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Clinical Judgment
CJMM Process Reference

NCSBN 2019 6 Cognitive Operations D442 Reference

Clinical Judgment Measurement Model

A complete process reference for WGU pre-licensure nursing students. Clinical judgment is the observable result of critical thinking and decision-making that guides the nurse's actions and decisions, ultimately influencing the plan of care.

Sound clinical judgment is critical because nurses' decisions directly influence patient outcomes.

1 · Recognize Cues 2 · Analyze Cues 3 · Prioritize Hypotheses 4 · Generate Solutions 5 · Take Action 6 · Evaluate Outcomes

Overview: The 6 Cognitive Operations

Step	Operation	Core Question
1	Recognize Cues	What information exists and what matters?
2	Analyze Cues	What does the data mean?
3	Prioritize Hypotheses	Which problem is most urgent?
4	Generate Solutions	What is the plan?
5	Take Action	Implement the plan
6	Evaluate Outcomes	Did it work?

Iterative process: A declining or unchanged status at Step 6 restarts the cycle at Step 1 with updated data.

Step 1 Recognize Cues

Gather Data

Type	Definition	Sources
Objective	Measurable; gathered via 5 senses	Physical exam, EHR, labs, diagnostics, observation
Subjective	Non-measurable; patient/family report	Health history, hand-off report, family/caregiver, care team

Optimize Data Collection

The First Few Minutes Count

Observe before acting. Jumping into tasks without first listening and observing leads to missed cues and overlooked key information.

Recognize Nonverbal Cues

Ensure a nonjudgmental environment
Look for congruence between body language, facial expressions, and verbal messages

Therapeutic Communication

Open-ended statements
Repeating information for clarity
Active listening
Use of silence

Communication Barriers

Culture and language barriers
Level of consciousness
Developmental level and age
Emotional state; presence of others

Health History Components

Patient ProfileMedical HistorySurgical HistoryMedication HistoryAllergiesNutritional HistoryReview of SystemsSocial HistoryHealth-Related Quality of Life

Social history is especially important for older adults: living arrangements, economic resources, family/friend support, and community resources.

Review of Systems (ROS)

System	Key Cues to Elicit
Constitutional	Energy level, fatigue, unexplained weight changes, fever
Senses (HEENT)	Vision/hearing changes; dental caries; taste/smell changes; bleeding gums
Respiratory	Shortness of breath and circumstances; frequency of respiratory problems; need to sleep with head elevated
Cardiac	Chest/shoulder/jaw pain; palpitations; antianginal medication use; bruising/bleeding on anticoagulants
Vascular	Extremity cramping; decreased sensation; edema (time of day/amount); cyanosis or skin color changes
Urinary	Changes in urine stream; difficulty starting stream; incontinence (circumstances, degree, strategies)
Sexual	Desire and ability; age-related changes (vaginal dryness, erectile dysfunction)
Musculoskeletal	Joint/back/muscle pain; gait changes; stiffness; effect of limited mobility on daily life
Neurological	Sensation changes; memory changes; cognitive activities; balance/dizziness; history of falls, trips, slips
Gastrointestinal	Incontinence, constipation, bloating, anorexia; changes in appetite
Integumentary	Dryness; injury frequency; healing speed; itching; skin cancer history; sun exposure

Older adults: Full head-to-toe exam is rarely possible with medically complex/frail patients. Prioritize based on the presenting problem. Include proxy information for cognitively impaired patients.

Head-to-Toe Physical Examination

The examination begins with the initial patient encounter and proceeds systematically to minimize position changes and conserve patient energy.

Phase 1 — General Inspection (All Positions)

Observe from the moment of greeting:

Skin colorFacial expressionMobility & postureDress & hygieneSpeech & hearingOrientation & mental alertness

Vital Signs:

Temperature · Pulse · Respirations · Blood Pressure · Oxygen Saturation

Phase 2 — Patient Seated (Gown On): HEENT, Neck, Upper Extremities

Head & Face

Skin characteristics; scalp/hair; facial bones; TMJ; CN V, VII testing (clench jaw, smile, wrinkle forehead)

Eyes

Eyelids, iris, sclera, conjunctiva; pupillary response; extraocular movements (CN III, IV, VI); visual fields (CN II); red reflex

Ears

Inspect auricle; whisper test (CN VIII); Rinne and Weber tests if indicated

Nose

Septum structure/position; nostril patency; mucosa, septum, and turbinates

Mouth & Pharynx

Lips, gums, oropharynx, teeth, tongue (CN XII); gag reflex and soft palate (CN IX, X)

Neck

Thyroid; ROM; shoulder shrug (CN XI); carotid pulses (one at a time); tracheal position; lymph nodes; auscultate carotids and thyroid

Upper Extremities

Skin/nails; muscle mass symmetry; joint ROM and strength (fingers, wrists, elbows, shoulders); radial and brachial pulses

Phase 3 — Patient Seated (Back & Chest Exposed): Lungs, Heart, Breasts

Posterior Chest / Lungs

Inspect thorax and skin; palpate for expansion and tactile fremitus; percuss (including diaphragmatic excursion); auscultate breath sounds systematically

Anterior Chest / Heart

Palpate for thrills, heaves, pulsations; locate apical pulse; palpate axillary lymph nodes; auscultate at aortic, pulmonic, second pulmonic, mitral, and tricuspid areas

Female Breasts (Seated)

Inspect in 4 positions (arms at sides, overhead, hands on hips, leaning forward); bimanual digital palpation

Male Breasts

Inspect for symmetry, enlargement, surface characteristics; palpate breast tissue

Phase 4 — Reclining at 45°

Inspect chest; assess jugular venous distention and jugular pulsations.

Phase 5 — Supine (Chest & Abdomen Exposed)

Heart

Palpate for thrills, heaves, pulsations; auscultate; may turn patient left to repeat

Abdomen

Inspect contour, pulsations; auscultate 4 quadrants (bowel sounds) and aorta/renal/iliac/femoral arteries (bruits); percuss all quadrants and liver borders; lightly then deeply palpate; palpate midline for aortic pulsation. Inspect before percussing.

Inguinal Area

Palpate for lymph nodes, pulses, and hernias

Female Breasts (Supine)

Palpate with arm over head using light, medium, and deep palpation; depress nipple into areola

Male Genitalia

Inspect penis, urethral meatus, scrotum, pubic hair; palpate scrotal contents; test cremasteric reflex

Phase 6 — Supine (Legs Exposed)

Palpate hips for stability; test hip ROM and strength. Inspect skin, hair distribution, muscle mass. Palpate temperature, texture, edema, and pulses (dorsalis pedis, posterior tibial, popliteal). Test ROM and strength of toes, feet, ankles, and knees.

Phase 7 — Female (Lithotomy Position)

Don gloves; drape appropriately. Examine external genitalia (pubic hair, labia, perineum, anus); palpate labia and Bartholin glands; speculum exam (vagina and cervix); collect specimens if needed; bimanual palpation (uterus and cervix); rectovaginal or rectal exam if indicated.

Phase 8 — Patient Standing: Spine, Neuro, Male Genitalia & Rectal

Spine

Ask patient to bend at waist; inspect and palpate spine; assess ROM: flexion, hyperextension, lateral bending, trunk rotation

Neurologic

Romberg test · Heel-to-toe walking · Single-leg stance (eyes closed) · Hopping in place · Assess for inguinal and femoral hernias

Male Genitalia & Rectal (Standing)

Inspect glans penis, urethral opening, scrotum; palpate for testes, hernia, hydrocele. Rectal exam: lean over table, toes inward; inspect sacrococcygeal/perianal area; palpate sphincter tone, rectal masses, and prostate gland; test for occult blood if indicated.

Categorize Findings

Nurses sort collected assessment data into three categories (NCSBN, 2019) to provide context for decision-making and prioritizing patient needs.

Category	Sub-label	Definition
Relevance	Relevant Irrelevant	Relevant: Important information about the disease condition or patient complaint — gathered from interview, physical exam, observation, health record, and signs/symptoms. Irrelevant: Information that does not affect the patient's current condition.
Importance	Important	The most significant of the patient findings — these take priority in the plan of care.
Degree of Concern	Urgent	Demands immediate attention — generally relates to airway, breathing, circulation, and safety.

Category	Cues
Relevant	Fever, yellowish mucus, labored breathing, coarse crackles, elevated vital signs, O₂ use, prolonged capillary refill, oriented, age
Irrelevant	Gender
Important	Respiratory signs/symptoms, oxygenation, and circulation
Urgent	Shortness of breath, adventitious breath sounds, labored breathing (increased work of breathing)

Step 2 Analyze Cues

Cue clustering is the process of grouping linked/related cues that point toward the same problem and generating an ICNP hypothesis from each cluster. The terms hypothesis and ICNP diagnosis are used interchangeably in the CJMM framework.

Tools That Support Cue Analysis

Tool	Purpose
SAMPLE	Signs/Symptoms · Allergies · Medications · Pertinent Hx · Last Oral Intake · Events — generates raw cue data for clustering
OPQRST	Onset · Provocation/Palliation · Quality · Region/Radiation · Severity · Timing — characterizes symptoms to distinguish competing hypotheses
Medication Reconciliation	Surfaces interaction risk, adherence patterns, and medication history cues
Teach-Back Method	Generates cues about patient understanding and readiness to learn

ICNP Hypotheses by Clinical Domain

Personal Hygiene

Cue Cluster	Hypothesis
Physical barrier to self-care (broken arm, impaired mobility)	Self-Care Deficit
Cognitive barrier to self-care (dementia, confusion)	Impaired Health Maintenance
Fatigue/dyspnea with activity; poor hygiene	Activity Intolerance
Red gums, halitosis, lesions, dry mouth, gingivitis	Impaired Oral Mucous Membrane
Flaky, cracking skin; systemic dehydration	Dry Skin
Redness/tissue loss over bony prominence	Pressure Ulcer/Injury
Redness, swelling, weeping from sudden injury	Traumatic Wound

Key distinction: Self-Care Deficit = physical barrier · Impaired Health Maintenance = cognitive barrier

Mobility

Direct

Cue Cluster	Hypothesis
Limited ROM, fractures, contractures, amputations, inability to ambulate	Impaired Mobility
Loss of sensation/movement; quadriplegia, paraplegia, hemiplegia	Paralysis
Weakness, dizziness, orthostatic hypotension, high fall score, reduced bone density	Fall / Risk for Fall
Dyspnea on exertion; O₂ sat <90% during activity; pulse >100 bpm with activity	Activity Intolerance

Indirect (complications of immobility)

Cue Cluster	Hypothesis
Immobility/bed rest; leg cramps; calf pain; redness	Risk for Deep Vein Thrombosis
Muscle atrophy; loss of strength; unsteady gait; orthostatic hypotension	Weakness
Redness/breakdown over bony prominence; Braden ≤18; immobile/paralyzed	Impaired Skin Integrity / Risk for Impaired Skin Integrity
No desire to eat; intake <30%; muscle weakness; weight loss	Deficient Food Intake / Risk for Deficient Food Intake
Hard/infrequent stools; straining; hypoactive bowel sounds; opioid use; immobility	Constipation / Risk for Constipation
Withdrawn; anxious; angry; depressed; alone due to mobility alterations	Social Isolation / Risk for Social Isolation

Nutrition

Cue Cluster	Hypothesis
Weight loss; poor intake; low BMI; cachexia	Deficient Food Intake
Excess intake; obesity; high BMI	Excess Food Intake
Gagging/choking with oral intake; coughing during/after swallowing; spitting out food	Impaired Swallowing
Reluctance to move; loss of appetite; social withdrawal; psychomotor slowing	Depressed Mood
Dry mucous membranes; poor skin turgor; decreased urine output	Dehydration

Medication Administration

Cue Cluster	Hypothesis
Inappropriate route for patient condition (e.g., IM ordered with insufficient muscle mass)	Risk for Injury
Allergy history + newly prescribed cross-reactive drug (e.g., sulfur allergy + sulfonamide)	Risk for Allergic Reaction
Multiple pharmacies; multiple providers; supplements; no primary HCP	Risk for Adverse Medication Interaction
Patient cannot name or explain medications (e.g., "heart pill", "sugar pill")	Lack of Knowledge of Medication Regimen
Dexterity/memory impairment + older adult living alone	Impaired Ability to Manage Medication Regimen

Urinary Elimination

Cue Cluster	Hypothesis
Hesitancy; weak stream; bladder fullness; minimal urine output	Urinary Retention / Impaired Urination
Leakage with coughing, sneezing, or lifting	Stress Incontinence
Leakage with sudden urgent need to void	Urge Incontinence
Both stress and urge patterns present	Mixed Incontinence
Mobility/cognitive limitation preventing timely toilet access	Functional Incontinence
Dribbling; incomplete emptying; overflow leakage	Overflow Incontinence
Fever; dysuria; cloudy urine; catheter in place	Risk for Urinary Tract Infection / CAUTI
Constant moisture from urine leakage on perineal/sacral skin	Risk for Impaired Skin Integrity

Bowel Elimination

Cue Cluster	Hypothesis
Infrequent hard stools; straining; hypoactive bowel sounds; abdominal distension	Constipation
No BM for days + palpable hard mass + liquid stool seeping around mass	Fecal Impaction
Frequent loose or liquid stools; increased transit time	Diarrhea
Inability to control passage of stool	Bowel Incontinence
High-volume diarrhea + dry mucous membranes + poor skin turgor + decreased output	Dehydration
Bowel incontinence + immobility + moisture on skin	Risk for Impaired Skin Integrity
Social withdrawal; embarrassment; avoidance related to elimination issues	Disturbed Body Image

Step 3 Prioritize Hypotheses

Once hypotheses are identified, rank them using the following hierarchy in order:

#	Priority Level	Criteria	Examples
1	Life-Threatening	Always addressed first	Anaphylaxis, sepsis, pulmonary embolus, cervical fracture affecting breathing
2	ABCs	Airway → Breathing → Circulation	Respiratory and cardiac problems take priority over all others. Active/uncontrolled bleeding is a Circulation priority — hemodynamic compromise threatens perfusion and is addressed at this tier.
3	Immediate Concern	Most urgent, serious, or likely; consider probability	Active problems addressed before potential ones; likelihood matters
4	Eliminates Other Hypotheses if Resolved	Resolution cascades and removes lower-tier problems	Resolving Weakness eliminates Risk for Fall; resolving Self-Care Deficit resolves Dry Skin

The ABC Framework in Depth

ABCs is the foundational triage algorithm nurses use to rank hypotheses when multiple problems coexist. The sequence is strict: A → B → C. A hypothesis threatening a higher letter always takes precedence over one threatening a lower letter, regardless of how urgent the lower problem appears.

A — Airway

Without a patent airway, no other intervention matters.

Obstruction (foreign body, edema, secretions, tongue)
Stridor, absent/diminished breath sounds
Inability to speak, swallowing impairment threatening aspiration
Post-extubation edema; anaphylaxis-related swelling

Nurse actions: position, suction, call rapid response, prepare for intubation

B — Breathing

Airway open but ventilation or oxygenation compromised.

SpO₂ <90%; RR <8 or >30; labored breathing
Adventitious sounds: crackles, wheezes, absent breath sounds
Accessory muscle use; intercostal retractions
Respiratory distress from asthma, COPD exacerbation, pneumothorax, pulmonary edema

Nurse actions: apply O₂, elevate HOB, administer bronchodilators, prepare for intubation if escalating

C — Circulation

Airway and breathing intact but perfusion threatened.

Active/uncontrolled bleeding → direct pressure, IV access, fluids
Hypotension, tachycardia, weak/thready pulse
Capillary refill >3 sec; pale/mottled/diaphoretic skin
Chest pain with hemodynamic instability (MI, PE)
Severe dysrhythmias; signs of shock

Nurse actions: IV access, fluid resuscitation, cardiac monitoring, notify provider, prepare vasoactive medications

Key decision rule: When cue analysis produces both an ABC hypothesis and a non-ABC hypothesis simultaneously, the ABCs always win. For example, if a patient has both Risk for Allergic Reaction (threatening airway/circulation) and Lack of Knowledge of Medication Regimen, address the allergic reaction first — a knowledge deficit poses no immediate physiological threat. Education waits until the patient is stable.

Maslow's Hierarchy as a Supporting Framework

Maslow's hierarchy produces the same prioritization sequence as the ABCs but explains why: physiological needs (oxygenation, circulation, fluid balance, thermoregulation) must be met before safety needs (freedom from injury, medication error), which must be met before psychosocial/learning needs (knowledge of regimen, self-management). Use Maslow when students ask "why does this rank higher?" — the ABCs tell you what to do first; Maslow tells you why.

Special Consideration: When Is a Fever a Priority?

Fever is not automatically high-priority — its tier depends entirely on the accompanying clinical picture.

Priority	Clinical Scenario	Rationale
1 — Life-Threatening	Fever + hypotension + tachycardia + cold/clammy skin + altered mentation	Sepsis / septic shock — systemic infection has infiltrated the bloodstream; multi-organ failure risk
2 — ABCs	Fever + tachypnea + SpO₂ <90% + labored breathing (e.g., pneumonia)	Respiratory compromise (B) is now present; fever is a cue pointing to the source but the breathing problem sets the tier
3 — Immediate Concern	Fever >102 °F in an adult with stable vitals; fever >100.4 °F indicating pathogen colonization; any fever ≥100 °F in an older adult	Requires prompt assessment and provider notification but no immediate physiological crisis; in older adults even a low-grade fever may signal pending sepsis
4 — Monitor	Low-grade fever (<100.4 °F) in a young, otherwise stable patient with a known viral illness (e.g., influenza day 2)	Expected finding; monitor for escalation but no immediate intervention required

Older adult rule: Temperatures as low as 100 °F may indicate pending sepsis in older adults. Never dismiss a low-grade fever in a frail or medically complex patient — escalate and monitor closely.

Step 4 Generate Solutions

Write Measurable Goals (SMART)

SpecificMeasurableAttainableRealisticTimely

Every goal must answer: Who will achieve it · What is the achievement · When will it be achieved

Address both short-term (during hospitalization) and long-term (post-discharge) needs.

Care Plan Principles

Individualized based on patient needs
Involves the patient as much as possible
Does not rush the patient

Interdisciplinary Collaboration & Delegation

Team Member	Role
Physician / Health Care Provider	Medical diagnosis and treatment plan
Social Worker	Resources to help people improve their lives
Occupational Therapist	ADLs and adjustment to chronic conditions
Physical Therapist	Ambulation, ROM, and movement
Speech Therapist	Swallowing, chewing, and communication
Registered Dietitian (RDN)	Nutritional assessment and dietary planning
Mental Health Professional	Psychological or emotional issues
Home Care Agency	Post-discharge caregiving
Family Members	Physical, emotional, and financial support
UAP (Unlicensed Assistive Personnel)	Assistance with ADLs — nurse retains ultimate responsibility

SBAR — Escalating High-Priority Hypotheses

Component	Content
S — Situation	State the hypothesis and why it is urgent
B — Background	Patient history, medications, relevant context
A — Assessment	Clinical interpretation; hypothesis and severity
R — Recommendation	Specific action requested (order change, referral, intervention)

Step 5 Take Action

Carry out interventions specific to the identified hypothesis and domain
Apply patient-centered adaptations (cognitive impairment, sensory deficits, cultural/personal preferences)
Document: care type, date/time, assessment findings, patient response to care

"If you didn't document it — you didn't do it!"

Step 6 Evaluate Outcomes

Status	Indicators	Next Step
Improving	Patient meets expected indicators; goals achieved; self-care achieved	Continue and update plan as needed
Declining	Status worsens (e.g., falls, infection, skin breakdown)	Reassess; notify team; revise plan
Unchanged	Goals not yet met; patient continues to require assistance	Adjust interventions or timeline; restart the cycle

Example Outcome Statements

"Patient's skin is clean and intact."
"Patient uses large-handle toothbrush to perform oral care twice daily."
"Patient ambulates 25 ft without fatigue or shortness of breath."
"Fewer incontinence episodes within 48 hours."
"Patient verbalizes understanding of medication regimen before discharge."

The CJMM Cycle

1 · Recognize Cues→2 · Analyze Cues→3 · Prioritize Hypotheses→4 · Generate Solutions→5 · Take Action→6 · Evaluate Outcomes

If outcomes are Unchanged or Declining at Step 6, loop back to Step 1 with updated assessment data.