Description
Do clinical judgement plan based off of given case study also a example is provided fill out entire case stufy and make sure there is no plagiarism, cite sources and put references and use in text citationsfill out the doc provided
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Student Name
Pediatric Clinical Judgement Plan
West Coast University
Professor Name
Date
OB Version Feb 2022
PEDIATRICS Clinical Judgement Plan
Student Name:
DATE Care Provided and UNIT:
Patient Information
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).
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)
(1)
Patient Initials:
Age & Gender: Age in years/not DOB
Height/Weight:
Medical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED MEDICAL PROBLEMS
For each disease identified, define, it, describe pathophysiology, and cite source
Code Status:
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
Family History:
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)
❋ Economic Stability
❋ Education
❋ Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
List three psycho-social concerns you may have.
OB Version Feb 2022
Erickson’s Developmental Stage Related to pt. & Cite References (1)
*List and Discuss specific stage (based on objective assessment)
(SEE RUBRIC REQUIREMENTS)
PEDIATRICS Clinical Judgement Plan
Student Name:
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
Lab Tests or
Diagnostic Scan
Normal
Ranges
Admission
Lab Values
Current Lab
Values
Medical Management and Collaborative Plan
(from MD, PT, OT notes….etc.) *Consider past 24 – 48 hours
Explain Abnormal Labs R/T
Your Pt & NI
(USE SEPARATE ATTACHED
WORD DOC → WHEN
NEEDED)
Patient Education (In Pt.) for Transfer/ Discharge Planning
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
TIME OUT!!! Student
instructions:
INCLUDE:
Appropriate Diagnostic
Tests/ ProceduresDATEs and RESULTS
(Can add → See
attached Word Doc)
OB Version Feb 2022
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or
DISCHARGE
EQUIPMENT
( MAY DELETE THESE ‘TIPS” TO USE SPACE)
MEDS
TREATMENT
REFERRALS NEEDED
PEDIATRICS Clinical Judgement Plan
Student Name:
TIME OUT!!! Student instructions:
DATE Care Provided and UNIT:
Medication Name
Include BOTH Generic
AND Trade names for
RX; include OTC,
herbal (nonpharmacological items)
OB Version Feb 2022
Dose
Please
include
dosage
calculatio
n for min
and max
per
weight
Allergies:
Medications & Allergies (2)
Route
Freq.
NOTE:
PRN
‘alone’ ≠
Freq
Indications
(PRN meds must
include MD
ordered
Indication)
Mechanism of Action
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?)
PEDIATRICS Clinical Judgement Plan
Student Name:
DATE Care Provided and UNIT:
ASSESSMENT & 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:
OB Version Feb 2022
MISC
PEDIATRICS Clinical Judgement Plan
Student Name:
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
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)
Responding
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.
OB Version Feb 2022
PEDIATRICS Clinical Judgement Plan
Student Name:
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.
OB Version Feb 2022
Cardiology OP Clinic
Case Study
L-transposition of the great arteries
M U RI E L A LM E I DA ,
DI E T E T IC I N T E RN DE CE M BE R 0 2 , 2 0 2 1
• 17-month-old female born full term at 40 weeks, via C-section, AGA
• Dx at birth with multiple congenital heart defects:
Patient Profile
o L-transposition of the great arteries (L-TGA) w/ Pulmonary Atresia (PA)
o Secondary: Ventricular Septal Defect (VSD), Persistent left superior
vena cava (LSVC)/bilateral SVCs, right aortic arch
• Desats at birth, placed on CPAP, then intubated at OSH. Echo
suggested L-TGA and PA. Transferred to CHLA/CT-ICU for surgical
management.
• Underwent central shunt and PDA ligation on DOL #4,
• Complex anatomical correction hear surgery at 10 mo old.
• Hx of feeding intolerance and poor weight gain requiring PN,
continuous NGT feeds, formula fortification and most recently oral
supplements.
Delayed sternal closure 7d post anatomical correction op (4/1/21)
Clinical
Course
Complicated recovery with AKI requiring PD (4/06), following
hypotension w/ bacteremia treated w/ abx for 10 days
1 month post surgery (4/29/21):
– Transferred to CTICU w/ respiratory failure and arrested during intubation
– Started on abx, new PICC line was placed + inotropic support w/ epi drip,
w/ significant clinical improvement. successfully extubated 1 wk later
Recovery well w/ normal cardiac function. Digoxin d/c early May
(~1 year old). D/c 48 days later
L-transposition of
the great arteries
• Rare Congenital Heart Defect: Noncyanotic form that accounts for
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