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clincial judgement plan for Med surg 3 **files (2)** – ## CamScanner5-3-2620.35.pdf – ## NURS481LClinicalJudgmentPlan.docx **## CamScanner5-3-2620.35.pdf** [https://v3.camscanner.com/user/download](https://v3.camscanner.com/user/download) [https://v3.camscanner.com/user/download](https://v3.camscann…

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clincial judgement plan for Med surg 3

**files (2)**

– ## CamScanner5-3-2620.35.pdf

– ## NURS481LClinicalJudgmentPlan.docx

**## CamScanner5-3-2620.35.pdf**

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**## NURS481LClinicalJudgmentPlan.docx**

**Clinical Judgement Plan**

**Instructor:**

**DATE Care Provided and UNIT:**

Student Name

Clinical Judgement Plan

West Coast University

Professor Name

Date

**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**

**Interprofessional Consults and Multidisciplinary Plan**

**Discharge Planning**

**Lab Tests with Values**

(Include normal ranges, dates, and rationales of abnormal results)

| | | | | |
| — | — | — | — | — |
| **Lab Tests or**<br>**Diagnostic Tests** | **Normal Ranges** | **Admission Lab Values** | **Current Lab Values** | **Explain Abnormal Results**<br>**R/T Your Patient**<br>**(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**

**HEENT**

**Hormone Regulation/Reproduction/**

**Endocrine (13)**

**IV Lines/Drains/Tubes**

**Psychosocial (14)**

**Vital Signs/Height/Weight (4)**

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:

**Respiratory (7)**

**Cardiovascular (6)**

**Neurological (5)**

**Genitourinary (GU) (10)**

**Musculoskeletal and Activity (11)**

**Hydration/Nutrition (8) and Gastrointestinal (GI) (9)**

**Integumentary (12)**

Responding

Observation

Interpreting

Implement

Planning

Analysis

Assessment

**Take Action**

**Generate Solutions**

**Prioritize Hypotheses**

**Analyze Cues**

**Recognize Cues**

Evaluate

**Evaluation**

1.

2.

3.

4.

**Reference Page**

**## NURS481LClinicalJudgmentPlan.docx**

**Clinical Judgement Plan**

**Instructor:**

**DATE Care Provided and UNIT:**

Student Name

Clinical Judgement Plan

West Coast University

Professor Name

Date

**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**

**Interprofessional Consults and Multidisciplinary Plan**

**Discharge Planning**

**Lab Tests with Values**

(Include normal ranges, dates, and rationales of abnormal results)

| | | | | |
| — | — | — | — | — |
| **Lab Tests or**<br>**Diagnostic Tests** | **Normal Ranges** | **Admission Lab Values** | **Current Lab Values** | **Explain Abnormal Results**<br>**R/T Your Patient**<br>**(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**

**HEENT**

**Hormone Regulation/Reproduction/**

**Endocrine (13)**

**IV Lines/Drains/Tubes**

**Psychosocial (14)**

**Vital Signs/Height/Weight (4)**

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:

**Respiratory (7)**

**Cardiovascular (6)**

**Neurological (5)**

**Genitourinary (GU) (10)**

**Musculoskeletal and Activity (11)**

**Hydration/Nutrition (8) and Gastrointestinal (GI) (9)**

**Integumentary (12)**

Responding

Observation

Interpreting

Implement

Planning

Analysis

Assessment

**Take Action**

**Generate Solutions**

**Prioritize Hypotheses**

**Analyze Cues**

**Recognize Cues**

Evaluate

**Evaluation**

1.

2.

3.

4.

**Reference Page**

**## CamScanner5-3-2620.35.pdf**

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**## NURS481LClinicalJudgmentPlan.docx**

**Clinical Judgement Plan**

**Instructor:**

**DATE Care Provided and UNIT:**

Student Name

Clinical Judgement Plan

West Coast University

Professor Name

Date

**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**

**Interprofessional Consults and Multidisciplinary Plan**

**Discharge Planning**

**Lab Tests with Values**

(Include normal ranges, dates, and rationales of abnormal results)

| | | | | |
| — | — | — | — | — |
| **Lab Tests or**<br>**Diagnostic Tests** | **Normal Ranges** | **Admission Lab Values** | **Current Lab Values** | **Explain Abnormal Results**<br>**R/T Your Patient**<br>**(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**

**HEENT**

**Hormone Regulation/Reproduction/**

**Endocrine (13)**

**IV Lines/Drains/Tubes**

**Psychosocial (14)**

**Vital Signs/Height/Weight (4)**

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:

**Respiratory (7)**

**Cardiovascular (6)**

**Neurological (5)**

**Genitourinary (GU) (10)**

**Musculoskeletal and Activity (11)**

**Hydration/Nutrition (8) and Gastrointestinal (GI) (9)**

**Integumentary (12)**

Responding

Observation

Interpreting

Implement

Planning

Analysis

Assessment

**Take Action**

**Generate Solutions**

**Prioritize Hypotheses**

**Analyze Cues**

**Recognize Cues**

Evaluate

**Evaluation**

1.

2.

3.

4.

**Reference Page**

**## CamScanner5-3-2620.35.pdf**

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**## NURS481LClinicalJudgmentPlan.docx**

**Clinical Judgement Plan**

**Instructor:**

**DATE Care Provided and UNIT:**

Student Name

Clinical Judgement Plan

West Coast University

Professor Name

Date

**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**

**Interprofessional Consults and Multidisciplinary Plan**

**Discharge Planning**

**Lab Tests with Values**

(Include normal ranges, dates, and rationales of abnormal results)

| | | | | |
| — | — | — | — | — |
| **Lab Tests or**<br>**Diagnostic Tests** | **Normal Ranges** | **Admission Lab Values** | **Current Lab Values** | **Explain Abnormal Results**<br>**R/T Your Patient**<br>**(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**

**HEENT**

**Hormone Regulation/Reproduction/**

**Endocrine (13)**

**IV Lines/Drains/Tubes**

**Psychosocial (14)**

**Vital Signs/Height/Weight (4)**

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:

**Respiratory (7)**

**Cardiovascular (6)**

**Neurological (5)**

**Genitourinary (GU) (10)**

**Musculoskeletal and Activity (11)**

**Hydration/Nutrition (8) and Gastrointestinal (GI) (9)**

**Integumentary (12)**

Responding

Observation

Interpreting

Implement

Planning

Analysis

Assessment

**Take Action**

**Generate Solutions**

**Prioritize Hypotheses**

**Analyze Cues**

**Recognize Cues**

Evaluate

**Evaluation**

1.

2.

3.

4.

**Reference Page**

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