clinical judgement plan

Hi I need help doing an assignment. I will attach two documents. One is named (clinical judgement plan 1) this attachment will be filled out based on the attachment (process 4) if the information is missing then make it up based on what’s appropriate according to the patient. Please use app citations for all the sources. thank you.

Room
23
Patient/Age/Sex
Sherrow, Jacqueline 77
YO F
Attending & consults
Allergies
NKA
Admit date
11/29/23
Primary diagnoses CC/HPI
SOB Pneumonia
77 yo HPTN CHF COPD Picked up from rehab O2 sat 85% given nitro spray EMS
placed O2 increased 95% denies recent fever chills cough congestion
Isolation & organism
Code status
Full code
Past medical hx
CHF, HTN, Diabetes
Past surgical hx
None
Neuro/Psych
GCS Labs BGM frequency _____ / 07 _____ 11 _____ 17 _____ 21 _____
WBC: 9.6 x 10.3
Primary language
Eyes _____
Level of consciousness Verbal _____ Orientation & follow commands HbG: 10.2
Hct: 33.3
Motor _____
Plt: 47x 10.3
Mood/behavior
Total _____
AST: 20
Pupils
Alk Phos: 100
Muscle strength: LUE _____ / RUE _____ / LLE _____ / RLE _____
ALT: 33
Normocephalic atraumatic A/O x4 Normal speech no focal neuro
PT: 10.4
deficit observed Pupils Perla x2 extraocular movement intact
INR: 0.94
Na: 149
Cardiac
Echo EF _____ % Heart rate trends Tele rhythm
K: 4.5
trends
Cl: 116
SBP/MAP trends & goal parameters Temp trends & method/fevers &
Co2; (HCo3) 22
Cr: 0.80
Tmax
Glu: 389
Pulses: L rad _____ / R rad _____ / L ped _____ / R ped _____
Ca: 9.3
Edema & grading
Mag:1.9
Regular heart rhythm / rate no murmur no cardiac rub edema
bilateral lower extremities
[ ] Pacemaker / [ ] AICD
Respiratory
IS [ ] & trends/max _____ ml Lung sounds & work of
breathing/rhythm
O2 delivery _____ @ _____ LPM / _____%
O2 sat trends
Secretion amt & character/suction method
Chest tube(s) output & character
Respiratory tachypneic breath sounds diminished rhonchi present O2
delivery method no breather mask
GFR
76________ HgbA1C ________
Troponin
__188______ Lactate ________
BNP
________ Procal ________
CK
________ CRP
________
D-dimer
________ ESR
________
Fibrinogen ________ Amylase ________
Ammonia
________ Lipase ________
UA _________________________________
Cultures ___________________________
____________________________________
ABG date _____: pH _____ / pCO2 _____ / HCO3 _____ / pO2 _____
GI
Lt NG / Rt NG taped @ _____ cm / PEG
Continent/incontinent Suction __________ / Output _____ ml Last BM
& character Current TF rate @ _____ ml/hr Bowel sounds TF goal
rate _____ ml/hr
Abdomen appearance & palpation
TF max residual _____ ml
Diet/TF formula
Rectal tube/colostomy output & character
Soft non tender guarding negative rebound negative
Diagnostics/Imaging XR chest 1 view frontal No evidence pulmonary
embolus large consolidation R upper lobe with multifocal smaller
consolidations within lung fields concerning multifocal broncho
pneumonia
XR
CT
MRI
Ultrasound
EEG
Fluid restriction _____ ml/day
GU
Foley
insert
date
_____
Indication
__________
Continent/incontinent Last bladder scan _____ ml @ _____ Voiding
method Last I&O cath _____ ml @ _____
Shift/hourly urine output
Urine character
Normal within limits
HD sched __________ & last HD amt removed _____ ml
Musculoskeletal/Safety & Mobility
[ ] SCDs [ ] VTE ppx meds
Pain & scale utilized
Assistive devices
Level of assist
Calls for assist/safety concerns
Restraint type & location
Sitter/tele-sitter
Normal within limits Warm, dry, trachea midline
Specialty: Advanced Med/Surg
Neuro/Psych –
Richmond
AgitationSedation Scale
RASS
Cardiac – Hemodynamics
PA cath @ _____ cm
CI _____ / SvO2 _____ / CVP _____ / PAP _____ / SVR _____
Respiratory – Artificial airway & mechanical ventilation
ETT size _____ taped @ _____ cm @ teeth / gum / lip
Trach brand __________ & size _____
Vent mode ____________
Rate _____ VT/PS _____
FiO2 _____% PEEP _____
GI – Enteral tube
Rehab consults: [ ] PT [ ] OT [ ] SLP
OG taped @ _____ cm
None
Skin & Drains/Tubes
Pressure injuries/wounds
Wound tx/dressings output & character
Drains/tubes output & character
Normal within limits
Wound care consult [ ]
IV Lines
1 right antecubital protocol 72
H interval
2
3
4
5
6
7
8
Continuous IV Drips
1 none
2
3
4
5
6
7
8
OTOs/PRNs given & time last given
Tylenoyl 650 mg 2 tabs oral PRN
Pain Q4H
Docusate (docusate sodium) 100 mg
/ 1 cap oral BID oral PRN
constipation
To-do/Follow-up/Notes
Monitor associated risk
factor hypoxia hemodynamic
management
07/19 none
08/20
none
09/21
none
10/22
none
Temp &
source
97.2 F
oral
94 BPM
HR &
rhythm
11/23
none
12/00
none
13/01
none
14/02
none
148/95
BP & MAP
28
hr/min
Resp
rate
15/03
none
16/04
none
17/05
none
18/06
none
SpO2 &
delivery
method
Pain &
pain
scale
used
Medication Administration Record – provide 5 most critical/priority medications
Generic & trade name
Pharm class
Dose
Route
Freq
Indication(s) r/t patient
Prednisone (DELTASONE,
Corticosteroids
oral
BID
TAKE TWICE A DAY WITH FOOD
20
RAYOS)
steroids
mg PO
BID
Common SEs/ADEs (at least 3)
Weight Gain and Fluid Retention:
Prednisone can lead to an increase
in appetite and fluid retention,
resulting in weight gain. This
effect is more pronounced with
higher doses and longer-term use.
Insomnia and Mood Changes:
Prednisone may cause sleep
disturbances, including insomnia.
Additionally, some individuals may
experience mood swings,
irritability, anxiety, or even
depression while taking prednisone.
These psychological effects are
more common at higher doses and
with prolonged use.
Gastrointestinal Issues: Prednisone
can irritate the lining of the
stomach, leading to symptoms such
as indigestion, nausea, and in some
cases, peptic ulcers. To minimize
these effects, prednisone is often
recommended to be taken with food.
95%
15L/ min
5/10
Nursing considerations (at least 3)
Monitoring for Adverse Effects:
Prednisone is associated with a range
of potential side effects, including
but not limited to weight gain, fluid
retention, hypertension, mood
changes, and increased susceptibility
to infections. Nurses should
carefully monitor patients for these
effects, especially those on longterm or high-dose therapy.
Regular assessments of vital signs,
weight, and mood can help identify
and manage potential adverse effects.
Monitoring for signs of infection,
such as fever, is essential, as
prednisone can suppress the immune
system.
Patient Education on Tapering:
Prednisone should not be abruptly
stopped, as it can lead to withdrawal
symptoms and potential adrenal
insufficiency. Nurses play a crucial
role in educating patients on the
importance of adhering to the
prescribed tapering schedule.
Patients need to understand the risks
associated with abrupt
discontinuation and the need to
communicate with healthcare providers
if they experience any unusual
symptoms during the tapering process.
Bone Health and Calcium Intake:
Long-term use of prednisone can lead
to decreased bone density and an
Ibuprofen (ADVIL,
MOTRIN)
nonsteroidal
antiinflammatory
drugs
(NSAIDs)
800
MG
PO
TID
PRN PAIN
Gastrointestinal Issues:
Ibuprofen can irritate the stomach
lining, leading to symptoms such as
heartburn, indigestion, nausea, or,
in more severe cases, stomach
ulcers. Taking ibuprofen with food
or milk can help mitigate this
effect.
Kidney Effects: Prolonged use or
high doses of ibuprofen may cause
kidney problems, including fluid
retention, high blood pressure, and
potential kidney damage. It’s
important to stay hydrated and use
the medication as directed to
minimize this risk. Cardiovascular
Risks: Ibuprofen, like other
nonsteroidal anti- inflammatory
drugs (NSAIDs), may be associated
with an increased risk of
cardiovascular events such as heart
attack or stroke, especially with
long-term and high-dose use. This
risk is more pronounced in
individuals with pre-existing
cardiovascular conditions.
increased risk of fractures. Nurses
should assess patients for factors
that may contribute to bone loss,
such as age, menopausal status, and
nutritional status.
Patient education on maintaining
adequate calcium and vitamin D
intake, along with weight-bearing
exercises, is important to support
bone health. In some cases,
healthcare providers may recommend
calcium and vitamin D supplements.
Assessment of Medical History and
Allergies:
Before administering ibuprofen,
nurses should obtain a thorough
medical history from the patient. It
is crucial to identify any preexisting conditions such as
gastrointestinal ulcers, kidney
problems, or cardiovascular issues,
as ibuprofen may exacerbate these
conditions.
Assess the patient for any known
allergies to NSAIDs (nonsteroidal
anti-inflammatory drugs) like
ibuprofen. Individuals with a history
of allergic reactions, including skin
rash, swelling, or difficulty
breathing, should not receive
ibuprofen.
Monitoring for Gastrointestinal
Effects:
Ibuprofen can cause gastrointestinal
irritation and increase the risk of
ulcers or bleeding. Nurses should
monitor patients for symptoms such as
abdominal pain, nausea, vomiting, or
black, tarry stools.
It is advisable to administer
ibuprofen with food or milk to help
minimize the risk of stomach upset.
Patients with a history of
gastrointestinal issues should be
closely monitored, and alternative
pain relief options may be
considered.
Fluid Balance and Renal Function:
Ibuprofen, like other NSAIDs, can
affect renal function and fluid
balance. Nurses should assess
patients for signs of fluid
retention, such as swelling in the
extremities, and monitor renal
function through laboratory tests.
Patients with pre-existing kidney
conditions, heart failure, or
hypertension may be at a higher risk
of experiencing adverse effects on
renal function. Adjustments to the
dosage or considering alternative
pain management strategies may be
necessary in these cases.
Plan of Care (Clinical Judgment Plan) Priority
problem #1 [hypothesis]: If patient is given
pain medication then the patient pain level
will decrease from 6 to 0
Pertinent assessment data [cues]: Patient
complains of pain on scale of 1-10 score 6
Interventions with frequency & rationale [actions]:
S.M.A.R.T. goal/outcome #1 [solution]:
Assess/monitor:
Specific:
Reduce the patient’s pain from a pain score of 6 (on a
scale of 0 to 10) to a pain score of 3 within the time of
discharge
Measurable:
Measure the patient’s pain using a pain scale, such as a
numeric rating scale every hour to track changes in pain
intensity.
Achievable:
Collaborate with physicians and nurses to make a plan
which included prescription for and address any potential
underlying causes of the abdominal pain.
Relevant:
The goal is relevant to the patient’s well-being and
quality of life. Effective pain management not only
addresses the symptom but also contributes to improved
overall patient comfort, satisfaction, and adherence to
the treatment plan.
Time-Bound:
Achieve the reduction in pain within the time of
discharge. Regularly assess and reassess the patient’s
pain level throughout patients stay at ED to determine
the effectiveness of the interventions and adjust the
plan as needed.
Priority problem #2 [hypothesis]: If patient given SABA
medications for respiratory then patients resp rate will
increase
Pertinent assessment data [cues]: Patient O2 levels are
low on room air
S.M.A.R.T. goal/outcome #2 [solution]:
Specific:
Goal: Increase oxygen saturation levels in the patient.
Measurable:
Target: Achieve and maintain oxygen saturation levels
above 92%.
Measure oxygen saturation levels regularly using a pulse
oximeter.
Achievable:
Ensure that the goal is realistic and can be accomplished
with the available resources and interventions.
Collaborate with respiratory therapists, physicians, and
other healthcare professionals to determine appropriate
interventions.
Relevant:
Ensure the goal is relevant to the patient’s overall
health and well-being.
Consider the underlying cause of low oxygen levels and
address it appropriately (e.g., pneumonia, chronic
obstructive pulmonary disease).
Time-bound:
Set a timeframe for achieving the goal.
Assess/monitor: O2 sat level
Manage:
Priority problem #3 [hypothesis]: If patient is given IV
fluids then they will become hydrated
Pertinent assessment data [cues]: Patient lab levels low
point to dehydrated
S.M.A.R.T. goal/outcome #3 [solution]:
Specific:
Goal: Improve and maintain adequate hydration status in
the patient.
Measurable:
Target: Achieve and maintain normal vital signs,
including stable blood pressure, heart rate, and urine
output.
Measure intake and output, assess skin turgor, and
monitor vital signs regularly.
Achievable:
Ensure that the goal is realistic and achievable based
on the patient’s condition and overall health.
Collaborate with the healthcare team to determine
appropriate fluid rates and monitor for signs of fluid
overload or dehydration.
Relevant:
Ensure the goal is relevant to the patient’s health
status and any underlying conditions that may impact
fluid balance.
Consider the reason for dehydration and address it
appropriately (e.g., vomiting, diarrhea, inadequate
fluid intake).
Time-bound:
Set a timeframe for achieving and maintaining optimal
hydration.
O2 sat levels
Educate: Let patient know why they are being given
oxygen therapy
Interventions with frequency & rationale [actions]:
Assess/monitor: repeat labs after being given IV fluids
Manage:
Vitals
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met): none
Educate: Let patient know why they are being given IV
fluids and let them know that its to maintain hydration
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met): NONE
Manage:
none
Educate:
Let
patient
know why
they are
being
given pain
medication
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):
Shift Notes
Vitals
08/20
12/00
16/04
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