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Hi I need help doing an assignment. I will attach two documents. One is named (clinical judgement plan 1) this attachment will be filled out based on the attachment (process 5) if the information is missing then make it up based on what’s appropriate according to the patient. Please use apa citations for all the sources my professor is strict on that as it does go through turn it in.com. thank you.
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SK/DW 2/22 pg. 1
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
Patient Information
(1)
History of Present Illness (HPI)
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY
GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC → WHEN
NEEDED) (SEE RUBRIC REQUIREMENTS)
Patient Initials:
Age & Gender: Age in years/not DOB
Height/Weight:
Code Status:
Medical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED MEDICAL PROBLEMS
For each disease identified, define, it, describe pathophysiology, and cite source
Living Will/ DPOA:
Chief Complaint
Ex: SUBJECTIVE (Abnormal – Bullet Points)
What is the cause of the patients problem
now describing i.e., Pt is having SOB 8/10
with exertion?
Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
For each procedure identified, define & describe it; include year of procedure & cite source
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)
❋Economic Stability
❋ Education
❋Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
Final Version 3/10/22 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:
INCLUDE:
Appropriate Diagnostic
Tests/ ProceduresDATEs and RESULTS
(Can add → See
attached Word Doc)
Ex: The primary pathophysiologic process in COPD is
persistent but variable inflammation of the airways
(SEE RUBRIC REQUIREMENTS)
hospitalization)
Final Version 3/10/22 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 3/10/22 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 SYTEMS
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 3/10/22 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
Assessment
Recognize Cues
Obtain information from
different sources (e.g., the
environment, the pt., the
family, another nurse,
EHR) in different formats
(e.g., visual observation,
audio perception, lab
results, text description,
etc.).
Interpreting
Responding
Analysis
Analyze Cues
Interprets cues from their
existing knowledge base and
nursing perspective, evaluate
cues in terms of relevancy,
importance, and
interrelationship among other
cues, organize cues in the
mental representation of the
scenario (e.g., organize cues
in clusters), and then
develops a group of probable
client needs/concerns and
problems
Prioritize Hypotheses
Evaluates the probable client
needs/concerns and problems
generated previously in
various dimensions and
organize them into an ordered
list where the priority
hypotheses are on the top.
(ABCs, Maslow, safety, acute
v chronic, unstable v stable,
urgent v non-urgent)
Planning
Implement
Generate Solutions
Develops a list of actions to
address the hypotheses.
Give rationales for each
solution.
Take Action
Sorts the actions (based on
their evaluation in various
dimensions) and carries
out the action(s) to address
the hypothesis/hypotheses
with highest priority first.
Clinical Judgement (The expected/anticipated outcomes or SMART GOALS)
These should be written in a SMART format for patient goals.
For examples:
The patient will have decreased pain by verbalizing pain score 3/10 or below by the end of the shift.
The patient will maintain clear airway by effectively coughing by the end of the shift.
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 3/10/22 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 3/10/22 DW/ss & MS Team
Room
10
Patient/Age/Sex
E.J/ 75/ Male
Attending & consults
Bakhtary, Mariam MD
Allergies
None
Admit date
11/24/23
Isolation & organism
None
Code status
Full
Past medical hx
DM (2)
DVT, both lower extremities
CC/HPI
Back Pain, Necrotic Sacral Wound (from exacerbated DM)
Primary diagnoses
Past surgical hx
Pacemaker
Active DVT, Afib, Spinal cord abscess, infected pacemaker, cauda equina
(paralysis from waist down) Bacteremia
Neuro/Psych
GCS
Primary language English
Level of consciousness 4x
Eyes ___4__ WBC
Verbal 5___
Orientation & follow commands: Yes
Motor_6__
Mood/behavior: Good.
Total _15____
Pupils: PERRLA
Muscle strength: LUE __3___ / RUE ___3__ / LLE _0____ / RLE __0___ AST
Cardiac
Echo EF _____ % Heart rate trends Tele rhythm
trends AFIB
SBP/MAP trends & goal parameters AFIB
Temp trends & method/fevers & Tmax
Pulses: L rad ___2__ / R rad __2___ / L ped __2___ / R ped __2___
Edema & grading 2+
[YES ] Pacemaker / [ ] AICD
Respiratory
IS [ ] & trends/max _____ ml Lung sounds & work of
breathing/rhythm Normal Rate. Symmetrical
O2 delivery _____ @ _____ LPM / ___98__%
O2 sat trends Normal. (8% Rm air.
Secretion amt & character/suction method: NONE
Chest tube(s) output & character: NONE
ABG date __No info___: pH __7.37___ / pCO2 __4.5___ / HCO3 __24___
/ pO2 __77___
GI
Lt NG / Rt NG taped @ _____ cm / PEG
Continent/incontinent
Suction __________ / Output _____ ml NO info
Last BM & character: Morning, Brown, Normal
Current TF rate @ _____ ml/hr NONE
Bowel sounds ACTIVE
TF goal rate _____ ml/hr NONE
Abdomen appearance & palpation: Flat
TF max residual _____ ml NONE
Plt
Hgb
Hct
Glu
Na
Cl
K
CO2(HCO3) Cr
Ca Mag
BUN
Bili
Phos
ALT
INR
PT
aPTT
Alb
Alk
Phos
Labs BGM frequency _____ / 07 _____ 11 _____ 17 _____ 21 _____
GFR
________ HgbA1C ________
Troponin
________ Lactate ________
BNP
________ Procal ________
CK
________ CRP
________
D-dimer
________ ESR
________
Fibrinogen ________ Amylase ________
Ammonia
________ Lipase ________
UA _________________________________
Cultures ___________________________
____________________________________
WBC: 4.2
HGB: 9.4
PLT: 176
HCT: 25.4
GFR: 102
NA: 132
K: 4.2
Diagnostics/Imaging
12-lead ECG
XR
CT
MRI
Ultrasound
EEG
ANGIO BILAT DVT, NEEDS SURGERY
XR FLUORO REMOVAL OF PACEMAKER
Diet/TF formula: Heart Healthy Diet
Rectal tube/colostomy output & character NONE
PATIENT HAS NO NG TUBE
Fluid restriction __1.2__ ml/day
GU
Foley insert date _11/24/23____
Continent/incontinent
Last bladder scan __270___ ml @ _____
Voiding method Last I&O cath _____ ml @ _____ FOLEY
Shift/hourly urine output 1081 ML
Urine character Normal.
Specialty: Advanced Med/Surg
RASS
NO INFORMATION FOUND.
HD sched __________ & last HD amt removed _____ ml No info found
Neuro/Psych –
Richmond
AgitationSedation Scale
Musculoskeletal/Safety & Mobility
[ ] SCDs [YES ] VTE ppx meds
Pain & scale utilized 0/10
Assistive devices No info found
Level of assist FULL assist
Calls for assist/safety concerns No info found
Restraint type & location None
Sitter/tele-sitter NONE
PT PARALYZED WAIST DOWN
Rehab consults: [ YES] PT [ YES] OT [ ] SLP
Cardiac – Hemodynamics
PA cath @ _____ cm
CI _____ / SvO2 _____ / CVP _____ / PAP _____ / SVR _____
NO INFO
Respiratory – Artificial airway & mechanical ventilation
ETT size _____ taped @ _____ cm @ teeth / gum / lip
Trach brand __________ & size _____
Vent mode ____________
Rate _____ VT/PS _____
FiO2 _____% PEEP _____
NONE.
GI – Enteral tube
OG taped @ _____ cm
NONE.
Skin & Drains/Tubes
Pressure injuries/wounds SACRAL
Wound tx/dressings output & character NECROTIC
Drains/tubes output & character
NONE
Wound care consult [ YES]
IV Lines
1 RIGHT AC 20
2 LEFT AC 22
3
4
5
6
7
8
Continuous IV Drips
1
2
3
4
5
6
7
8
OTOs/PRNs given & time last given
Acetaminophen PRN, 650 MG PO
To-do/Follow-up/Notes
None found.
07/19
08/20
09/21
10/22
37.2
Temp &
source
97 AFIB
HR &
rhythm
11/23
12/00
PT HAD SURGERY TO REMOVE
PACEMAKER DUE TO INFECTION
13/01
PT CANNOT HAVE COFFEE. DECAF
ONLY.
14/02
161/91
BP & MAP
20
Resp
rate
15/03
16/04
17/05
18/06
SpO2 &
delivery
method
Pain &
pain
scale
used
Medication Administration Record – provide 5 most critical/priority medications
Generic & trade name
Pharm class
Dose
Route
Freq
Indication(s) r/t patient
Oxacillin
Antibiotic
2,000
IV
Over
Bacteremia
mg
30 min
Midodrine
Alpaadrenergic
agonists
10 mg
PO
BID
Treats Hypotension
98 RM
AIR
0/10
Common SEs/ADEs (at least 3)
Hypotension
Rash
Edema
Nursing considerations (at least 3)
Assess BP
Assess for an allergic reactions
Assess any edema
Chills
Urinary issues
Stomach pain
Assess kidney function
Assess blood pressure
Should not be taken 4 hours before
bed time
Plan of Care (Clinical Judgment Plan)
Priority problem #1 [hypothesis]:
Optimize Mobility
Priority problem #2 [hypothesis]:
Priority problem #3 [hypothesis]:
Pertinent assessment data [cues]:
Pertinent assessment data [cues]:
S.M.A.R.T. goal/outcome #2 [solution]:
S.M.A.R.T. goal/outcome #3 [solution]:
Interventions with frequency & rationale [actions]:
Assess/monitor:
Interventions with frequency & rationale [actions]:
Assess/monitor:
Manage:
Manage:
Educate:
Educate:
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):
Pertinent assessment data [cues]:
Work with physical therapy
Interventions with frequency & rationale [actions]:
S.M.A.R.T. goal/outcome #1 [solution]: Patient will
continue PT while in hospital.
Assess/monitor:
Assess for any difficulty.
Manage: Orthostatic HYPOTENSION
Educate:
Educate
patient
to stay
consisten
t with PT
and OT,
even
after
discharge
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):
Shift Notes
Vitals
08/20
12/00
16/04
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