Kibata

Sign In

Our Services

Get 15% Discount on your First Order

Order Now
[rank_math_breadcrumb]

CJP

Clinical Judgement Plan

Instructor:

DATE Care Provided and UNIT:

Student Name

Clinical Judgement Plan

West Coast University

Professor Name

Date


OB History

GTPAL:


Prenatal Panel

Blood Type/Rh:
GBS:
Hep B:
HIV:
Rubella:
RPR:
Chlamydia:
Gonorrhea:
HSV:


Delivery Summary

Gestational age:

Delivery Type:

Delivery Time:

Postpartum Day:
Placenta Delivery Time:
Lacerations/Episiotomy:
QBL:
APGAR Score:

ROM type and time:

Complications:


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





Discharge Planning


Interprofessional Consults and Multidisciplinary Plan





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

Postpartum BUBBLE Assessment

Time of care: ____________________________________



Labor Assessment


Episiotomy/Laceration/


Incision


Vital Signs/Height/Weight

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:


Bowel


Bladder



Uterus


Breasts


Respiratory


Cardiovascular


Neurological


Emotional


DVT


Lochia

Time of care: ____________________________________


HEENT


Psychosocial


Hydration/Nutrition


Vital Signs/Height/Weight

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:


Genitourinary (GU)


Vaginal Exam/Leopold’s


Lines/Drains/Tubes


Gastrointestinal (GI)


Safety


Respiratory


Cardiovascular


Neurological


Musculoskeletal and Activity


Integumentary


Endocrine



Responding

Observation

Interpreting

Implement

Planning

Analysis

Assessment


Take Action


Generate Solutions


Prioritize Hypotheses


Analyze Cues


Recognize Cues

Evaluate


Evaluation

Reference Page

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Order Now

Related Questions

week8 case study

Common Health Conditions with Implications for Women Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, and diagnostic approaches, as well as to the development

Journal Response MODULE 4_DNP850

 describe the various roles of the DNP as a nurse educator.   Considering your readings from Module 4, describe the various roles of the DNP as a nurse educator. What education preparation and experience do you feel is vital for the role of the nurse educator? How do you think

Nursing MODULE 4 ASSIGNMENT_DNP850

 Compare and contrast the principles behind each of these doctoral degrees and how they lend to scholarly work. Doctoral Prepared Nursing Educators Write a 2000 word essay addressing each of the following points/questions. Be sure to completely answer all the questions for each bullet point. Separate each section in your

Lorem, ipsum

Assignment Developing a Healthcare Improvement Process Instructions Objective: The objective of this assignment is to provide you with an opportunity to examine your current practice setting or your desired future practice setting through the lens of healthcare improvement processes. You will outline a healthcare improvement process aimed at addressing a specific

nursing

To prepare: Review the studies and articles provided in the Learning Resources. Consider the strengths and limitations of systematic reviews and meta-analyses. Make sure you are clear on the difference between the two approaches. By Day 3 of Week 8 Post a brief summary of your informed opinion regarding the validity

nursing

To Prepare: Review resources about nursing profession issues in the United States. Look specifically at the NLN and ANA website resources. Review the global issues explored by the International Council of Nurses. Consider a nursing issue that may impact you.  Consider what might be done about this issue.  By Day

powerpoint slides

THIS IS A POWERPOINT ASSIGNMENT Screenshot of directions and rubric attached in files Instructions: In a 5- to 10-slide PowerPoint presentation, address the following. Your title and references slides do not count toward the 5- to 10-slide limit.  Provide an overview of the article you selected. What population (individual, group,

DISC 5

   Review      the Resources and reflect on the various strategies presented throughout      the course that may be helpful in disseminating effective and widely cited      EBP. This       may include: unit-level or organizational-level presentations, poster       presentations, and podium presentations at organizational, local,       regional, state, and national levels, as well as publication in

(week 2)The Connection between Academic and Professional Integrity

plz see attachment for instructions Part 2, Section 1: Writing Sample: The Connection between Academic and Professional Integrity · Explanation for the relationship between academic integrity and writing · Explanation for the relationship between professional practices and scholarly ethics · Cite at least two resources that support your arguments, being

AMP450Topic 5 DQ 2

Organizational behavior is important in health care, as it helps you as the leader learn what motivates employees, what makes them feel supported, and what causes them to be unhappy. Describe how knowing this can help you make organizational improvements and changes, while positively impacting employee satisfaction and organizational growth.

314Topic 5 DQ 2

Select a current or emerging trend in the delivery of health care or in professional practice from the allied health perspective in one of the following areas: (1) health care reform, (2) provider shortages, (3) leadership challenges, or (4) ethics surrounding professional practice. Provide a summary analysis of the trend,

314Topic 5 DQ 1

Explain telemedicine, and describe how it is typically being used in either a rural or an urban setting at the present time. For the setting you chose, what are telemedicine’s overall strengths? What are its overall weaknesses? Select an allied health profession and describe how telemedicine is now or could

AMP450Topic 5 DQ 1

The Agency for Health Care Research and Quality (AHRQ) supports research that improves the quality of health care and performance improvement. Select and describe one of the data sources available from AHRQ. Include in your discussion the role of the health care leader in promoting safe, effective evidence-based patient care.

W8A5 RATIO ANALYSIS

READ W8A5 RATIO ANALYSIS Your personal decisions regarding purchases are likely made, in no small part, based on your financial position. You will likely consult your bank statements and checkbook before buying. But the extent that you will go beyond current resources—including loans and financing—will depend on factors such as

Module 6-discussion

Scenario – You are working in a hospital, and a group of nurses have become vocal about the working conditions. The nurses are from different units in the hospital, and they are upset about the nurse:patient ratio, the mandatory meetings they are required to attend and not get paid, the

Pharmacology

Aprocitentan (Tryvio) .This is the medication to be use. · Approval: The U.S. Food and Drug Administration (FDA) approved this medication in March 2024 for patients with resistant hypertension (high blood pressure not controlled by other medicines). Preparing the assignment Follow these guidelines when completing this assignment. Speak with your