Judgment
a year ago 5
NURS121L-ClinicalJudgmentPlan.docx
NURS121L-ClinicalJudgmentPlan.docx
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date
Social History
Patient Information
Patient Initials:
Admission Date:
Chief Complaint:
Age & Gender:
Admission Weight:
Allergies:
Code Status:
Living Will/ DPOA:
History of Present Illness (HPI)
Admitting Diagnosis & Pathophysiology
Medical History & Pathophysiology
Surgical History & Pathophysiology
Erikson’s Developmental Stage Related to Patient (1) *List and discuss specific stage (based on objective assessment)
Social Determinants of Health
Ethnicity
Occupation
Religion
Family support
Insurance
3 Psychosocial Considerations/Concerns
Teaching Assessment and Client Education
Interprofessional Consults and Multidisciplinary Plan
Discharge Planning
Lab Tests with Values
(Include normal ranges, dates, and rationales of abnormal results)
|
Lab Tests or Diagnostic Tests
|
Normal Ranges |
Admission Lab Values
|
Current Lab Values |
Explain Abnormal Results R/T Your Patient (USE additional pages at the end of template WHEN NEEDED) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Diagnostics
(3) Relevant Diagnostic Procedures with Results
(2) Medications
Medication Name
Include Generic name, Trade name, and Medication Class.
Include OTC, herbal (non-pharmacological items) and PRN medications given during clinical
Dose
Route
Frequency
Purpose of Medication for Your Patient
Mechanism of Action
Side Effects/
Adverse Reactions
Nursing Considerations Specific to Your Patient/Teaching
Physical Assessment/Review of Systems
HEENT
Hormone Regulation/Reproduction/
Endocrine (13)
IV Lines/Drains/Tubes
Psychosocial (14)
Vital Signs/Height/Weight (4)
Temp:
HR:
BP:
RR:
SpO2:
Pain:
Height:
Weight:
Respiratory (7)
Cardiovascular (6)
Genitourinary (GU) (10)
Musculoskeletal and Activity (11)
Hydration/Nutrition (8) and Gastrointestinal (GI) (9)
Integumentary (12)
Responding
Observation
Interpreting
Implement
Planning
Analysis
Assessment
Take Action
Generate Solutions
Prioritize Hypotheses
Analyze Cues
Recognize Cues
Evaluate
Evaluation
1.
2.
3.
4.
Reference Page
NURS121L-ClinicalJudgmentPlan.docx
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date
Social History
Patient Information
Patient Initials:
Admission Date:
Chief Complaint:
Age & Gender:
Admission Weight:
Allergies:
Code Status:
Living Will/ DPOA:
History of Present Illness (HPI)
Admitting Diagnosis & Pathophysiology
Medical History & Pathophysiology
Surgical History & Pathophysiology
Erikson’s Developmental Stage Related to Patient (1) *List and discuss specific stage (based on objective assessment)
Social Determinants of Health
Ethnicity
Occupation
Religion
Family support
Insurance
3 Psychosocial Considerations/Concerns
Teaching Assessment and Client Education
Interprofessional Consults and Multidisciplinary Plan
Discharge Planning
Lab Tests with Values
(Include normal ranges, dates, and rationales of abnormal results)
|
Lab Tests or Diagnostic Tests
|
Normal Ranges |
Admission Lab Values
|
Current Lab Values |
Explain Abnormal Results R/T Your Patient (USE additional pages at the end of template WHEN NEEDED) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Diagnostics
(3) Relevant Diagnostic Procedures with Results
(2) Medications
Medication Name
Include Generic name, Trade name, and Medication Class.
Include OTC, herbal (non-pharmacological items) and PRN medications given during clinical
Dose
Route
Frequency
Purpose of Medication for Your Patient
Mechanism of Action
Side Effects/
Adverse Reactions
Nursing Considerations Specific to Your Patient/Teaching
Physical Assessment/Review of Systems
HEENT
Hormone Regulation/Reproduction/
Endocrine (13)
IV Lines/Drains/Tubes
Psychosocial (14)
Vital Signs/Height/Weight (4)
Temp:
HR:
BP:
RR:
SpO2:
Pain:
Height:
Weight:
Respiratory (7)
Cardiovascular (6)
Genitourinary (GU) (10)
Musculoskeletal and Activity (11)
Hydration/Nutrition (8) and Gastrointestinal (GI) (9)
Integumentary (12)
Responding
Observation
Interpreting
Implement
Planning
Analysis
Assessment
Take Action
Generate Solutions
Prioritize Hypotheses
Analyze Cues
Recognize Cues
Evaluate
Evaluation
1.
2.
3.
4.
Reference Page