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Pre-Sim Clinical Judgment Worksheet Brenda Patton
Medical-Surgical Nursing II (NSG 223)
Herzing University
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CLINICAL JUDGMENT ACTIVITY
PART 1: Recognizing Cues, Analyzing Cues, & Prioritizing Hypotheses
Review scenario (DocuCare Case & vSim) assigned by instructor. Describe what you know about your client’s admitting diagnosis or chief complaint. Rupture of membranes is a rupture of the amniotic sac during or 24 hrs. before the starting labor. Amniotic fluid, the liquid contained in the membranes surrounding the fetus, leaks out the vagina as the membranes rupture.
Review the SBAR report associated with this vSim as well as the provided data (history provided in the narrative, patient’s chart)
Recognize Cues: Think about the data or cues that stand out to you. What are they? Place them in the first box.
Recognize and Analyze Cues: Identify the data you feel is essential to address in this patient’s scenario/ condition. What are they? Why are they essential? Place in the middle box.
Analyze Cues: Prioritize the data you feel is relevant. What patient data should be addressed first, second, etc. List them in the last box.
Patient Data:
Brenda Patton 18 yrs. old G1P0 38 2/7 wks. Admitted for labor assessment and rupture of membrane 50% effacement of cervix 4 cm dilation of cervix Fetus at -2 station GBS culture positive
Relevant/Essential Patient Data:
Rupture of membrane- increases chance of infection. GBS positive- if left untreated the baby may develop sepsis, meningitis, and pneumonia.
Prioritize Data:
GBS positive Rupture of membrane
CLINICAL JUDGMENT ACTIVITY
PART 2 Generating Solutions, Taking Action, and Evaluating Outcomes
Based on the prioritized problems identified in part 1, what problem is essential to address first? Write it in the appropriate box.
What independent and collaborative nursing interventions would you utilize to address your concerns and which parameters would you monitor while caring for this patient. Write your answers in the appropriate boxes.
Obtain CBC labs. Check if pt. has any allergies. Give prescribed anti- infective. Alert physician of any increase in temperature.
Monitor temperature every 2 hrs. for fever. Monitor WBC count. Monitor for anaphylaxis after giving prescribed anti-infective.
GBS positive
Actions to Take: Parameters to Monitor:
Priority Patient Problem:
Pre-Sim Clinical Judgment Worksheet Brenda Patton
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
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