Description
Do a Clinical Judgement Plan based on the document uploaded.
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Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date
SK/DW 2/22 pg. 1
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
History of Present Illness (HPI)
Patient Information
(1)
Patient Initials:
Age & Gender:
Medical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED MEDICAL PROBLEMS
Height/Weight:
Code Status:
Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
Living Will/ DPOA:
Chief Complaint
Ex: SUBJECTIVE (Abnormal – Bullet Points)
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Admitting Diagnosis & Admission
Date
Cultural considerations, ethnicity, occupation, religion, family support, insurance.
(1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial
Considerations/Concerns: include the following Social Determinants of Health
(SDOH) (SEE RUBRIC REQUIREMENTS)
Erickson’s Developmental Stage Related to pt. & Cite References (1)
*List and Discuss specific stage (based on objective assessment)
(SEE RUBRIC REQUIREMENTS)
Final Version 3/15/22 DW/ss & MS Team
Clinical Judgement Plan
Medical Management and Collaborative Plan
(From MD, PT, OT notes…. etc.) *Consider past 24 – 48 hours
(SEE RUBRIC REQUIREMENTS)
Instructor:
DATE Care Provided and UNIT:
TIME OUT!!! Student instructions:
Include Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values
(With normal ranges), include dates and rationales supported with Evidence Based Citations
Include 2-3 nursing interventions for abnormal labs and for all diagnostic procedures
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
EQUIPMENT
Lab Tests or
Diagnostic Scan
Normal
Ranges
Admission
Lab Values
Current Lab
Values
Explain Abnormal Labs R/T
Your Pt & NI
(USE SEPARATE ATTACHED
WORD DOC → WHEN
NEEDED)
MEDS
TREATMENT
TIME OUT!!! Student instructions:
(SEE RUBRIC REQUIREMENTS)
Patient Education (In Pt.) for Referrals/ Discharge Planning
REFERRALS NEEDED/CASE Management
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
TIME OUT!!! Student instructions:
Pathophysiology of Primary Medical Dx (reason for
hospitalization) Support with Evidence Based Citations
Pathophysiology of Primary Medical Dx (reason for
TIME OUT!!! Student
instructions:
hospitalization)
INCLUDE:
Appropriate Diagnostic
Tests/ ProceduresDATEs and RESULTS
(Can add → See
attached Word Doc)
Final Version 3/15/22 DW/ss & MS Team
Clinical Judgement Plan
Instructor:
TIME OUT!!! Student instructions:
DATE Care Provided and UNIT:
Medication Name
Include BOTH Generic
AND Trade names for
RX; include OTC,
herbal (nonpharmacological items)
Dose
Medications & Allergies (2)
Route
Freq.
Indications
Mechanism of Action
NOTE:
PRN
‘alone’
≠ Freq
(PRN meds must
include MD
ordered Indication)
Final Version 3/15/22 DW/ss & MS Team
Side Effects/
Adverse Reactions
Nursing Considerations specific to this
patient with citations
What cues will you observe for?
What will you monitor (labs, vitals, etc?)
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
ASSESSMENT/History of Present Illness /REVIEW OF SYSTEMS
TIME OUT!!! Student instructions:
Physical Assessment Findings including presenting signs and symptoms that you will complete for this patient supported with Evidence Based Citations
Vital Signs (4)
Neurological (5)
Cardiovascular (6)
Respiratory (7)
Musculoskeletal (8)
GI/Hydration/Nutrition (9)
GU (10)
Rest/ Exercise (11)
Integumentary (12)
Endocrine (13)
Psychosocial (14)
BP:
HR: (Rhythm)
RR:
Temp:
O2 (any supplemental)
Pain (0/10)
Ht (cm)
Wt. (Kg)
BMI:
Final Version 3/15/22 DW/ss & MS Team
MISC:
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
TIME OUT!!! Student instructions:
To be sure your clinical judgement statements written below are accurate. You need to review the defining characteristics and related factors associated with and see how your patient data match.
Do you have an accurate match or are additional data required, or does another cue from abnormal assessment findings need to be investigated?
Observation
Interpreting
Assessment
Recognize Cues
Responding
Analysis
Analyze Cues
Planning
Prioritize Hypotheses
Generate Solutions
Implement
Take Action
Clinical Judgement (The expected/anticipated outcomes or SMART GOALS)
Reflecting
Evaluate
Evaluation
Compare and contrast what happened with your plan of care against what was expected/anticipated (disease progression, unique client
response) and decide whether additional clinical decisions are needed.
Final Version 3/15/22 DW/ss & MS Team
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
References
Use APA format and hanging indents for all references.
If you have any questions, please consult the APA 7th Edition.
Final Version 3/15/22 DW/ss & MS Team
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