Nursing Clinical Judgement Plan Pediatrics

SK/DW 2/22 pg. 1

Student Name

Clinical Judgement Plan

Professor Name

Date

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

Final Version 3/10/22 DW/ss & MS Team

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

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 à 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

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

Patient Information (1)

Patient Initials: Age & Gender: Age in years/not DOB Height/Weight: Code Status: Living Will/ DPOA:

Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage (based on objective assessment)

(SEE RUBRIC REQUIREMENTS)

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

Final Version 3/10/22 DW/ss & MS Team

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 à WHEN NEEDED)

TIME OUT!!! Student instructions: INCLUDE: Appropriate Diagnostic Tests/ Procedures- DATEs and RESULTS (Can add à See attached Word Doc)

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

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

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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?)

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

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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) BP: HR: (Rhythm) RR: Temp: O2 (any supplemental) Pain (0/10) Ht (cm) Wt. (Kg) BMI:

Neurological (5)

Respiratory (7)

Musculoskeletal (8)

Rest/ Exercise (11)

GI/Hydration/Nutrition (9)

GU (10)

MISC: Endocrine (13)

Cardiovascular (6)

Psychosocial (14)

Integumentary (12)

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

Final Version 3/10/22 DW/ss & MS Team

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?

Assessment Analysis Planning Implement

Observation Interpreting Responding

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.).

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)

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.

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.

Evaluate

Reflecting

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.

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

Final Version 3/10/22 DW/ss & MS Team

References Use APA format and hanging indents for all references. If you have any questions, please consult the APA 7th Edition.