judgment final

Description

needs to be added.

Socieoeconomic/physchosocial assessment (Needs improvement Vaguely describes socioeconomic and phsyosocial background in detail with limited to no evidence-based citations. Identifies at leaset 1 psychosocial concer.

Teaching Assessment & client Education : Identify areas of instructional needs, learning preference and learning barrier. provide client education that will aid in health promotion, health maintanance and self care activities.

Interprofessional Consults and Collaborative Plan: 2 appropriate collaborative issues/concerns. Evidence based rationals demnstrate adequate understanding of consults and interventions

Multidisplinary client outcome and dishcarge planing : Vaguely describe issues/concerns related to mutidisplinary discharge planning with limited to no evidence based rationales

Medications: Identify few components of the medication list with limited to no evidence-based citations, including name, class route dose frequency mechanism of action, applicable indication side and adverse effects. interactions and nursing considerations relevant to the client.

Recongnitions of cues: Identify imperative assessment cues, should be evidence based and cited .

Analysis of Cues: Link cues to a patient’s clinical presntation in establishing probable patient needs, concers, or problem. Analyze Clues with evidence based citations

Prioritization of hypothesis *(clincal judgments). Identify nursing clinical judgment and support rationale. Identify clinical decision with no correlation from the recognized cues based on priority setting freamework.

Implementation of actions(interventions): Identify at lease 12 action that are independent nursing interventions support by scientific reationale and evidence based practive

General Organization : APA format, Citation, and references. Grammar

Unformatted Attachment Preview

12/13/2023
Instructor:
DATE Care Provided and UNIT
Patient Information
(1)
Clinical Judgement Plan
History of Present Illness (HPI)
A 79-year-old male patient presented at the hospital for admission after he underwent a total right knee arthroplasty as treatment for his primary osteoarthritis on the right
Patient Initials: RV
knee. The patient’s history included multiple medical problems such as hypertension, Crohn’s disease, hyperlipidemia, and gastroesophageal reflux disease. Also, it involved
Age & Gender: 79
a bicuspid and mitral valve repair. These factors could be what contributed to the decision as the patient did keep on having the pain in the knees since it is because of
Height/Weight: 5ft 10, 216 lbs.
G
osteoarthritis
On arriving at the hospital, the patient was subjected to various pre-operative examinations for vital signs, labs investigations, radiological scans, and others.
Code Status: No
Medical History: (SEE RUBRIC REQUIREMENTS)
Living Will/ DPOA: None
PAST DIAGNOSED MEDICAL PROBLEMS
Hypertension (HTN): Hypertension, that is, high blood pressure, is a case of chronic disease that raises arterial blood pressure. Blood pressure depends on the volume of
blood your heart pumps and the resistance that flows through your arteries (Burger et al., 2021). Although, most cases of high blood pressure result from multifactorial
causes, genetics, excessive salt consumption, obesity, stress, and chronic kidney disease are implicated. Unchecked hypertension leads to fatal health issues like heart attack,
stroke, heart failure, and kidney disease.
Hyperlipidemia (HLD): Hyperlipidemia means an elevation of blood lipid (fat), very high cholesterol, and more than normal triglyceride amounts. Hyperlipidemia can
Chief Complaint
Right knee end-stage osteoarthritis is the
patient’s chief complaint. It is most probable
that it caused a right TKA. At present, the
patient’s primary concern involves pain
result from genetics, diet, and lifestyle factors (Correction to Heart disease and stroke statistics—2022 update: (American Heart Association Report, 2022). High lipid levels
may result in fatty deposits in the arteries, which increase the likelihood of atherosclerosis, cardiovascular problems, and various consequences.
Gastroesophageal Reflux Disease (GERD): ERD is an irreversible digestive problem that causes a return flow of acid or bile in the esophagus, leading to sourness and
heartburn (Hattangadi, 2022). The LES is often found relaxed beyond normal or weakened so that the stomach contents can pass therein. As a result, the esophageal lining
gets irritated, swollen, damaged, and inflamed.
after a knee operation.
Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
The patient’s past diagnosed surgical problem is “End stage osteoarthritis, right knee,” which led to the need for a “Right total knee arthroplasty” (TKA) on
Admitting Diagnosis and Admission Date
11/29/2023. Right Total Knee Arthroplasty (TKA, also known as total knee replacement, is a surgical procedure to resurface a knee damaged by severe arthritis (Subvastus
On November 29, 2023, the patient was
approach total knee replacement 2023) to replace it with an artificial joint made of metal and plastic components.
admitted into the hospital undergoing TKA
Social History:
with primary osteoarthritis of the right knee.
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ILLICIT DRUG USE
management and postoperative recuperation
Smoking: The patient is a never smoker, indicating no history of cigarette or tobacco use.
Alcohol: The patient denies the use of alcohol, suggesting no alcohol consumption.
Illicit Drug Use: The patient denies the use of recreational or illicit drugs, indicating no history of drug abuse.
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
❋Economic Stability: N/L
❋ Education: N/L
❋Social and Community Context: N/L
❋ Health and Health Care: The patient’s access to health care and utilization is
indicated by their
current hospitalization and surgical intervention.
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❋ Neighborhood and Built Environment N/L
Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage (based on objective
assessment) (SEE RUBRIC REQUIREMENTS)
The patient is 79 years old, indicating that he is likely in Erickson’s psychosocial developmental stage of “Ego Integrity vs.
Despair.” This stage is associated with late adulthood (65 years and older) and involves reflecting on one’s life, evaluating
accomplishments, and finding satisfaction and meaning in life (Jones and Waite-Stupiansky, 2022). In this stage, individuals may
review their life choices, resolve past conflicts, and come to terms with their mortality. They may also seek to contribute to future
generations through mentorship and leaving a legacy.
Instructor:
DATE Care Provided and UNIT
Clinical Judgement Plan
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
Lab Tests or
Diagnostic Scan
Sodium
Normal
Ranges
Admission
Lab Values
Current
Lab
Values
136-145
mmol/L
Explain Abnormal Labs R/T Your Pt & NI
(USE SEPARATE ATTACHED WORD DOC →
WHEN NEEDED)
Medical Management and Collaborative Plan
(From MD, PT, OT notes…. etc.) *Consider past 24 – 48 hours
NTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
The priority goals to be achieved for transfer or discharge could include:
Pain Management: Ensure adequate pain control for mobility and functional independence.
Wound Care: Monitor and manage the postoperative surgical site to prevent infections.
Mobility: Progress ambulation and weight-bearing as tolerated to increase independence.
Medication Management: Ensure a clear understanding of all prescribed medications and
follow-up care instructions.
EQUIPMENT: Walker or assistive devices for mobility.
MEDS: IV antibiotics, opioid and non-opioid options for pain
TREATMENT
(i) Physical Therapy: Continue with the ambulation plan and assistance as needed.
(ii) Wound Care: Proper care for the surgical site as per the surgeon’s instructions
Patient Education (In Pt.) for Referrals/ Discharge Planning
Referrals Needed/Case Management
1. Physical Therapy: Referral for ongoing physical therapy and rehabilitation to optimize
recovery following the right total knee arthroplasty.
2. Case Management: Arrangements and coordination of post-discharge care, such as home
health needs and outpatient follow-ups.
Assessment of Learning Style
1. Learning Preference: Evaluate the preferred learning style of the patient so that educational
resources will be tailored toward it
Learning Barriers
1. Language: It is essential to assess the patient’s level of language proficiency. If language
barriers exist, suitable educational materials should be utilized in the patient’s preferred
language.
2. Hearing or Visual Impairment: Determine if the patient can read, hear, see, and use
appropriate corrective devices such as spectacles
Pathophysiology of Primary Medical Dx (reason for
hospitalization) Support with Evidence Based Citations
TIME OUT!!! Student
instructions:
The patient’s primary medical diagnosis, ” right knee end-stage osteoarthritis,” leads to
progressively eroded cartilage tissue and degeneration of the joint space (Lung et al., 2023). It
INCLUDE:
Appropriate
Diagnostic Tests/
Procedures- DATEs
and RESULTS
(Can add → See
attached Word Doc)
results in pain, decreased movement, and stiffness, altering the life of the patient.
Pathophysiology of Osteoarthritis: Osteoarthritis is a degenerative joint disease in which the
articular cartilage deteriorates and the subjacent bone is resorbed. Though the precise cause of
osteoarthritis is not yet apparent, it seems to be associated with genetics, mechanics, and other
environmental aspects (Hattangadi, 2022). As a result, the smooth cartilage covering the ends
of bones in the joint wears out with time and causes pain, swellings, and difficulties in moving
such a joint. During the disease, spur-like growths called bone formation in the abnormal form
of the affected joint may also occur.
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See the contents Below
Instructor:
DATE Care Provided and UNIT
Lab Tests or
Clinical Judgement Plan
Normal
Admission
Ranges
Values
Lab
Current Lab
Values
136-145
141mmol/L
141 mmol/L
Diagnostic Scan
Sodium
mmol/L
Potassium
3.6-5.1
98-107
4.1 mmol/L
4.0 mmol/L
21-32mmol/l
The current sodium level on November 29, 2023, falls within the normal range, indicating no significant
The potassium level November 29, 2023, falls within the normal range, indicating no significant
abnormality.
101 mmol/L
101 mmol/L
mmol/L
Carbon Dioxide:
(USE SEPARATE ATTACHED WORD DOC → WHEN NEEDED)
abnormality.
mmol/L
Chloride
Explain Abnormal Labs R/T Your Pt & NI
The current chloride level, November 29, 2023, falls within the normal range, indicating no significant
abnormality.
25 mmol/L
25mmol/L
On November 29, 2023, the carbon dioxide level fell within the normal range. This stable result suggests
that the patient’s acid-base balance is within normal limits (Wieliczko and Małyszko, 2022), and there are
no immediate concerns related to carbon dioxide levels.
Anion Gap
5-15
N/L
5
the anion gap value of 5 falling within the normal range suggests that there is no significant abnormality in
the relationship between the measured electrolytes
Creatinine
0.70-1.30
N/L
1.25
The creatinine level of 1.25 mg/dL is within the normal range.
Blood Urea Nitrogen (BUN):
7-18 mg/dL
N/L
19 mg/dL
The elevated BUN level may indicate decreased kidney function or dehydration in the patient (Lung et al.,
2023). This abnormality could also be due to the stress of surgery and potential blood loss during the Total
Knee Arthroplasty procedure. Interventions could involve monitoring the patient’s fluid intake and output
to ensure adequate hydration and working closely with the medical team to monitor the patient’s renal
function, potentially including regular assessments of creatinine levels, urine output, and signs of fluid
overload.
Calcium
8.5-
N/L
8.8
The calcium level falls within the normal range, indicating no significant abnormality.
N/L
171
For the elevated glucose level, the nursing interventions may include:
10.1mg/dl
Glucose
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74-99mg. dl
Instructor:
DATE Care Provided and UNIT
Clinical Judgement Plan
1. Continuous Monitoring Implementing frequent monitoring of the patient’s blood glucose levels to assess
patterns (Lehn-Stefan et al., 2020), identify potential triggers for hyperglycemia, and facilitate timely
intervention.
2. Collaboration with Healthcare Team: Engaging in collaborative care with the healthcare team to
establish an individualized plan for glycemic control, which may involve medication adjustments, dietary
modifications, and the initiation of insulin therapy if deemed necessary.
TIME OUT!!! Student
instructions:
INCLUDE: Appropriate
Diagnostic Tests/ ProceduresDATES and RESULTS
The appropriate diagnostic
test/procedure performed was a
Total Knee Arthroplasty, which took
place on 11/29/2023. The procedure
results revealed a total right knee
arthroplasty in grossly anatomic
alignment. The procedure was
undertaken due to the patient’s endstage osteoarthritis of the right knee.
The 79-year-old male patient
underwent a comprehensive
evaluation of the risks and benefits
of total knee arthroplasty, and
informed consent was obtained. The
implants used during the procedure
included components from Smith
and Nephew and Stryker brands.
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Instructor:
DATE Care Provided and UNIT
Clinical Judgement Plan
Medications & Allergies (2)
Medication Name
Dose
Route
Include BOTH Generic AND
Trade names for RX; include
OTC, herbal (nonpharmacological items)
Freq.
NOTE: PRN
‘alone’ ≠
Freq
Indications
Mechanism of Action
(PRN meds must include MD
ordered Indication)
Nursing
Considerations
specific to this patient
with citations
What cues will you
observe for?
What will you
monitor (labs, vitals,
etc?)
Amlodipine (Norvasc)
5mg
By
mouth
Daily
Hypertension and chronic
stable angina.
Losartan (Cozaar)
100mg
By
mouth
Daily
hypertension and to reduce the
risk of stroke
Metoprolol (Toprol)
12.5mg
XL
By
mouth
Daily
Pantoprazole (Protonix)
40mg
By
mouth
Daily
Enoxaparin (Lovenox)
40mg
injection
Daily 0800
Bisacodyl (Dulcolax)
10mg
By
mouth
Daily at 2100
Hypertension, angina pectoris,
heart failure, and to improve
survival after myocardial
infarction.
gastroesophageal reflux
disease (GERD), erosive
esophagitis, and pathological
hypersecretory conditions.
Prevention of deep vein
thrombosis and pulmonary
embolism, and in the treatment
of acute coronary syndrome.
constipation and bowel
preparation for colonoscopy
Docusate (Sodium Docusate)
200mg
By
mouth
Twice Daily
constipation and for the
prevention of dry, hard stools
Allowing water and fats to
get into the stool.
Finasteride (Proscar)
5mg
By
mouth
Every
afternoon
Benign prostatic hyperplasia
(BPH) and male pattern
baldness.
Simvastatin (Zocor)
40mg
By
mouth
Every
afternoon
Hyperlipidemia and to reduce
the risk of cardiovascular
disease.
Decreasing the amount of a
natural body hormone (DHT)
that causes growth of the
prostate.
Inhibiting HMG-CoA
reeducates an enzyme that
controls the rate of
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Side Effects/
Adverse Reactions
works by inhibiting the influx
of calcium ions into vascular
smooth muscle and cardiac
muscle
works by blocking the
vasoconstrictor and
aldosterone-secreting effects
of angiotensin II
Blocking the action of certain
natural substances in the
body, such as epinephrine, on
the heart and blood vessels.
Reducing the amount of acid
produced in the stomach.
Edema, dizziness, and
flushing.
Accelerating the rate of
inactivation of coagulation
factors.
Bleeding,
thrombocytopenia, and
local irritation at the
injection site.
Abdominal discomfort,
diarrhea, and electrolyte
imbalance.
Diarrhea, abdominal
cramps, and rash.
Increasing the movement of
the intestines.
Dizziness, hyperkalemia,
and hypotension.
bradycardia, hypotension,
and fatigue.
Headache, diarrhea, and
abdominal pain.
Impotence, decreased
libido, and ejaculation
disorder.
Myopathy,
rhabdomyolysis, and liver
dysfunction.
Instructor:
DATE Care Provided and UNIT
Clinical Judgement Plan
cholesterol production in the
body.
Cefazolin (Ancef)
2,000mg
injection
intravenous
every 8 hours
the prevention of postoperative
infections
Tamsulosin (Flomax)
Tamsulosin HCl
0.4mg
By
mouth
Daily
Benign prostatic hyperplasia
(BPH)
Enoxaparin (Lovenox)
Enoxaparin Sodium
40mg
injection
Once a day
0800
Sodium Docusate (Docusate)
Docusate Sodium
200mg
By
mouth
Twice a day
Prophylaxis of deep vein
thrombosis, treatment of acute
ST-segment elevation
Constipation, prevention of
fecal impaction
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Interfering with the synthesis
of the peptidoglycan layer of
bacterial cell walls.
Selective antagonist of
alpha1-adrenergic receptors
in the prostate
Low molecular weight
heparin that inhibits
thrombus and clot formation
Surfactant laxative that
lowers the surface tension of
the stool, allowing water and
fat to penetrate the stool
Diarrhea, infusion site
reactions, and
hypersensitivity reactions.
Rhinitis, abnormal
ejaculation, asthenia,
dizziness
Bleeding, anemia,
thrombocytopenia,
injection site hematoma
Throat irritation (liquid),
diarrhea,
Instructor:
DATE Care Provided and UNIT
Clinical Judgement Plan
ASSESSMENT/History of Present Illness /REVIEW OF SYSTEMS
Vital Signs (4)
BP: 151/69mmHg
HR: 75bpm
RR: 18bpm
Temp: 98.1°F
O2:96.5%
Pain: (0/10) N/L
Ht: 177.8 cm
Wt.:98.3 kg
BMI: 31.0 kg/m²
Musculoskeletal (8)
1. The patient underwent right total
knee arthroplasty (TKA) for end-
Neurological (5)
1. The patient denies pain, nausea, or
vomiting post right total knee arth oplasty
(TKA).
2. No acute or focal neurological changes
were noted.
3. Neurological status must be monitored
through bilateral neurovascular checks on
arrival, every 4 hours through Postoperative
Day (POD) 1 while awake (Peng et al.,
2020), and then every 8 hours for potential
changes.
4. Monitoring of neurological status,
including incentive spirometry and pulse
oximetry, has been ordered to maintain
neurological function postoperatively.
Cardiovascular (6)
1. Normal heart sounds, regular rate, and
rhythm were noted during the
examination, indicating no acute
cardiovascular issues at the assessment
time.
2. No murmurs or abnormal heart
sounds were mentioned, suggesting no
significant valvular abnormalities.
3. Vital signs, fluid intake, and output
were documented, forming part of the
overall cardiovascular assessment
Respiratory (7)
GI/Hydration/Nutrition (9)
GU (10)
Rest/ Exercise (11)
N/L
N/L
1. The patient has been provided with
activity and ambulation plans, along with
the use of assistive devices such as a
walker, with monitoring for fall risk.
Endocrine (13)
Psychosocial (14)
N/L
The patient’s social history indicates a local
resident with no history of smoking, alcohol, or
illicit drug use
stage osteoarthritis.
2. Denies pain or discomfort
postoperatively
Integumentary (12)
N/L
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N/L
MISC:
Instructor:
DATE Care Provided and UNIT
Clinical Judgement Plan
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)
•
The patient will achieve independent ambulation, including walking with a walker and performing activities of daily living without assistance within four weeks post-operation.
•
The patient will demonstrate the ability to walk 100 feet with a walker and perform essential self-care tasks, such as dressing and bathing, independently by the fourth postoperative week.
•
The patient will report pain levels of 3 or less on a scale of 0 to 10 during movement and at rest within one-week post-operation.
•
The patient will be free from signs of infection, and there will be no evidence of deep vein thrombosis, with stable vital signs and no cardiac or respiratory complications during the recovery period.
Reflecting
Evaluate
Evaluation
The care plan aligns with the expected postoperative management following right total knee arthroplasty (TKA). The patient’s weight-bearing status was appropriately assessed and determined, with the
plan for weight-bearing as tolerated, consistent with the expected progression in post-TKA rehabilitation. It is noteworthy that the patient’s denial of alcohol and drug use aligns with the expected
postoperative management, as these factors can impact healing and recovery. Furthermore, the patient’s documented respiratory rate assessments align with the expected postoperative respiratory care
following pain management with PCA (patient-controlled analgesia). Given the additional medical history of Crohn’s disease, hyperlipidemia (HLD), gastroesophageal reflux disease (GERD), and
weehypertension, postoperative care should include monitoring for any exacerbation or impact of these conditions on the patient’s recovery. Assessment of the patient’s allergies, including the severe reaction to
captopril and uncertainty about budesonide, is essential to avoid any adverse events. The inability to obtain a complete review of systems due to sedation is a noteworthy factor that may require additional
clinical decisions once the patient is vigilant and responsive.
Instructor:
DATE Care Provided and UNIT
Clinical Judgement Plan
References
Burger, C. D., DuBrock, H. M., Cartin-Ceba, R., Moss, J. E., Shapiro, B. P., & Frantz, R. P. (2021). Topic-based, recent literature review on pulmonary hypertension. Mayo Clinic Proceedings,
96(12), 3109–3121. https://doi.org/10.1016/j.mayocp.2021.05.026
Correction to: Heart disease and stroke statistics—2022 update: A report from the American Heart Association. (2022). Circulation, 146(10). https://doi.org/10.1161/cir.0000000000001074
Hattangadi, S. (2022). How can the NIDDK Cooperative Centers of Excellence in Hematology help with your research? The Hematologist, 19(5). https://doi.org/10.1182/hem.v19.5.202253
Jones, E., & Waite-Stupiansky, S. (2022). The Erikson’s psychosocial developmental theory. Theories of Early Childhood Education, 34–49. https://doi.org/10.4324/9781003288077-4
Lehn-Stefan, A., Peter, A., Machann, J., Schick, F., Randrianarisoa, E., Heni, M., Wagner, R., Birkenfeld, A. L., Fritsche, A., Häring, H.-U., Staiger, H., & Stefan, N. (2020). Elevated circulating
glutamate is associated with subclinical atherosclerosis independently of established risk markers: A cross-sectional study. The Journal of Clinical Endocrinology & amp; Metabolism,
106(2). https://doi.org/10.1210/clinem/dgaa898
Lung, B., Callan, K., McLellan, M., Kim, M., Yi, J., McMaster, W., Yang, S., & So, D. (2023). The impact of dehydration on short-term postoperative complications in total knee arthroplasty.
BMC Musculoskeletal Disorders, 24(1). https://doi.org/10.1186/s12891-022-06118-7
Peng, B., Li, J., Li, X., Wang, X., Zhu, H., Liang, W., Liang, H., & Chen, W. (2020). Neuropsychological deficits in patients with electrical status epilepticus during sleep: A non-invasive analysis
of neurovascular coupling. Brain Topography, 33(3), 375–383. https://doi.org/10.1007/s10548-020-00759-4
Subvastus approach total knee replacement. (2023). OrthoMedia. https://doi.org/10.1302/3114-230111
Wieliczko, M., & Małyszko, J. (2022). Acid–base balance in hemodialysis patients in everyday practice. Renal Failure, 44(1), 1091–1098. https://doi.org/10.1080/0886022x.2022.2094805
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Instructor:
DATE Care Provided and UNIT
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Clinical Judgement Plan

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