Please follow rubric, which I will send as additional files. Do NOT direct quote, only paraphrase and use APA citations. I will include a PDF of the Professor’s direct instructions! Also if the information does not fit into the boxes, use a separate document please.
Requirements: Very in depth answers please
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date
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
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
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?
References
Use APA format and hanging indents for all references.
If you have any questions, please consult the APA 7th Edition.
Generic / Brand name Drug / Therapeutic class MOA Nursing Considerations Side effects / Black box warning Pt teaching
PROFESSORÕS INSTRUCTIONS-Patient initials: if the patient’s chart has a daughter sister automatically dpoa (designated power of attorney).- Chief complaint should be short, what did they come in for? be careful because chief complaint is not necessarily only what happened, but what happened before they came in. For example, if the patient was found down under a bridge, include these details.-Admitting diagnosis: history of present illness should again not be copy pasted under any circumstances you need to summarizeÉ how you would give a report to an oncoming nurse. -Medical diagnosis: needs to have an explanation ; APA cited ; pathogenesis not Pathophysiology ; If a patient came for hypertensive crisis how did this start? Any causes? Maybe the patient was a raging smoker for the past 35 years of their life. Whatever led to what is all she wants. Put as much info as possible to explain all the problems. -Medical history: If they are sick they will have a lot of history. Pathogenesis with APA again Pathophysiology is included as well. Try to Þnd as many connections as possible. -Surgical history: a little bit about surgery, have APA ;talks about how it’s done, why it’s done?-Social history: whatever the chart says ; for example meth user, smoker, illicit drug use, alcohol use . doesn’t need you to make up occupation but only needs to talk about their social history that’s mainly on the chart ; make sure to have APA ; keep it short and sweet and to the point-Teaching: youÕre going to split it into two sections ; inpatient and discharge/outpatient-Inpatient: what do you want to teach patients when they are in the hospital? Teach them about anything you want, lights, doctor time arrival. Don’t mix the subjects together ; for example keep medications in medications so you don’t self-plagiarize. Don’t talk about diagnosis or disease process. Figure out what you want to be taught when you’re in the hospital. Make it make sense. APA cited. What does the day look like, when do people come? All these should be noted. Anything you need to teach the patient should be in this section. Look into patients’ eyes and teach them. You need to have a pretty big chunk of lessons taught don’t keep it 1-2 words because that means you didn’t teach them anything. If you get stuck ask the professor-Discharge: if the patient has a brand new diagnosis, teach them how to be safe. If they wear a watch and it gets tighter and tighter it’s telling you that it is swelling. If there are apps that keep patients on track with calculations, reminders with medications can be used. Any organizations, phone numbers, anything where the patient can get info to help them out can??be used. Teach the patient how to be safe to not return to hospital. -Equipment: need 3 equipment that the patient will need at home ; if you were to discharge them what would you send them with them. Teach them all the equipment and how to use it. Three medications to manage disease processes at home. Need to research APA cite and make sure your giving the correct medication
-Treatment consists of different things: such as CPT, basically anything that the patient can beneÞt from-Case Management: doesn’t care ; can take out-Labs: not gonna be easy ; it’s a lot; wants to see high or low not everything in between. She has charts; wants to be as wide as possible. Make sure to connect to patients and pathophysiology. Whatever helps you on her chart should be used. Most labs are current lab values make sure to have that test and have an explanation. She Wants to see lab tests, lab value, high or low, unit per deciliter / liter whatever it is and an explanation.-Example: Patients’ lactic acid is elevated due to and that leads to because so and so. All labs need their own citation. Don’t use one for all of them. Each is different. APA is grading of its own will lose points if you don’t use APA. -Medications: limit up to 10 she will give you the ones you will use. She will give you the important ones. Same way. Same sheet for med pass put it down, include nursing consideration: mechanism of action should be the only thing copy-pasting: don’t be vague and list monitor CBC, specify what are you monitoring ; how; monitor vital signs ; blood pressure ; hypertension and so onÉ BE SPECIFIC!! Medication is the most important thing since it can be vital to the patient. Have realistic nursing consideration always.-Fun fact: assessment Þndings she provided takes a big chunk of what you have to do so you can concentrate on the important stuff. Be careful what you put into each category.Basically donÕt plagiaries ; be precise ; make sure you know what your talking about ; explain a lot so there is no confusion ; DO NOT COPY PASTE, PARAPHRASE ONLY and have APA citations
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