Executive Solution Overview
– ## NURS316L-AClinicalJudgementPlan1.docx **## NURS316L-AClinicalJudgementPlan1.docx** **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: …
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– ## NURS316L-AClinicalJudgementPlan1.docx
**## NURS316L-AClinicalJudgementPlan1.docx**
**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**<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)** |
| | | | | |
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| | | | | |
| | | | | |
| | | | | |
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**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**
**## NURS316L-AClinicalJudgementPlan1.docx**
**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**<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**
**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**
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