outline draft

Fitz Gerald Que

Clinical Judgement Plan

West Coast University

Professor Roxanne Mayo

August 3, 2025

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

History of Present Illness (HPI)

G.M. is an 88-year-old woman admitted due to dehydration. She primarily complains of general weakness, a history of frequent

falls, inability to walk, and urinary incontinence. The most recent provider order specifies that she should receive only comfort

care.

Admitting Diagnosis & Pathophysiology

Dehydration: occurs when the body loses more fluid than is replaced, resulting in a fluid shortage. This can impair cellular

functions and potentially lead to organ failure. In older adults, decreased thirst sensation and diminished kidney function can

heighten this risk (Mayo Clinic, 2025).

Medical History & Pathophysiology

- Depression: Involves an imbalance of neurotransmitters that regulate mood and behavior such as dopamine, norepinephrine, and serotonin (Chand & Arif, 2021).

- Generalized Anxiety: Involves the hyperactivity of the amygdala and neurotransmitter imbalances such as GABA, serotonin, and norepinephrine (Munir & Takov, 2021).

- Age-Related Osteoporosis: Osteoporosis is a result of unbalance bone creation and destruction. Age becomes a factor due to the lessened activating of osteoblasts that speeds up the decay of bone (Föger-Samwald et al., 2020).

- Repeated falls: Most often occur in older adults due to weakened muscle strength with hindered balance along with slower reflexes (Berry & Miller, 2018).

Surgical History & Pathophysiology

- Artificial Right Hip Joint: This procedure involves completely replacing the femoral head and acetabulum, forming a new ball-and-socket joint. It is often performed for conditions like osteoarthritis and rheumatoid arthritis, both of which damage cartilage and cause joint deterioration and deformity (Mayo Clinic, 2022).

Patient Information

Patient Initials: G.M.

Admission Date:

Chief Complaint: General Weakness

Age & Gender: 88 F

Admission Weight: 120 lbs.

Allergies: No Known Allergies

Code Status: DNR

Living Will/ DPOA: Yes

Social History

N/A

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

Social Determinants of Health Ethnicity: White Occupation: Antique Collector Religion: Not given Family support: Yes Insurance: Medi Cal 3 Psychosocial Considerations/Concerns Risk of Isolation – The patient faces a risk of isolation because of her living conditions in the care facility, which limit family visits and social interactions. Depression – The risk of depression during episodes is concerning given the patient's medical history. Currently, the patient is receiving treatment with Escitalopram Oxalate. Anxiety – The risk of anxiety during certain episodes is a concern given the patient's medical history. The patient is currently being treated with Lorazepam for these episodes.

Erikson’s Developmental Stage Related to Patient (1) *List and discuss specific stage (based on objective assessment)

Considering the patient's age, they are in late adulthood based on Erikson’s Developmental Stages. This phase focuses on integrity versus despair, when

individuals often review their lives (McLeod, 2025). Such reflection can result in feelings of satisfaction or regret, either wishing they had achieved more or

believing they still can. This stage relates to the virtue of "wisdom," which helps people accept and find fulfillment in their lives. Conversely, regret can lead to

bitterness and, ultimately, despair.

The patient is in late adulthood, influenced not just by her age but also by her depression and anxiety diagnoses. These may be affected by her living conditions or

overall health. She appears to be developing her reflective abilities, supported by a caring family that visits often. However, her physical limitations, such as

mobility issues, urinary incontinence, and reduced movement, are likely to cause mental distress, potentially leading to episodes of depression or anxiety.

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

Interprofessional Consults and Multidisciplinary Plan Assistive personnel should manage general palliative care for the patient and attempt to provide emotional support for the patient when the family isn’t present.

Physical Therapy should provide passive ROM exercise for the patient to maintain joints and reduce the possibility of falls. Provider should be contacted at the end of care period for evaluation of health and needs.

Discharge Planning

G.M. is not currently scheduled for discharge and remains on comfort care for at least 90 days, per the provider's order, until further

evaluation. The goals for G.M. include providing regular daily ROM therapy, repositioning frequently to prevent further skin breakdown

due to limited mobility, and increasing emotional support through more frequent family visits.

Teaching Assessment and Client Education

Since G.M. has limited mobility, education should be focused on the assistive personnel and the family. Pressure injury prevention should be amongst the

highest priorities with constant repositioning and hygiene of the skin. Then incontinence care should be prevalent such as frequent linen changing and care

of the perineal area to avoid possible infections. Emotional support education should be provided for the family due to her history in order to benefit G.M.

mental psyche.

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

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)

Complete Blood Count:

Protein

6.0-8.3 5.5 5.5 Low protein indicates poor nutrition or

dehydration.

Complete Blood Count:

Albumin

3.7-5.3 2.9 2.9 An indicator of hydration status, low

levels indicate malnutrition

Complete Blood Count:

BUN

7-25 30 30 High BUN indicates impaired kidney

function (Mayo Clinic, 2023).

Diagnostics

(3) Relevant Diagnostic Procedures with Results

Not Applicable.

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

(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

Acetaminophen (Extra

Strength)

1 tab

500

mg

PO Every 6 hrs. PRN for mild pain Inhibits prostaglandin

synthesis

Liver Toxicity

Monitor liver function

Acetaminophen 2-tab 325

mg

PO Once a day PRN for mild pain Inhibits prostaglandin synthesis

Liver Toxicity

Monitor liver function

Ascorbic Acid 1 tab 500

mg

PO Once a day For supplement Aids collagen synthesis and immune support

GI upset

Monitor nutritional intake

Aspirin 1 tab

81 mg

PO Once a day For CVA PPX Inhibits COX-1/COX-2

GI bleeding

Monitor signs of bleeding

Atorvastatin Calcium 1 tab

20 mg

PO At bed For hyperlipidemia Inhibits HMG-CoA reductase

Muscle pain

Monitor lipids

Docusate Sodium 1 cap

100

mg

PO PRN For constipation Lowers stool surface tension

Diarrhea

Encourage fluid intake

Escitalopram Oxalate 1 tab

20 mg

PO At bed Depression manifest

by sadness

Inhibits serotonin reuptake

Drowsiness Monitor mood

Hydrocodone-Acetaminophen 1 tab 5-325

mg

PO Every 4 hrs. For Severe pain Binds opioid receptors

Sedation, constipation

Monitor RR and bowel function

Lisinopril 1 tab 20 mg

PO Once a day For HTN Inhibits the conversion of angiotensin 1 to angiotensin 2

Cough, hypotension, hyperkalemia

Monitor BP

Lorazepam 1 tab

0.5 mg

PO Two times a

day

For anxiety Potentiates GABA

Sedation, Dizziness

Fall risk

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

Physical Assessment/Review of Systems

Vital Signs/Height/Weight (4)

Temp: 97.9

HR: 72

BP: 112/65

RR: 17

SpO2: 98%

Pain: 0/10

Height: 65 inches

Weight: 120 lbs.

Neurological (5)

- Moving all extremities - Face midline

symmetrical

Respiratory (7)

- Lung sounds clear in all anterior and posterior lung fields

- Normal effort breathing at rest

- RR within normal range for patient

Hydration/Nutrition (8) and

Gastrointestinal (GI) (9)

- Soft - Positive bowel sounds - Non-distended

Integumentary (12)

- Warm and Dry - Thin and Fragile - Signs of stage 1 pressure

injuries in coccyx area - Signs of skin tearing along

forearms

Genitourinary (GU) (10)

- Perineal area intact (No odor, no edema noted)

- Incontinent

Musculoskeletal and Activity (11)

- Generalized Weakness - ROM within functional limit - Muscle Strength +2 - Capillary refill < 3 sec. - Bed bound

HEENT

- No head irregularities noted - No ear irregularities noted - Pupils equal, round, and

reactive to light - Eyes accommodating - No use of accessory muscles

noted

Psychosocial (14)

- Family visitation - Social isolation - Depression - Anxiety

Cardiovascular (6)

- Regular rate and rhythm - BP and HR within normal

range for patient

IV Lines/Drains/Tubes

- No lines, drains, or tubes of note

Hormone

Regulation/Reproduction/

Endocrine (13)

- No hormone regulation issues noted

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

Assessment Analysis Planning Implement

Observation Interpreting Responding

Recognize Cues

- Limited Mobility

- Dependent on staff

for ADLs

- Urinary incontinence

- Limited family

interaction

- Fall Risk

- Has depressive

episodes

- Has anxiety episodes

Analyze Cues

- Immobility increases

fall risk

- Urinary incontinence

and limited mobility can

cause an increased risk

of skin breakdown and

UTI

- Depression and Anxiety

can cause decreased

mental well-being

Prioritize Hypotheses

Primary Hypothesis

- Impaired physical

mobility as evidenced

by general weakness

and need for assistance

with ambulation and

ADLs

Secondary

- Risk of skin integrity

- Risk for falls

- Risk for mental distress

Generate Solutions

- Assist the patient with

ambulation and

transfers from bed to

chair

- Include and encourage

the family with

emotional support

- Educate the Assistive

Personnel on care and

prevention of pressure

injuries.

Take Action

- Reposition the patient

every 2 hours

- Provide consistent

incontinence care

- Consult physical

therapy for passive

ROM training

- Assistive Personnel

educated on care and

prevention of

pressure injuries

Evaluation

1. G.M. pressure injuries remain intact with no signs of further progression of stage 1 injuries; skin interventions appear effective.

2. Patient has had no new cases of falls; ROM efforts seem to be effective in reducing the risk.

3. Family visits are longer and overall improved G.M. mental well-being.

4. Patient remains at 0/10 pain, comfort measures and medication have been effective.

Evaluate

Clinical Judgement Plan

Instructor: DATE Care Provided and UNIT:

Reference Page

Berry, S. D., & Miller, R. R. (2018). Falls: Epidemiology, pathophysiology, and relationship to fracture. Current Osteoporosis Reports, 6(4), 149–

154. https://doi.org/10.1007/s11914-008-0026-4

Chand, S. P., & Arif, H. (2021). Depression. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430847

Föger-Samwald, U., Dovjak, P., Azizi-Semrad, U., Kerschan-Schindl, K., & Pietschmann, P. (2020). Osteoporosis: Pathophysiology and therapeutic

options. EXCLI Journal, 19(1), 1017–1037. https://doi.org/10.17179/excli2020-2591

Mayo Clinic. (2025, May 2). Dehydration - symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-

conditions/dehydration/symptoms-causes/syc-20354086

Mayo Clinic. (2023, August 5). Blood urea nitrogen (BUN) test . Mayoclinic.org. https://www.mayoclinic.org/tests-procedures/blood-urea-

nitrogen/about/pac-20384821

Mayo Clinic. (2022). Hip replacement - Mayo Clinic. Mayoclinic.org. https://www.mayoclinic.org/tests-procedures/hip-replacement/about/pac-

20385042

McLeod, S. (2025, March 12). Erikson’s Stages of Development. Simply Psychology. https://www.simplypsychology.org/erik-erikson.html#Stage-8-

Ego-Integrity-vs-Despair-65-Years

Munir, S., & Takov, V. (2021). Generalized Anxiety Disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870