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Clinical judgement plan sample
Introduction to Medical Surgical Lab (NURS 121L)
West Coast University
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West Coast University
SK/DW 2/22 pg. 1
Instructor: DATE Care Provided and UNIT: 2/11/ Oncology Unit
Patient Information (1) Patient Initials: x.y
Age & Gender: 72 yrs.
Height/Weight: 150cm/63
Code Status: full code
Living Will/ DPOA: yes
Chief Complaint Ex: SUBJECTIVE (Abnormal - Bullet Points) Lysed weakness, history of falls due to weakness, and chronic lung diseases
Admitting Diagnosis & Admission Date Lysed weakness 2/8/
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) The patient presents with chronic lung disease, lysed weakness, and a history of falls due to weakness.
Medical History: (SEE RUBRIC REQUIREMENTS) PAST DIAGNOSED MEDICAL PROBLEMS For each disease identified, define, it, describe pathophysiology, and cite source Congested heart failure is a severe condition in which the heart does not pump blood as efficiently as it should. Pathophysiology: Congested heart failure starts gradually when there are changes in the heart muscle that disturb the way the heart pumps blood. As a result, blood back up and fluid build up in the lungs, arms, or legs signaling congested heart failure. COPD: chronic obstructive pulmonary disease is a serious disease that damages the lungs which makes it difficult to breathe. Pathophysiology: chronic obstructive pulmonary disease involves progressive and permanent damage to lung structures, leading to symptoms of breathlessness, cough, wheezing, and sputum production Hypertension is when blood pressure is higher than normal. This condition happens when there is a high force against the blood artery. Pathophysiology: when the systolic blood pressure contracts, this shows the systole reading, and diastolic blood pressure reflects the blood pressure during the relaxation. The dysfunction in any of these readings can lead to the development of hypertension. A venous stasis ulcer is a leg wound caused by a damaged vein. Pathophysiology: Venous stasis ulcers happened because of poor blood flow in the leg veins.
Surgical History: (SEE RUBRIC REQUIREMENTS) PAST DIAGNOSED SURGICAL PROBLEMS: The patient has no surgical history. For each procedure identified, define & describe it; include year of procedure & cite source
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: The patient lives with her husband in their home in Dallas. Her husband takes care of her at home. He serves as her primary caregiver. ❋ Education: The patient’s educational background is unknown ❋Social and Community Context: The patient has limited mobility. ❋ Health and Health Care: The patient is not cooperative this morning. This may be a result of her dependency on others for assistance. ❋ Neighborhood and Built Environment: The patient is bedridden and a fall risk due to a venous ulcer and lysed weakness.
Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage (based on objective assessment) (SEE RUBRIC REQUIREMENTS) The patient is 82 years old lady married for fifty-eight years living with her husband, although she has chronic lung disease and lots of health ailments, which put her in the ego integrity versus despair stage.
Instructor: DATE Care Provided and UNIT: 2/11/ Oncology Unit
Instructor: DATE Care Provided and UNIT: 2/11/ Oncology Unit
TIME OUT!!! Student instructions:
Medications & Allergies (2)
Medication Name
Include BOTH Generic AND Trade names for RX; include OTC, herbal (non- pharmacological items)
Dos e
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?)
diltiazem 2tabl
ets
oral Q4H hypertension to treat high blood pressure
Headache, dizziness, and swollen hand and feet
Monitor patient blood pressure, ECG during therapy. Monitor patient I&O and daily weight
Ethanol topical daily IV 72hrs infection Decrease bacteria on
surface
Difficulty breathing, face, tongue swelling.
Monitor patient for any side effect.
furosemide 20m
g
IV
push
Q12 hypertension Lower blood pressure Hyponatremia, hypotension
Monitor patient vital sign. Assess for orthostatic hypotension
Gabapentin 100
mg
oral BID seizure To treat seizure and neuropathic pain
Nausea and vomiting, dry mouth
Monitor patient for any sign of confusion, depression and drowsiness.
Guaifenesin 600
mg
oral BID Nonproductive cough
To remove accumulated secretions from upper and lower airway
Stomach pain, skin rash, nausea and vomiting
Assess lung sound.
Metoprolol 25m
g
oral BID Heart failure To prevent block clot and improve blood flow
Headache, dizziness, stomach pain
Monitor blood pressure. Monitor side effect
Acetaminophen 2tab
s
oral Q4H pain To reduce pain Rash, hives, difficulty
breathing
Assess pain level before therapy. Monitor pain level
Levothyroxine 1tab oral Daily
before
breakfas
t
hypothyroidism To replace the thyroxine level t3 and t4 in the body
Chest pain, heat intolerance, dilated neck veins.
Administer medication on empty stomach with water. Assess heart rate, and heart sound.
Oxybutynin 1tab oral daily Urinary urgency To treat symptoms of
an overactive bladder
Dry mouth, dizziness, constipation, stomach pain
Monitor patient for confusion, agitation and hallucination. Monitor patient temperature
Pantoprazole 40m
g
oral daily Gastroesophageal
reflux disease
To suppress gastric acid production
Blurred vision, trouble breathing, fruit like breath odor
Auscultate patient bowel sound.
Naloxone 1ml IV As
directed
Opioid antagonist To reverse opioid overdose
Irregular heartbeat, trouble breathing, body aches
Assess heart rate, respiratory status and pain.
Instructor: DATE Care Provided and UNIT: 2/11/ Oncology 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?
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., the environment, the pt., the family, another nurse, EHR) in different formats (e., visual observation, audio perception, lab results, text description, etc.).
Evaluation
The patient met goal #1. She was able to assist using her walker to get up from bed to use the bed side commode throughout the shift.
The patient met goal #2. During the wound care dressing change, she did not feel much pain and never request for pain medicine for the rest of
the day.
Clinical Judgement (The expected/anticipated outcomes or SMART GOALS) These should be written in a SMART format for patient goals.
By the end of the shift, the patient will be able to bear weigh on her feet with minimal assistance to use the bedside commode. By the end of the shift, the patient will have less pain in her feet compared to yesterday.
Generate Solutions Develops a list of actions to address the hypotheses. Give rationales for each solution.
Observation Interpreting Responding
Assessment Analysis Planning Implement
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., organize cues in clusters), and then develops a group of probable client needs/concerns and problems
Instructor: DATE Care Provided and UNIT: 2/11/ Oncology Unit
References
Dudkiewicz, M., Yang, C., Goss, S., & Ilonzo, N. (2017). A case of superficial femoral arteriovenous fistula
and severe venous stasis ulceration, managed with an iliac extender prosthesis. Case Reports in Vascular Medicine, 2017(2017).
Ernlund, A. W., Moffatt, L. T., Timm, C. M., Zudock, K. K., Howser, C. W., Blount, K. M., Alkhalil, A., Shupp, J. W., & Karig, D. K. (2021).
Examining the effect of wound cleansing on the microbiome of venous stasis ulcers. Wound Repair and Regeneration : Official Publication of
the Wound Healing Society [and] the European Tissue Repair Society, 29(5), 766–776.
doi/10.1111/wrr.
García Josias E, & Wright, V. R. (Eds.). (2010). Congestive heart failure: symptoms, causes and treatment.
(Ser. Cardiology research and clinical developments). Nova Science Publishers.
Kaplan, N. M., Victor, R. G., & Flynn, J. T. (2015). Kaplan's clinical hypertension (Eleventh).
Wolters Kluwer.
Wilbanks, S. (2015). Copd. The Journal for Nurse Practitioners, 11(4), 37.
doi/10.1016/j.nurpra.2015.01.
Clinical judgement plan sample
Course: Introduction to Medical Surgical Lab (NURS 121L)
University: West Coast University
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