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Some of the spaces in the Clinical Judgement Plan are not provided in the prompt that was given but you can make up information to fill up the spaces. You can find all the information needed attached below, if any other information is needed please feel free to let me know. Thankyou.
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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:
Patient Information
(1)
Patient Initials:
Age & Gender: Age in years/not DOB
Height/Weight:
Code Status:
Living Will/ DPOA:
EDC:
EGA:
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?
Admitting Diagnosis & Admission
Date
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)
OB History
GTPAL
Need to identify previous pregnancies
year , and type of delivery
Prenatal Panel
Medical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED MEDICAL PROBLEMS
For each disease identified, define, it, describe pathophysiology, and cite source
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
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)
Blood Type/Rh:
GBS:
Hep B:
HIV:
Rubella:
RPR:
Chlamydia:
Gonorrhea:
HSV:
Delivery Summary
Delivery Type & Time:
Placenta Delivery Time:
Lacerations/Episiotomy:
EBL:
Hemorrhage Medications
Given:
APGAR Score:1 minute____ 5
minute______
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
GBS, Ferning, Ultrasound, CBC, Type and Screen, Glucose, ALT, AST, Plts, Protein
EQUIPMENT
MEDS
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)
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:
TIME OUT!!! Student
instructions:
INCLUDE:
Appropriate Diagnostic
Tests/ ProceduresDATEs and RESULTS
(Can add → See
attached Word Doc)
Pathophysiology of Primary Medical Dx (reason for
hospitalization) Support with Evidence Based Citations
Pathophysiology of Primary Medical Dx (reason for
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
Temperature:
Pulse:
Respirations:
Blood Pressure:
Pain Level:
Breasts
Size:
Nipple:
Shape:
Engorgement:
Colostrum:
Lochia
Amount:
Odor:
Color:
Clots:
Pad Changes:
EBL:
Neurological
LOC:
PMS:
PERRLA:
Vision:
Face:
Strength:
Uterus
Location:
Midline:
Firm/Boggy:
Contractions:
Episiotomy/Laceration
Location:
Stitches:
Edema:
Redness:
Approximation:
Cardiovascular
Color:
Cap Refill:
Tele Rhythm:
Peripheral Edema:
Heart Sounds:
Pulses:
Bladder
BR:
Incontinence:
Indwelling Catheter:
Urine Color/Consistency:
Urine Output:
Homan’s Sign
Redness:
Tenderness:
Pain:
Swelling:
Homan’s:
Final Version 3/10/22 DW/ss & MS Team
Respiratory
Lung Fields:
Breathing Pattern:
Sputum:
Cough:
Suctioning:
Pulse Oximetry:
Supplemental O2:
Bowel
Bowel Sounds:
Abdomen:
Last BM:
Incontinence:
Bedpan:
Abd. Pain:
Ostomy:
Drains:
Emotional
Bonding:
Support:
Emotional State:
Maternal Phase:
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
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:
Fetal Heart Rate Tracing
Heart Rate:
Variability:
Acceleration:
Deceleration:
Category:
Contractions
Frequency: ________
Duration:
________
Final Version 3/10/22 DW/ss & MS Team
___________
___________
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
Rita Case Study
Directions: Use the following information to complete your Concept Map
Scenario
History of Present Problem:
Pt arrived at the hospital complaining of strong regular contractions stating” I am in so much pain, the
contractions are crazy strong and I feel so much pressure”
Rita Garcia is a 23-year-old student G2P2000, weight 130lb, height 5’5. She is married. NKDA. A+, hep -,
HIV -, Rubellaand Varicella Immune, GBS +
She has no past medical history and no surgical history. History of Postpartum Blues with her first baby.
Her oldest child is 3 ½ years old She delivered a 9 pound 12-ounce baby boy at 41-week gestation,
following an 18-hour Pitocin-augmented labor with epidural anesthesia this morning.
Her second stage was two hours. She was given a mediolateral episiotomy, and the baby’s head was
delivered by vacuum extractor after she experienced difficulty pushing. Her estimated blood loss (EBL)
was 400 mL right after delivery. Immediately after delivery her VS were BP 110/70, temperature 98,
pulse 68, and respirations 20. She did not breastfeed her first child states baby did not want the breast.
She attended breastfeeding class and is planning on breastfeeding this child, her goal to exclusively
breastfeed but is open to supplementing. Rita is upset her husband could not make it to the delivery due
to having to work. Rita is also concerned about having to leave her older child with a neighbor as she has
no family in the area.
She has been clinically stable and is about to be transferred to the postpartum unit after a two-hour
recovery period. Oxytocin 20 units in 1000 mL of Lactated Ringer’s is infusing at a fixed rate of 125 mL/hr
in a 20 g. peripheral IV in her left hand. Type and screen done on admission, Hgb 12.6/Hct 38.
Her last set of vital signs were:
• T: 99.4 F/37.4 C
• P: 95
• R:18
• BP: 110/67. She has gotten up to void once and had 50 mL of blood-tinged urine. Her fundus is firm
at the umbilicus, and has a small amount of dark red lochia. She is physically exhausted and has been
anxious since delivery because her labor and delivery were harder than she ever expected, she was
expecting an easier delivery since it was her second baby.
Rita delivered two hours ago and has just been transferred to the postpartum floor. She has an IV of
Lactated ringers, which is to be discontinued when it is completed. Upon assessing her, the postpartum
nurse notes that the Rita is trickling bright red blood from the vagina and has soaked a large pad into the
under padabout 30 to 40 minutes after she changes it. Her perineum is swollen and red, no bruising
noted and stitches appear intact and wound edges are approximated from her mediolateral episiotomy.
Her vital signs are BP 90/68, pulse 110, and respiration 28. She appears restless.
Rita arrived in her room ten minutes ago. You were delayed by another mother who required pain
medication, but the nursing assistant collected the first set of vital signs posted below. You introduce
yourself, orient her to the room and unit, and begin your BUBBLE-HE assessment:
Current VS:
P-Q-R-S-T Pain Assessment (5th VS):
T: 99.9 F/37.6 C (oral)
Provoking/Palliative:
P: 110 (regular) Quality:
Cramp
R: 28 (regular) Region/Radiation:
BP: 90/68
Severity:
O2 sat: 98% room air
Vaginal delivery
Lower abdomen
6/10
Timing: Started one hour after delivery
Lab Results:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
Complete Blood Count (CBC):
Current:
WBC (5-15.0 mm 3/Pregnant)
18.5
13.5
Hgb (12-16 g/dL)
7.9
12.6
Hct (33-45%)
28
38
Platelets (150-450x 103/μl)
158
140
Neutrophil % (42-72)
PT/INR: 0.9
PTT: 30
Fibrinogen: 44
72
68
High/Low/WNL?
Previous:
Current Assessment:
GENERAL APPEARANCE:
Appears uncomfortable, restless
RESP:
Breath sounds clear with equal aeration bilaterally, non-labored
respiratory effort
CARDIAC:
Pink, warm/dry, no edema, heart sounds regular with no abnormal
beats, equal with palpation at radial/pedal/post-tibial landmarks
NEURO:
Alert and oriented to person, place, time, and situation (x4)
BUBBLE-HE
BREAST:
Lactating; soft, non-tender with evidence of drops colostrum
UTERUS:
Right of umbilicus, slightly boggy
BLADDER:
Voided 50 ml after delivery, bladder distended
BOWELS:
Abdomen soft/non-tender, bowel sounds audible per auscultation in
all four quadrants
LOCHIA:
Rubra. Soaked entire peri pad with 10-12” diameter puddle of
blood weight= 550 mL
HOMANS:
Negative
EPISIOTOMY: Perineum is swollen and red, no bruising noted and stitches appear intact and wound
edges are approximated from her mediolateral episiotomy.
Care Provider Orders:
Establish large bore peripheral IV
Administer 0.9% Normal Saline 1000 mL IV bolus
Oxytocin 20 units in 1000 mL Lactated Ringers (LR) infuse over 30 minutes. Titrate to vaginal bleeding
(AWHONN Guideline)
Methylergonovine 0.2 mg IM x1stat
The following meds are standing orders and in the hemorrhage cart to be given as needed if oxytocin
ineffective:
Carboprost 250 mcg IM PRN Misoprostol 800 mcg rectal or SL PRN
Contact OR for possible D&C or repair
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