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
| 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) |
| TIME OUT!!! Student instructions:
INCLUDE: Appropriate Diagnostic Tests/ Procedures- DATEs and RESULTS (Can add See attached Word Doc) |
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
**Clinical Judgement Plan**
**Instructor:**
**Date Care Provided and Unit:**
**Student Name:** Yaneisy Yanez
**Institution:** West Coast University
**Professor:** Viego
**Date:** 08/01/2024
—
### **Patient Information**
1. **Patient Initials:** [Insert Initials]
2. **Age & Gender:** 2-year-old male
3. **Height/Weight:** [Insert Height/Weight]
4. **Code Status:** [Insert Code Status]
5. **Living Will/DPOA:** [Insert Information]
6. **Chief Complaint:**
– Pt is experiencing significant pain in the right lower limb, described by the mother as starting from a bite and progressively worsening over the past week. There is notable redness and induration on the right inner thigh, which is tender on palpation with well-defined edges.
### **Admitting Diagnosis & Admission Date**
– **Diagnosis:** L03.115 – Cellulitis of the right lower limb
– **Admission Date:** [Insert Date]
### **History of Present Illness (HPI)**
The patient was brought to the hospital by his mother due to a painful lesion on his right lower limb that began as a bite and worsened over the week. Upon arrival, physical examination revealed redness, induration, and tenderness. A CBC showed a slightly elevated white blood cell count. Initial treatment included an IM dose of Rocephin, and the lesion’s borders were marked to monitor changes.
### **Medical History**
– **Past Diagnosed Medical Problems:** [List medical problems, define each, and describe pathophysiology]
– **Example:** Asthma – A chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production (American Lung Association, 2020).
### **Surgical History**
– **Past Diagnosed Surgical Problems:** [List procedures, define, and describe each; include year of procedure]
– **Example:** Tonsillectomy – The surgical removal of the tonsils, performed in [Year] due to recurrent tonsillitis.
### **Social History**
– **Substance Use:** No history of smoking, alcohol, or illicit drug use.
– **Cultural Considerations:** [Insert details]
– **Ethnicity:** [Insert ethnicity]
– **Occupation:** N/A (Patient is a child)
– **Religion:** [Insert religion]
– **Family Support:** [Insert details]
– **Insurance:** [Insert details]
### **Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns**
– **Economic Stability:** [Insert details]
– **Education:** N/A (Patient is a child)
– **Social and Community Context:** [Insert details]
– **Health and Health Care:** [Insert details]
– **Neighborhood and Built Environment:** [Insert details]
### **Erickson’s Developmental Stage Related to Patient**
– **Stage:** Autonomy vs. Shame and Doubt
– At this stage, children develop a sense of personal control over physical skills and a sense of independence. Successful resolution leads to autonomy, while failure results in feelings of shame and doubt (Erikson, 1963).
### **Pathophysiology of Primary Medical Diagnosis (Cellulitis)**
– **Cellulitis**: An acute bacterial infection of the dermis and subcutaneous tissue, characterized by localized erythema, pain, and swelling. It typically occurs following a breach in the skin, such as an insect bite, allowing bacteria to enter and multiply (Stevens et al., 2014).
### **Patient Education (Inpatient) for Referrals/Discharge Planning**
– **Referrals Needed:** Case management for follow-up care, possible referral to pediatric infectious disease specialist.
– **Learning Style:** [Insert learning style]
– **Learning Preference:** [Written, video, etc.]
– **Learning Barrier(s):** [Language, education level]
– **Assistive Devices:** [Glasses, hearing aids, etc.]
### **Medical Management and Collaborative Plan**
– **From MD, PT, OT Notes:**
– **Last 24-48 Hours:** Administered Rocephin IM, marked lesion borders, recommended ibuprofen prn for fever and pain.
– **Anticipated Transfer/Discharge Planning:**
– **Priority Goals:** Reduction in lesion size, decreased pain, and no fever.
– **Equipment:** N/A
– **Meds:** Continue antibiotics as prescribed, ibuprofen for pain and fever.
– **Treatment:** Monitor lesion, follow-up visit to assess changes.
### **Relevant Diagnostic Procedures/Results & Pertinent Lab Tests/Values**
– **Lab Tests:**
– CBC: Slightly elevated white blood cell count (Normal range: 4,000-11,000 cells/µL)
– **Diagnostic Procedures:**
– [Include dates and results]
### **Medications & Allergies**
1. **Medication Name:**
– **Generic:** Ceftriaxone
– **Trade Name:** Rocephin
– **Dose:** [Insert Dose]
– **Route:** IM
– **Frequency:** [Insert Frequency]
– **Indications:** Bacterial infection
– **Mechanism of Action:** Inhibits cell wall synthesis.
– **Side Effects/Adverse Reactions:** Rash, diarrhea, nausea.
– **Nursing Considerations:** Monitor for allergic reactions, assess site for improvement.
### **Assessment/History of Present Illness/Review of Systems**
– **Physical Assessment Findings:**
– **Integumentary:** Redness, induration, tenderness on the right inner thigh.
– **Vital Signs:**
– BP: [Insert BP]
– HR: [Insert HR]
– RR: [Insert RR]
– Temp: [Insert Temp]
– O2: [Insert O2]
– Pain: [Insert Pain Score]
– Ht: [Insert Ht]
– Wt: [Insert Wt]
– BMI: [Insert BMI]
### **Clinical Judgement**
**Recognize Cues:** Information obtained from physical examination, patient history, lab results.
**Analyze Cues:** Interpretation of elevated WBC and localized symptoms indicating bacterial infection.
**Prioritize Hypotheses:** Immediate need to control infection and manage pain.
**Generate Solutions:** Administer antibiotics, monitor lesion, provide pain relief.
**Take Action:** Implement treatment plan, educate caregiver.
**Evaluate:** Assess effectiveness of interventions, adjust plan as needed.
**SMART Goals:**
1. The patient will have decreased pain, reporting a pain score of 3/10 or below by the end of the shift.
2. The patient will show reduced redness and swelling of the affected area within 48 hours.
### **References**
– Erikson, E. H. (1963). *Childhood and society*. Norton.
– Stevens, D. L., Bisno, A. L., Chambers, H. F., Dellinger, E. P., Goldstein, E. J. C., Gorbach, S. L., … & Wade, J. C. (2014). Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. *Clinical Infectious Diseases*, 59(2), e10-e52.
– American Lung Association. (2020). *Asthma*. Retrieved from [source]
—
This clinical judgement plan provides a comprehensive approach to managing the patient’s cellulitis, ensuring thorough assessment, evidence-based interventions, and ongoing evaluation.
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