Please provide rough draft and completed assignment using info providedClinical Judgement PlanInstructor:

Clinical Judgement Plan

Instructor:

DATE Care Provided and UNIT:

Yaneisy Yanez

Clinical Judgement Plan

West Coast University

Professor Viego

08/01/2024

Patient Information

(1)

Patient Initials:

Age & Gender:
Age in years/not DOB

Height/Weight:

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?

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
)

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
)

❋Economic Stability

❋ Education

❋Social and Community Context

❋ Health and Health Care

❋ Neighborhood and Built Environment

Erickson’s Developmental Stage Related to pt. & Cite References (1) *
List and Discuss specific stage (based on objective assessment)

(SEE RUBRIC REQUIREMENTS
)

TIME OUT!!! Student instructions:

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)

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.

Medical Management and Collaborative Plan

(From MD, PT, OT notes…. etc.) *Consider past 24 – 48 hours

(SEE RUBRIC REQUIREMENTS
)

ANTICIPATED TRANSFER/ DISCHARGE PLANNING:

DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE

EQUIPMENT

MEDS

TREATMENT

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

TIME OUT!!! Student instructions:

Medications & Allergies (2)

Medication Name

Include BOTH Generic AND Trade names for RX; include OTC, herbal (non-pharmacological items)

Dose

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?)

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

MISC:

Integumentary (12)

Psychosocial (14)

Endocrine (13)

Vital Signs (4)

BP:

HR: (Rhythm)

RR:

Temp:

O2 (any supplemental)

Pain (0/10)

Ht (cm)

Wt. (Kg)

BMI:

Respiratory (7)

Cardiovascular (6)

Neurological (5)

GI/Hydration/Nutrition (9)

GU (10)

Musculoskeletal (8)

Rest/ Exercise (11)

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?

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.

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)

Reflecting

Evaluate

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.).

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.

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.

Generate Solutions

Develops a list of actions to address the hypotheses. Give rationales for each solution.

Responding

Interpreting

Observation

Implement

Planning

Analysis

Assessment

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

References

Use APA format and hanging indents for all references.

If you have any questions, please consult the APA 7th Edition.

SK/DW 2/22 pg. 1

Final Version 3/10/22 DW/ss & MS Team