the risk of cognitive function, and output closely. provide responsiveness.
complications such as lead to weakness and • Provide oral assistive • Decrease in
Assessments organ dysfunction, instability, all consistent devices. tremors and
rehydration
Neuro: shock, and even death if with the assessment solutions or • Ensure timely drooling.
• Patient left untreated. findings. It’s the highest fluids in small, medication • Stable vital
responds to • Delayed priority as dehydration frequent administration. signs.
questions capillary refill can quickly lead to amounts.
slowly.
suggests serious complications in • Assess for signs Decline:
Cardiac:
decreased elderly patients. of electrolyte • Continued
• +1 pulses imbalance and refusal of fluids.
peripheral
(indicating a
perfusion, adjust • Decreased urine
weak pulse). medication
which may output or signs
• Warm, dry skin. accordingly. of worsening
• Capillary refill of indicate
• Ensure timely dehydration.
4 seconds ongoing
medication • Increased falls
(slightly hypovolemia
administration. or instability
delayed). despite the • Implement fall despite
GI: administration precautions and interventions.
• Firm abdomen. of IV fluid bolus. assistive devices • Decline in
• Slightly • +1 pulses and to prevent cognitive
distended. slightly further falls. function or
GU: distended responsiveness.
 • 100 mL of urine abdomen are • Educate patient
output in the also indicative and family on
last hour. of hypovolemia, the importance
• Clear yellow as the body of hydration
urine. attempts to and medication
Resp: compensate for adherence.
• Clear breath decreased
sounds.
blood volume.
• Regular non-
• Slow response
labored effort.
to questions
Vital Signs:
may be a sign of
• T: 99.4°F (oral
cerebral
temperature).
hypoperfusion
• HR: 90 beats due to
per minute. inadequate
• RR: 18 breaths blood volume.
per minute. Postoperative
• BP: 110/70 mm Complications
Hg. • Firm and
• Sats: 98% on slightly
room air. distended
The patient’s slow abdomen may
response to questions indicate
may indicate altered postoperative
neurological function. complications
The +1 pulses and such as bowel
delayed capillary refill obstruction,
suggest possible ileus, or surgical
hypoperfusion. site
The firm abdomen and complications
slight distension could like hematoma
be related to or seroma
postoperative effects or formation.
underlying conditions. • Elevated
The urine output of 100 temperature of
mL in the last hour is 99.4°F oral may
within the expected suggest a
range. postoperative
inflammatory
The clear yellow urine response or
indicates normal renal possible
function. infection.
Vital signs are generally Risk factors
stable, except for the • Trauma
slightly elevated • Fluid Loss
temperature.