Nursing care plan
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choose like a reason why the child came into the unit and cite certain areas but the rest can just be typed and it doesn’t have to be cited because it is supposed to be like if you actually saw the child yourself.
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date
Patient Information
(1)
Patient Initials:
Age & Gender:
Age in years/not DOB
Height/Weight:
Code Status:
Living Will/ DPOA:
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
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
)
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
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
Erickson’s Developmental Stage Related to pt. & Cite References (1) *
List and Discuss specific stage (based on objective assessment)
(SEE RUBRIC REQUIREMENTS
)
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
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 (USE SEPARATE ATTACHED WORD DOC WHEN NEEDED) |
|
TIME OUT!!! Student instructions:
(Can add See attached Word Doc) |
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?)
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
MISC:
Integumentary (12)
Psychosocial (14)
Endocrine (13)
Vital Signs (4)
BP:
HR: (Rhythm)
RR:
Temp:
O2 (any supplemental)
Pain (0/10)
Ht (cm)
Wt. (Kg)
BMI:
Respiratory (7)
Cardiovascular (6)
Neurological (5)
GI/Hydration/Nutrition (9)
GU (10)
Musculoskeletal (8)
Rest/ Exercise (11)
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.g., the environment, the pt., the family, another nurse, EHR) in different formats (e.g., visual observation, audio perception, lab results, text description, etc.).
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.
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.
Generate Solutions
Develops a list of actions to address the hypotheses. Give rationales for each solution.
Responding
Interpreting
Observation
Implement
Planning
Analysis
Assessment
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
References
Use APA format and hanging indents for all references.
If you have any questions, please consult the APA 7th Edition.
SK/DW 2/22 pg. 1
Final Version 3/10/22 DW/ss & MS Team
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeAssessment & History of Present Illness
Recognizing cues focused on observation
|
4 pts Proficient HPI explains in detail with accurate and in- depth understanding of chief complaint and supported by evidence-based citations. |
3.04 pts Acceptable HPI explains in some detail with moderate understanding of chief complaint or no support from evidence-based citations. |
2.4 pts Needs Improvement HPI explains in limited detail with insufficient understanding of chief complaint or support from evidence-based citations. |
0 pts Unsatisfactory HPI details limited with poor understanding of chief complaint and no evidence-based citations to support. |
4 pts
This criterion is linked to a Learning OutcomeRecognizing assessment parameters
Clinical thinking and assessment cues
|
8 pts Proficient Identifies the 4 imperative assessment cues and or medical diagnoses supported by evidence-based citations. |
6.08 pts Acceptable Identifies 2 imperative assessment cues and or medical diagnosis supported by evidence-based citations. |
4.8 pts Needs Improvement Identifies 1 imperative assessment cues and or medical diagnosis, vaguely supported by evidence-based citation. |
0 pts Unsatisfactory Unable to identify any imperative assessments parameters relevant to medical diagnosis and without supported evidence-based citation. |
8 pts
This criterion is linked to a Learning OutcomeInterpreting diagnostic criteria & diagnostic tests and procedures
Clinical reasoning and analysis of cues
|
4 pts Proficient Clearly and accurately describes the client’s diagnostic criteria which clearly supports the chief complaints and presenting signs/symptoms. |
3.04 pts Acceptable Adequately describes the client’s diagnostic criteria which adequately supports the identified chief complaint and presenting signs/symptoms |
2.4 pts Needs Improvement Vaguely describes the client’s diagnostic criteria which vaguely supports the identified chief complaint and presenting signs/symptoms. |
0 pts Unsatisfactory Lack description of the client’s diagnostic criteria that does not support the identified chief complaint and presenting signs/symptoms |
4 pts
This criterion is linked to a Learning OutcomePast medical & surgical history, pathophysiology
Clinical judgment and recognizing cues
|
8 pts Proficient Past medical/surgical history detailed with full explanation of pathophysiology for admitting diagnosis and for each diagnosis & accurate detail with specific detail related to the client’s history and symptoms and supported by evidence-based citations. |
6.08 pts Acceptable Past medical/surgical history given with partial explanation of identified admitting diagnosis and preexisting medical diagnoses, intermittent details related to the client’s history and symptoms, or not completely supported by evidence-based citations. |
4.8 pts Needs Improvement Past medical/surgical history given with minimal explanation of identified admitting diagnosis and preexisting medical diagnoses; few to no details related to the client’s history and symptoms; or not supported by evidence-based citations. |
0 pts Unsatisfactory No past medical/surgical history given or given without explanation; no admitting diagnosis and or pre-existing medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence. |
8 pts
This criterion is linked to a Learning OutcomeSocioeconomic/psychosocial assessment
The impact of socioeconomic and cultural background
|
8 pts Proficient Describes socioeconomic and cultural background in complete detail with references; identified 3 or more psychosocial concerns. |
6.08 pts Acceptable Describes socioeconomic and cultural background with limited detail without references; identified 1-2 psychosocial concern. |
4.8 pts Needs Improvement Describes socioeconomic and cultural background in vague detail without references; identified 1 psychosocial concern. |
0 pts Unsatisfactory Describes socioeconomic and cultural background with no detail without references; identified no psychosocial concerns. |
8 pts
This criterion is linked to a Learning OutcomeInterprofessional consults & discharge referrals
Generating outcome data for plans
|
4 pts Proficient Lists 2-3 appropriate collaborative issues/concerns; rationale demonstrated satisfactory understanding of consults and interventions. |
3.04 pts Acceptable Lists 1-2 appropriate collaborative issue/concern Rationale and demonstrated limited understanding of consults and interventions. |
2.4 pts Needs Improvement Lists 1 appropriate collaborative issue/concern Rationale and demonstrated vague understanding of consults and interventions. |
0 pts Unsatisfactory Lists inappropriate collaborative issues/concerns; rationale demonstrated unsatisfactory understanding of consults and intervention |
4 pts
This criterion is linked to a Learning OutcomeRisk assessment
Interpreting risk data analyses of cues
|
4 pts Proficient The goal clearly supports the nursing diagnosis and plan of care. The goals are specific, measurable, attainable, realistic and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative interventions. |
3.04 pts Acceptable The goal somewhat supports the nursing diagnosis and plan of care. The goals are somewhat measurable and realistic, and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative interventions. |
2.4 pts Needs Improvement The goals are inconsistent with the nursing diagnosis and plan of care. The goals are vaguely realistic, measure and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention. |
0 pts Unsatisfactory The goals lack support and nonspecific from gathered data, Outcome criteria are not specific, realistic, measurable, attainable, nor timed. Does not evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention. |
4 pts
This criterion is linked to a Learning OutcomeMultidisciplinary Client Outcome & Discharge Planning
Analysis of teamwork and collaborative cues; analysis of collaboration with discharge planning
|
4 pts Proficient Clearly and accurately describes concerns related to multidisciplinary discharge planning. |
3.04 pts Acceptable Adequately describes concerns related to multidisciplinary discharge planning. |
2.4 pts Needs Improvement Vaguely describes concerns related to multidisciplinary discharge planning. |
0 pts Unsatisfactory Fails to describe concerns related to multidisciplinary discharge planning. |
4 pts
This criterion is linked to a Learning OutcomeTeaching assessment & client education
Responding and implementation; responding to identified client educational needs.
|
8 pts Proficient Clearly and accurately identifies areas of instructional needs, learning preference, and learning barriers. Provided clear and concise client education that will aid in health promotion, health maintenance and self-care activities. |
6.08 pts Acceptable Adequately identifies areas of instructional needs, learning preference and learning barriers. Provided some and adequate client education that aids in health promotion, health maintenance and self-care activities. |
4.8 pts Needs Improvement Vaguely identifies areas of instructional needs, learning preference and learning barriers. Provided minimal and vague client education that will aid in health promotion, health maintenance and self-care activities. |
0 pts Unsatisfactory Fails to identify areas of instructional needs, learning preference and learning barriers. Did not provide client education that will aid in health promotion, health maintenance and self-care activities. |
8 pts
This criterion is linked to a Learning OutcomePertinent lab test & abnormal involuntary movement
Interpreting data for analyses of cues
|
4 pts Proficient Clearly and accurately identifies pertinent laboratory tests with abnormal values and identifying trends related to a client’s disease process |
3.04 pts Acceptable Adequately identifies pertinent laboratory tests with abnormal values and identifying trends related to the client’s disease process. |
2.4 pts Needs Improvement Vaguely identifies pertinent laboratory tests with abnormal values and identifying trends related to the client’s disease process. |
0 pts Unsatisfactory Fails to identify pertinent laboratory tests with abnormal values and identifying trends related to the client’s disease process. |
4 pts
This criterion is linked to a Learning OutcomeNursing clinical judgments
Interpreting data for prioritizing hypotheses; this criterion is linked to a clinical outcome: nursing clinical judgment.
|
8 pts Proficient The 4 nursing clinical judgements are accurate and prioritized with clear etiology and data to support rationale. The clinical decision is consistent and presents correlation from the assessment data based on Maslow’s Hierarchy and Mental Status Examination. |
6.08 pts Acceptable The 4 nursing clinical Judgments are adequate and prioritized with sufficient etiology and data to support rational. The nursing clinical decision is adequate and presents correlation from assessment data based on Maslow’s Hierarchy and Mental Status Examination. |
4.8 pts Needs Improvement The 4 clinical judgments are vague and not prioritized with vague etiology and unclear correlation from the assessment data that may or may not be classified based on Maslow’s Hierarchy and Mental Status Examination. |
0 pts Unsatisfactory No clinical judgment is listed and or are based on Maslow’s Hierarchy and Mental Status Examination. |
8 pts
This criterion is linked to a Learning OutcomeNursing clinical goals
Evaluation of nursing clinical judgment; clinical thinking + clinical reasoning = clinical judgment
|
8 pts Proficient Clearly and accurately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal clearly supports the clinical decisions and plan of care. The goals are easily measurable and realistic. |
6.08 pts Acceptable Adequately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal somewhat supports the nursing diagnosis and plan of care. The goals are somewhat measurable and realistic. |
4.8 pts Needs Improvement Vaguely establishes client’s outcome criteria and may or may not be achieved with nursing assistance. The goals are inconsistent with the nursing diagnosis and plan of care. The goals are vaguely realistic and measurable. |
0 pts Unsatisfactory Fails to establish client’s outcome criteria that cannot be met by nursing assistance. The goals lack support and nonspecific from gathered data, Outcome criteria are not realistic and not measurable. |
8 pts
This criterion is linked to a Learning OutcomeNursing interventions criteria & rationale
Interpret planning to generate solutions
|
8 pts Proficient Clearly and accurately Identifies independent nursing interventions criteria with teaching supported by scientific rationale and evidence-based practice. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the client’s goals and directed at the stated health deviation based on nursing assessment and Erickson’s stages of development. |
6.08 pts Acceptable Adequately Identifies nursing interventions with adequate teaching. Scientific rationale is adequately supported by evidence-based practice. Interventions are adequate, individualized, organized, specific and realistic. Interventions can be implemented adequately that is focused on client’s goal and health deviation based on nursing assessment and Erickson’s stages of development. |
4.8 pts Needs Improvement Vaguely Identifies nursing interventions with unclear teaching. Scientific rationale is vaguely relevant & not supported by evidence-based practice. Interventions are inconsistent, non-specific, disorganized, and not adequately focused on the client’s goal. Interventions are difficult to implement and has weak relationship to nursing diagnosis based on nursing assessment and Erickson’s stages of development. |
0 pts Unsatisfactory Fails to identify interventions and teaching. Lack Scientific rationale and is not supported by evidence-based practice. Interventions are non-specific, inappropriate, unrealistic, un-measurable and do not relate to nursing diagnosis. Intervention does do not focus on client goals and/or the stated health deviation based on nursing assessment and Erickson’s stages of development. |
8 pts
This criterion is linked to a Learning OutcomeEvaluation
|
8 pts Proficient Skillfully and independently identifies criteria for evaluation. Evaluates effectiveness of interventions and measure’s goal completion. Modifies, revises, and recommends alternative intervention. |
6.08 pts Acceptable Adequately identifies criteria for evaluation. Adequately determines effectiveness of nursing interventions and measure’s goal completion with appropriate modification and revisions to the treatment plan. |
4.8 pts Needs Improvement Difficulty utilizing criteria for evaluation. Difficulty determining effectiveness of interventions and goal completion. Evaluation vaguely supports if goal is met or not met with inaccurate revisions to the treatment plan. |
0 pts Unsatisfactory Does not support nor utilize criteria for evaluation. Does not determine effectiveness of interventions and goal completion. There is a lack of alternative interventions to the treatment plan. |
8 pts
This criterion is linked to a Learning OutcomeMedications
|
8 pts Proficient Clearly and accurately identifies all components of the medication list, including mechanism of action, purpose, range, side effects, interactions, levels, and nursing considerations relevant to the client. |
6.08 pts Acceptable Adequately identifies components of the medication list. Adequate description of mechanism of action, purpose, range, side effects, interactions, levels, and nursing considerations relevant to the client. |
4.8 pts Needs Improvement Vaguely identifies components of the medication list. Lack description of mechanism of action, purpose, range side effects, interactions, levels, and nursing considerations relevant to the client. |
0 pts Unsatisfactory Fails to identify components of the medication list. Failed to include mechanism of action, purpose, range side effects, interactions, levels, and nursing considerations relevant to the client. |
8 pts
This criterion is linked to a Learning OutcomeGeneral Organization
|
4 pts Proficient Accurate APA format, appropriate citations, and references, No spelling or grammar errors. |
3.04 pts Acceptable Adequate APA format. Minimal citations and references are appropriate. Few spellings or grammar errors. |
2.4 pts Needs Improvement Numerous APA format errors, Inaccurate citations, and references. Few spelling and grammar errors. |
0 pts Unsatisfactory Fails to utilize APA format. No citations or references included numerous spelling and grammar errors. |
4 pts
Total Points: 100
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