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You complete a chart review, take note of current orders and enter the patient’s room to
introduce yourself and complete a full assessment.
You note that Mr. Burmond is awake, but lethargic when you enter his room. He knew the
time, but not the day of the week. His speech is clear and easy to understand. Pupillary
response was reactive to light. His wristband is in place and he responds correctly to his
name and date of birth. Both side rails are up and his bed is at the lowest position. You note
shortness of breath, especially with readjustment in the bed. Crackles are auscultated in the
lower lobes, but note no evidence of stridor or wheezing. Respirations are 19 per
minute. Saturation is 92% on 2L oxygen therapy. Temperature is 99.9 F. His heart sounds
are present, with no abnormal beats upon auscultation. His BP is 142/89 and heart rate is
92. Pulses are all present, 2+ in upper extremities and 1+ in the pedal region. Capillary refill
is less than 2 seconds. No edema noted in lower extremities. Bowels sounds present in all
quadrants. No pain disclosed. Active ROM and muscle strength is 1+ in all extremities. No
skin breakdown noted. Needs minor assistance, but has bathroom privileges. IV line in right
forearm flushed with no issues. IV fluid therapy infusing..
CHIEF COMPLAINT: “I have had trouble breathing for the past 3 weeks”
HISTORY OF PRESENT ILLNESS: 65-year-old Caucasian male complaining of shortness of
breath and productive cough with yellow sputum for 3 weeks. He also states that he has
been coughing accompanying with low-grade type fever. He also admits to having
intermittent headaches and bilateral chest pain that does not radiate to upper extremities
and jaws but worse with coughing. Patient initially had this type of episodes about 10
months ago but has intermittently getting worse since.
PMH: Asthma, Bronchitis PSH: none FH: Non-contributory SOCH: Married and lives with wife,
Mary, retired postal worker, has 3 children, 7 grandchildren. 100 packs/years and is a social
drinker. He denies any illicit drug use.
TRAVEL HISTORY: Denies any recent travel overseas
ALLERGIES: Sulfa
HOME MEDICATIONS: Albuterol 2 puffs bid prn.
REVIEW OF SYSTEMS REVEALS: Same as above
PHYSICAL EXAM: Vital signs are: Temp. 98 F / BP 126/82, Resp. 26, P 88
General: Patient is cachectic, anxious in mild acute respiratory distress. Lips are cyanotic.
He denies fever, night sweats
HEENT: Head: Atraumatic, normocephalic, Eyes: Conjunctiva clear; pupils 3 mm in size,
EOMI, PERLLA Ears: Tympanic membranes are pearly gray; no TM inflammation or
perforation. Nose: Nasal congestion with thick yellow rhinorrhea; swollen, erythematous
nasal turbinates; septum midline Throat: Pharyngeal erythema; post-nasal drainage; tonsils
mildly enlarged; there are no pustules, ulcers or exudate.
Face: Symmetrical; no maxillary or frontal sinus tenderness
Neck: Supple, no anterior or posterior cervical lymphadenopathy; thyroid is not palpable;
trachea is midline; no JVD
Heart: regular rhythm; normal S1 and S2; no S3 or S4; no murmurs, gallops or rubs.
Lungs: with rapid respirations, marked supraclavicular and intercostal retractions, using his
accessory muscles to breath.Bi-basilar crackles left > right, diffuse wheezes.
Chest exam revealed limited expansion, increased A-P diameter, hyperresonance and a
fixed diaphragm on percussion, marked inspiratory and expiratory wheezing, and a
prolonged expiratory phase.
Abdomen: No distention; no tenderness to palpation; no masses or organomegaly; bowel
sounds present in four quadrants; no bruits auscultated; no inguinal adenopathy.
Extremities: Warm, +1 pedal pulses. +clubbing. No edema.
Neuro: Moving all extremities well, 2+/4 reflexes throughout.
OSTEOPATHIC STRUCTURAL EXAM: He has bilateral paravertebral spasm, greater on the
right, T10-L5. The spine is flattened T10-L2. Generalized restriction of the lumbar to spring
towards rotation and sidebending both directions. Restriction to extension (restriction to
anterior spring) T10-L3. Articular restriction is greatest T10-12. T4 ESrRr, T2 FSlRl. Twelfth
ribs held in exhalation at an extremely acute angle static with respiration. Ribs 8-10 are held
in inhalation bilaterally. 1st and 2nd ribs are elevated on the right with right clavicle
elevated. The left 2nd rib is held in exhalation and there is bogginess to the tissues in the
area of the second ribs. The thorax has general restriction to exhalation. The diaphragm
was extremely tense and depressed with virtually no discernable movement during
respiration.
ASSESSMENT: Exacerbation of COPD related to respiratory infections.
PLAN: Treat with antibiotics and observe for improvement in status. Discharge home when
stable.
Chest X-ray
Imaging Results
Chest X-ray
COPD – Hyperexpansion In normal subjects the diaphragm is intersected by the 5th to 7th anterior ribs in t
with COPD as they are osteopenic due to long term steroid use – as in this patient In this image, the 7th ribs
level with the mid-clavicular line – so are the lungs hyperexpanded? Patient positioning and use of accessor
of the ribs on a chest X-ray Flattening of the diaphragm (red lines) is often a more reliable feature of lung hy
normal diaphragm shape and position
Diagnostic Study Results
Pulmonary Function Test
COMPLETE PULMONARY FUNCTION TESTING AND INTERPRETATION DATE OF TEST: REASON FOR THE TEST:
amount of deterioration over time. Spirometry showed forced vital capacity severely reduced to 49 percent
The ratio of FEV1 to forced vital capacity is reduced to 66 percent predicted. FEF 25-75 percent is severely re
reduced to 6 percent. Response to bronchodilators showed modest improvement with the maximum impro
Also there is marked improvement in the small airway, FEF 25-75 percent ratio that has improved to 20 per
change considering that small airway disease is still small. Total vital capacity was 63 percent predicted, whi
severe air trapping. Diffusion was decreased to 37 percent predicted with adjusted diffusion to hyperventila
showed severe obstructive defect with mild response to bronchodilators and evidence of obstructive sleep
defect. 2. Mild response to bronchodilators. 3. Severe air trapping. 4. Severe diffusion impairment. 5. Possib
Medication administration record : Approving Provider: John Mack, MD
Scheduled
FLUTICASONE PROPIONATE; SALMETEROL XINAFOATE
Details: , 2x Daily, Inhaled
(LEVAQUIN) LEVOFLOXACIN IN DEXTROSE 5% IVPB/DRIP
Details: 500 mg at 100 mL/hour, Daily, IVPB
prednisone
Details: 50 mg , Daily, Oral
PRN
ALBUTEROL
Details: 2 puffs , Every 6 Hours PRN, Inhaled
CONTINUOUS INFUSIONS
0.9% SODIUM CHLORIDE (NACL)
Details: at 50 mL/hour, Continuous, IV
Student Name
Clinical Judgement Plan
Professor Name
Date
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
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