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Please don’t expect it if you are not familiar with nursing and health care.Clinical Judgement Map on patient from your clinical unit the same patient . I will share the patient you need to fill the rest. See the explanation in the file for the clincica judgment maps.
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Abdulaziz
U N I V E RS I TY
5 Minute Care Plan
Medical Diagnosis: Acute respiratory failure with with hypoxia
Primary/Priority Physical Assessments Relating to the
Patient’s Diagnosis
1.
2.
3.
4.
Assess respiratory rate
Check oxygen saturation
Monitor level of consciousness
Evaluate skin color for signs of cyanosis
5.
Primary/Priority Interventions Relating to the Patient’s
Diagnosis
1.
2.
3.
4.
Administering medications
Positioning for optimal breathing(semiFowler
Administer supplements oxygen to
maintain target spO2 levels
Monitor patient’s anxiety.
5.
Primary/Priority Labs or Diagnostics Relating to the
Patient’s Diagnosis with Rationale
Primary/Priority Medications Relating to the Patient’s
Diagnosis with Rationale
1.
1.
Alburterol : help dilate the airways
ABGs to assess the levels of
Po2
improve airflow
oxygen.carbon dioxide,blood pH
55mmHg
2.
Chest X-ray, check the abnormal in the lungs , Edema, 2. Furosemid(Lasix) helping reduces excess fluid in
lungs
consolidation or other abnormalities in the lungs
3.
3.
4.
4.
5.
5.
Most Important Patient Education/Teaching Relating to the
Medical Diagnosis with Rationale
1.
Patient’s Primary Needs/Concerns with Discharge Relating to
the Medical Diagnosis with Rationale
1.
Recognize worsening symptoms like increased
breathlessness, confusion, or fatigue. This Allows
2. early intervention, prevents complications.
Lorazepam, use to relaxecalm state reduce
anxiety (sedatives)
Follow-up: Needed to adjust care; ensures
recovery.
2. Lifestyle changes, Smoking cessation can
improve lung function.
3. Practice breathing techniques.enhance lung capacity,
3.
4.
4. Explain medications and their schedules.
5.
ease breathing, and promote relaxation, which are
crucial for recovery.
Correct oxygen use: Prevents hypoxia, maintains
oxygen levels
KBV Spring 2024
Symptom Watch: Quick response to worsening
signs can be save your life.
5.
3
Concept Map/Clinical Judgement Instructions
1
U N I V E RS I TY
1847
NURS 420 Adult Health III
Concept Map Instructions and Clinical Judgement Assignment
Dr. Karen Black-Vetter
To obtain credit for any portion, it is imperative that you complete the entire assignment. Complete the patient-related
concept map according to the provided guidelines and complete the clinical judgement section according to the provided
guidelines.
The two sections to complete for this assignment• Part I: The Concept Map based on the Nursing Process
• Part II: Clinical Judgement
Part I: The Concept Map based on the Nursing Process
Patient Information: Pt’s Initials, Age, Gender, Medical Diagnosis, Allergies, and Code Status
Assessment: Subjective and Objective Data (minimum 4 required each- 8 total).
➢
Include relevant Subjective Data relating to Medical Diagnosis- Information provided by the patient,
family, or caregiver. Place in quotations if appropriate.
➢
Include relevant Objective Data related to Medical Diagnosis- Physical Assessment, Diagnostics, Labs,
etc.
Nursing Diagnosis: Actual Problems and Possible Risks reflects the patient’s current condition or main issue. Base the
diagnosis on patient-specific information.
➢
Actual Problem (minimum 3)- Urinary elimination, impairment- indicates disturbance in urinary
elimination.
➢
Possible Risk (maximum 2)- Risk for urinary retention- due to situation, there is a possibility retention of
urine may occur
Plan/Goals/Outcome: Short Term and Long Term (2 required each- 4 total)
➢
Short-Term Goals- focusing on one achievable outcome. Use the SMART pneumonic: Specific,
Measurable, Attainable, Realistic, and Timed. This is important to allow evaluation of patient’s
plan/goal/outcomes by the end of the clinical day.
➢
Long-Term Goals- focusing on a more extended outcome. The full evaluation may not be possible by
the end of the clinical day but by discharge, progress should be assessable. Use the SMART
pneumonic: Specific, Measurable, Attainable, Realistic, and Timed.
Interventions: (Include patient teaching)
➢
Short-term goal (minimum 3)- Ensure these interventions directly correspond to the goal, are patient-specific,
and provide a rationale.
KBV-Spring 2024
Concept Map/Clinical Judgement Instructions
➢
2
Long-term goal (minimum 3)- Ensure these interventions directly correspond to the goal, are patient-specific, and
provide a rationale.
Evaluations:
➢
Evaluate each of the short-term and long-term goals.
➢
If the goal was achieved, explain how. If not, analyze whether the patient was progressing toward the goal and in
what manner. Place the goal is “Met”, “Partially Met”, or “Not Met”.
Pathophysiology:
➢
Elaborate on the patient’s pathophysiology in accordance with APA format, incorporating relevant in-text citations
as necessary.
KBV-Spring 2024
Concept Map/Clinical Judgement Instructions
3
Part II: Clinical Judgement
Clinical judgment refers to the process by which nurses assess and interpret information, draw conclusions, and make
decisions in the context of patient care. It involves the ability to analyze complex and dynamic situations, integrate
knowledge and experience, and consider various factors to arrive at appropriate and timely decisions for patient
management.
Clinical judgment is essential in healthcare as it guides practitioners in delivering safe, effective, and patient-centered
care. It encompasses critical thinking, problem-solving, and the application of evidence-based practice to ensure that
decisions align with the best available evidence and the unique needs of each patient. Effective clinical judgment
contributes significantly to quality healthcare outcomes and is a fundamental skill for healthcare professionals across
various disciplines.
Breakdown of how to complete Part II of the assignment:
Recognize cues (What Matters Most?)
➢
The filtering of information from different sources (i.e., signs, symptoms, health history, environment).
Analyze cues (What does it Mean?)
➢
The linking of recognized cues to the client’s clinical presentation and establishing probable client needs,
concerns, and problems.
Prioritize hypotheses (Where do I start?)
➢
Establishing priorities of care based on the client’s health problems (i.e., environmental factors, risk assessment,
urgency, signs/symptoms, diagnostic tests, lab values).
Generate solutions (What can I do?)
➢
Identifying expected outcomes and related nursing interventions to ensure a client’s needs are met.
Take actions (What will I do?)
➢
To implement appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to
promote, maintain, or restore a client’s health.
Evaluate outcomes (Did it help?)
➢
To evaluate a client’s response to nursing interventions and reach a nursing judgment regarding the extent to
which outcomes have been met.
KBV-Spring 2024
5-Minute Assessment
Hand Washing
☐ Completed – Standard Precautions
Introduction
☐ Completed – Introduce self and purpose of assessment to
decrease role confusion and anxiety
Vital Signs
60 bpm
Pulse _________
Strength: Strong ☐ Weak ☐ Thready ☐
Assessing for Pain
Chest
Where is the pain? ____________________
5-days
How long has the pain lasted? ___________
Resting, up- bed position semiDoes the pain radiate? Yes
_________________
upright, pain relief
What makes it feel better? ______________
Coughing , physical activity.
What makes it worse? _________________
Regularity: Regular ☐ Irregular ☐
Temperature: ______
Type: Oral ☐ Rectal ☐ Tympanic ☐ Axillary ☐
B/P__________
Respirations__________
156/79
20
Neuro
Orientation (X4) Yes ☐ No ☐
2024
What year is this? ____________________
Tell me your name? ___________________
T.C
hospital
Tell me where you are? ________________
breathing difficulties
Tell me why you are here? his
_____________
Verbalization Clear?
Yes
Responds Appropriately?
Integumentary
Skin Turgor – 1 to 3 seconds norm
Return was ____Sec.
2
Skin Color: Pink ☐ Pale ☐ Jaundice ☐ Cyanotic ☐
Skin Temp – use back of hand to assess
Hot ☐ Warm ☐ Cool ☐
No
Incisions: ____________________________________
Pain Description: Sharp ☐ Stabbing ☐ Dull ☐
Pain Scale: 0-10, O being no pain and 10 being the worst pain
how would you rate your pain? 7
IV Line(s)
Left
IV: Note IV site: ______________
Saline
Fluids: ________________. Rate:
_________________ml/hr.
90
Dressing:____________________
Clean intact
No S/S of Infiltration or Infection:
Eyes
(PERRLA) Pupils, Equal, React to light & Accommodate
Sluggish ☐ No Change ☐ Brisk ☐
Normal ☐ Accommodate yes ☐ No ☐
Skin Breakdown Check
Check entire body for redness or skin breakdown. Check all
prominences.
No Skin Breakdown ☐
Skin breakdown ☐
Location:
Condition of area:
Drainage:
Wounds: _____________________________________
KBV Spring 2024
3
5-Minute Assessment
Cardiac Heart Sounds:
Patient at 45-degree angle ☐
Neck Veins: Flat ☐ Distended ☐
Listen to Apical pulse with stethoscope
Rate________
Rhythm__________ Regular? Yes
60
S1/S2 ☐ S3 ☐ S4 ☐ Murmur ☐
Any other
abnormal sounds noted
Telemetry w/reading?
Respiratory Continued
Abnormal Lung
Anterior
Sound
Wheezing
Yes
Capillary Refill
Toes ☐ Fingers ☐ (3 seconds or less)
2
Right Fingers _____Sec.
2
Left Fingers________Sec.
2
Right Toes ________Sec.
2
Left Toes _________Sec.
Delay or abnormal refill return? Yes ☐
Location: _______________________
Crackles
Rhonchi
Peripheral Edema
Edema found in dependent areas such as the feet, hands and
sacrum. Check with finger by pressing down on area.
Observe for pitting or indentation.
Feet
Hands
Sacrum
Y/N
Pitting
No
no
no
KBV Spring 2024
Right
Left
PUL
PLL
N
No
N
N
N
N
N
N
Good Air Flow ☐ Poor Air Flow ☐
Productive Cough ☐
GI/GU
Assess all 4 Quadrants; do not palpate the abdomen before
you auscultate, it may produce false B.S. if irregularities noted
in a certain quadrant do a further assessment of that
quadrant. The umbilicus is mid-point.
(Abdomen) – Check for condition
Soft ☐ Hard ☐ Distended ☐ Other ☐
morning 1/20
Last Bowel Movement _____________________________
Circulatory
Radial Pulses- Rate, Strength, Regularity
Right__________ Left ______________
Hand Strength – Two fingers only
Right Stronger ☐ Left Stronger ☐ Equal ☐
Pedal Pulses – Top of foot
Right Foot _______ Left Foot__________
SCD/TED Hose?
Numbness /tingling?
Location
Respiratory
Assess anterior and posterior chest as well as from side to
side. Have patient take deep breaths, do not move
stethoscope to rapidly to avoid hyperventilating on the
patients part.
Clear Bilaterally ☐ Left Only ☐ Right Only☐
Respirations even/unlabored? ______breaths/min.
20
Cough? Sputum? O2? IS?
Indent
N/V? NGT? Diet ________________________
Location
Absent
Hyperactive
Hypoactive
Yes
RUQ
RLQ
Yes
LUQ
Yes
LLQ
Yes
Musculoskeletal
Ambulate: Without assist ☐ With assist ☐
Moves All Extremities (Active or Passive): Yes ☐ No ☐
Contractures: Yes ☐ No ☐
Location: ___________________
No
Joint Swelling: __________________________________
Ortho Devices: __________________________________
Weak
Strength: ________________________________________
4
5-Minute Assessment
Closure
Let the patient know you are finished with your assessment
Let the patient know when you will be back again.
Make sure the following safety mechanisms are in place:
Bed rails up ☐ Bed in low position ☐ Call Light within reach ☐
Notes
Patient T.C 68 years old male, was admitted to hospital for difficulty breathing, on 1/15. He is diagnosed with
acute respiratory failure with hypoxia. He has history of COPD. His condition much better than when he came.
KBV Spring 2024
5
Rockford University
NURS 420 Adult Health III Clinical Judgement Map
Recognize Cues-What Matters
Most?
Analyze Cues- What does it
Mean??
Prioritize Hypotheses- Where do I
start?
Pt’s Initial, Age, Gender,
Medical Diagnosis, Allergies,
and Code Status
Evaluate Outcomes- Did it help?
Take Action- What will I do?
MEDICATIONS
Generate Solutions- What can I
do?
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