Clinical Judgement Plan
Fill out all the pages that are empty I will provide an example of a filled out judgment plan, please do a thorough and DETAILED job, very important.
The medication page is filled out
Fill out Assessment of patient pertaining to his disease, what signs would you see on a patient with Respiratory Failure
It is due tomorrow by 10pm
The patients diagnosis is: Respiratory Failure and Septic Shock
I will provide patient charts if you can use information from that and nurselabs https://nurseslabs.com/sepsis-and-septic-shock/
https://nurseslabs.com/category/nursing-care-plans…
whatever website is helpful with giving information use it.
Requirements: 4 pages
ASSESSMENT/History of Present Illness /REVIEW OF SYTEMS
References:
McGraw, D. (2014, January 1). Therapeutic drug monitoring with valproate–why product selection is an important factor. Allen Press. .
ASSESSMENT/History of Present Illness /REVIEW OF SYTEMS
References:
McGraw, D. (2014, January 1). Therapeutic drug monitoring with valproate–why product selection is an important factor. Allen Press. .
SK/DW 2/22 pg. 1Maria KaxandjianWest Coast UniversityProfessor Christopher TarangoNURS 481LJuly 14, 2023
Clinical Judgement PlanInstructor: Professor TarangoDATE Care Provided and UNIT: 4 WestCultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns:Patient M.M. is a 67-year-old African American male from a lower socioeconomic background. He comes from a culturally diverse community with a predominantly African American population. He has experienced challenges associated with his race, such as limited access to healthcare, educational opportunities, and employment options. M.M. is Christian, and this provides emotional support and a sense of purpose, helping him cope with his health challenges. Also influences his decisions regarding healthcare, including seeking spiritual guidance and prayer for healing. M.M. has a strong, loving, and supportive family: his wife, three daughters, and seven grandchildren. Family members provide emotional support, assist with daily activities, and help manage his medical care. Taking Social Determinants of Health into account, healthcare providers should consider their cultural background, ethnicity, occupation, religion, family support, and insurance coverage when developing a treatment approach. Collaborating with social workers, case managers, and community organizations can help mitigate the impact of socioeconomic and cultural barriers on his health and improve his overall quality of life.History of Present Illness (HPI) Patient M.M is a 67-year-old patient, date of birth January 05, 1956. Patient was brought to the emergency room where a Magnetic Imaging Test (MRI) was done of which showed bilateral optic nerve atrophic. Patient was noted to have gastrointestinal bleed with coffee-ground emesis he had GD done which showed erosive ulcerative esophagitis. Patient was discharged June 14, 2023, in the following two weeks patient M.M admitted himself in the emergency department with worsening of his mentation. Upon admission patients’ symptoms included the shortness of breath, noted to have confusion, was not able to ambulate or wake up. Due to M.M worsening condition the decision was taken to transfer him into telemetry for further care. Patient is allergic to the following items: Carvedilol, Lisinopril, Metformin and Sitagliptin. Vital Signs are the following: Blood Pressure: 129/64 Pulse: 67 bpm Respiration Rate: 18 Temperature: 97.9 Oxygen saturation: 98% with 2L of nasal canula. Medical History: PAST DIAGNOSED MEDICAL PROBLEMS See attached page.Surgical History: PAST DIAGNOSED SURGICAL PROBLEMSPatient has no record of sur2gical history.Social History:SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USEPatient denies having smoked tobacco, drank alcohol or any illicit drug use.Chief ComplaintShortness of BreathUnable to AmbulateConfusionUnconscious Admitting Diagnosis & Admission DateAdmitting Diagnosis: Congestive Heart FailureEnd-Stage-renal diseaseAdmission Date: 7/5/2023Patient Information (1)Patient Initials: M.MAge & Gender: 67-Year-Old, MaleHeight/Weight: 75in, 100.7kgCode Status: Full CodeLiving Will/ DPOA: N/AErickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage Mr. Mook is a 67-year-old male, which places him in Erikson’s Developmental Stage eight, known as “Ego Integrity vs. Despair.” This stage occurs during late adulthood; individuals reflect on their lives and evaluate their accomplishments and failures (Maree, 2021). Successfully resolving this stage involves developing a sense of fulfillment, wisdom, and integrity. However, if the individual fails to achieve a sense of integrity, feelings of despair and regret may arise. This stage becomes particularly significant for Mr. Mook facing the challenges of congestive heart failure and end-stage renal disease. The individual may experience physical limitations, dependency on medical interventions, and increased awareness of mortality (Smilde et al., 2009). These factors can profoundly impact one’s sense of self and provoke questions about the meaning and purpose of life. The patient may also face complex medical treatments and end-of-life care decisions, which can further contribute to feelings of despair and distress. Providing holistic care that covers both physical and psychological aspects is essential. Healthcare professionals should encourage open communication, allowing patients to express their fears, concerns, and hopes (Smilde et al., 2009). Involving patients in decision-making processes related to their medical care empowers them to maintain control and dignity (Maree, 2021). Palliative care, pain management, and psychological support should be incorporated into the patient’s treatment plan to address their condition’s physical and emotional aspects.
Clinical Judgement PlanInstructor: Professor TarangoDATE Care Provided and UNIT: 4 WestMedical History:End-Stage Renal Disease:Definition: The last stage of chronic kidney disease (CKD) is end-stage renal disease (ESRD). It happens when the kidneys’ ability to eliminate waste items from the blood and maintain fluid balance is compromised.Pathophysiology: Kidney damage: Various conditions, including diabetes, high blood pressure, infections, and autoimmune illnesses, can cause kidney damage. Scarring of the kidneys: Scarring of the kidneys occurs because of renal injury. This scarring impairs the kidneys’ ability to function normally. Waste product accumulation occurs when the kidneys cannot eliminate waste products from circulation. This can result in a buildup of toxins in the blood, leading to various health issues. Fluid imbalance: The kidneys are also in charge of regulating the body’s fluid balance. The kidneys are unable to manage fluid levels as they deteriorate. This can result in fluid overload, putting strain on the heart and other organs.Symptoms:FatigueNauseaVomitingLoss of appetiteWeight lossCongestive Heart Failure:Definition: Congestive heart failure (CHF) occurs when the heart is unable to pump enough blood to fulfill the body’s demands. This can occur if the heart is too weak or stiff to pump correctly, or if there is a blockage in the chambers or valves of the heart.Pathophysiology: As the heart fails, it goes through a process known as cardiac remodeling. This remodeling includes structural and functional changes to the heart. The cardiac muscle thickens and stiffens, and the chambers of the heart expand. These modifications make it more difficult for the heart to pump blood. Since the heart is weak, it is unable to adequately pump blood out of the lungs. This creates a buildup of fluid in the lungs, resulting in shortness of breath. Other regions of the body, such as the legs and abdomen, might also experience fluid buildup. As the heart fails, the body’s ability to control electrolyte levels in the blood suffers. This can result in sodium, potassium, and other electrolyte abnormalities. These imbalances can lead to a variety of health issues, including muscular weakness, irregular pulse, and disorientation.Symptoms:Shortness of breathFatigueSwelling in the feet, ankles, and legsCoughWeight gainErosive Ulcerative Esophagitis:Definition: Erosive ulcerative esophagitis is a disorder that causes the esophageal lining to become inflamed and degraded. This can cause discomfort, swallowing difficulties, and bleeding.Pathophysiology: Reflux of stomach contents into the esophagus is the most common cause of EUE. This can occur when the lower esophageal sphincter, a muscle that connects the esophagus to the stomach, fails to seal correctly. When stomach contents reflux into the esophagus, they can irritate and inflame the lining of the esophagus.Symptoms:Painful swallowing Blood in feces or sputumHeartburn
Clinical Judgement PlanInstructor: Professor TarangoDATE Care Provided and UNIT: 4 WestTIME OUT!!! Student instructions: Include Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (With normal ranges), include dates and rationales supported with Evidence Based CitationsInclude 2-3 nursing interventions for abnormal labs and for all diagnostic proceduresLab Tests orDiagnostic ScanNormal RangesAdmission Lab ValuesCurrent Lab ValuesExplain Abnormal Labs R/T Your Pt & NI (USE SEPARATE ATTACHED WORD DOC WHEN NEEDED)Red Blood Cell4.35k to 5.65k3.30 L3.04 LLow levels of Red Blood Cell play a role in Congestive Heart Failure which shows patient is Anemic.Hemoglobin14 to 185.7 L5.9 LDue to the Congestive Heart Failure causing anemia it has led to kidney damage which makes Anemia worsen.Hematocrit40 to 5432.2 L20.2 LHematocrit has decreased due to the red blood cells being at such a low level and not being able to oxygenate the blood.Platelet150k to 400k183159Na136 to 145129 L131 LHyponatremia is caused by fluid overload, due to the increase volume in blood vessels it is diluting the concentrations.K3.5 to 5.24.74.9CO223 to 302826BUN7 to 2038 H47 HPatient is diagnosed with CHF therefore blood is not properly pumping to the kidneys.Creatinine0.7 to 1.37.36 H7.33 HDue to the patient having Congestive Heart Failure the heart is not pumping therefore causing vascular congestion of the blood in kidneys.Glucose70 to 10095107Diagnostic Tests/ Procedures:Chest X-Ray:Preformed 07/06/2023Results: 07/06/2023Single frontal view of the chest was obtained.Moderate CardiomegalyPulmonary Vascular CongestionSmall Left Pleural EffusionNo PneumothoraxPatients Chest X-Ray results show Moderate Cardiomegaly with Small Left Pleural Effusion is due to the diagnosis of Congestive Heart Failure.Pathophysiology of Primary Medical Dx/Support with Evidence Based Citations:Congestive Heart Failure: Congestive heart failure is characterized by the inability of the heart to pump blood efficiently, leading to fluid congestion and inadequate tissue perfusion. A factor contributing to CHF is impaired myocardial contractility, often resulting from underlying conditions such as coronary artery disease or myocardial infarction. The impaired contractility reduces the heart’s ability to pump blood effectively, leading to decreased cardiac output.End-Stage-renal disease: End-stage renal disease refers to the final stage of CKD in which the kidneys have lost their ability to function adequately. There is a significant reduction in the GFR leading to the accumulation of waste products, electrolyte imbalances, and fluid overload. The impaired renal function in ESRD results in fluid and electrolyte imbalances, leading to volume overload and increased cardiac workload, exacerbating CHF. Pathophysiology of Primary Medical Dx (reason for hospitalization)Reference used: (Luke’s, 2022)Patient Education: Exercise as much as possible to strengthen your heart muscles. Low sodium diet, Limit alcohol once a day, limit daily liquids due to fluid overload. No smoking, take all prescribed medications, monitor daily weight, attend any scheduled appointment. When to contact provider: SOB, Increased extremity swelling, sudden weight gain starting at 2 lbs. in 1 day to 4 lbs. in 6 days.When to contact 911: Severe chest pain, irregular/fast heartbeat, numbness to any part of body and slurred speech.REFERRALS NEEDED/CASE Management: Social worker needed to transfer patient from hospital setting to Skilled Nursing Facility. Needed to provide family with coping skills/counseling during transition as patients status is declining.ASSESS LEARNING STYLE: Patient prefers nurses verbally explain all procedures and medications fast and get everything done. He does not like long explanationsLEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL: Patient uses glasses when accessing his phone and watching television, we can communicate in English. He does have difficulty hearing therefore we need to speak up at certain times.Medical Management and Collaborative Plan/ANTICIPATED TRANSFERReference used: (Donis et al., 2023)DISCHARGE PLANS: Patient is unstable to be discharged home, instead will be transported to a Skilled Nursing Facility (SNF) within the next two weeks.PRIORITY GOALS: Evaluate fluid balance, blood circulation throughout body, and maintain cardiac output shown by blood pressure and heart rate.EQUIPMENT: Dialysis Machine, IV Machine, Compression Device, Bed Commode.MEDS: Atorvastatin Calcium, Heparin Sodium, Calcium AcetateTREATMENT: Place patient on low sodium diet, fluid deficit, fluid balance, manage patient fluid overload and improve contractibility of heart.
Clinical Judgement PlanInstructor: Professor TarangoDATE Care Provided and UNIT: 4 WestTIME OUT!!! Student instructions: Medications & Allergies (2)Medication Name Dose RouteFreq.IndicationsMechanism of ActionSide Effects/Adverse ReactionsNursing Considerations specific to this patient with citationsAspirinHalfprin81mgPODAILYReduce risk of blood clots.Aspirin blocks the -1 in the platelets preventing them from forming clots.Bloody/Tarry stoolSevere Nausea/VomitingStomach PainRapid BreathingConfusion/HallucinationsBleedingStomach UlcersMonitor for toxicity: (Matt Vera BSN, 2023)DiplopiaEKG changesHepatic FunctionConfusionLethargyAnaphylaxisAtorvastatin CalciumLipitor80mgPOQHSImprove the function of the left ventricle.Atorvastatin Calcium inhibits the enzyme that forms cholesterol by preventing conversion of HMG-CoA to mevalonate.NauseaHeadachesSore ThroatConstipationSneezingNosebleedMonitor For: (McIver, 2022)Serum Lipid levelsLiver Function TestFall PrecautionMuscle painConcentrationFolic Acid1mgPODAILYDecrease homocysteine in blood to reduce chance of stroke.Folic Acid nucleoprotein synthesis and the maintenance of normal erythropoiesis.NauseaLoss of appetiteBloatingIrritabilitySkin ReactionConfusionMonitor For: (Rnpedia, 2019)WBC & Platelet productionHGB, HCTSkin LesionsFolic Acid TestSerum FolateMetoprolol Tartrate Lopressor25 mgPOBIDHigh Blood PressureMetoprolol Tartrate competitively blocks beta1-receptors, it produces a dose-dependent reduction on heart rate and cardiac output.NauseaHeadachesDizzinessStomach painWeight GainCold hands/feetMonitor For: (Gil Wayne BSN, 2023)Blood PressureHeart RateRespiratory RateHold if HR <50Wheeze in lungsIsosorbide MononitrateImdur30mgPODAILYPrevent chest paint/ treat CHF.Imdur relaxes the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its workload.HeadachesDizzy/WeakNauseaFlushTiredSwelling in lower extremitiesMonitor For: (Balasubramanian, 2023)HypotensionBradycardiaDizzinessBalance Fatigue/weaknessAcetaminophenTylenol650mgPOPRNMild pain or elevated temperature.Acetaminophen blocks prostaglandin synthesis by inhibiting the enzymes, COX-1 and -2.RashHivesItchingHoarsenessSwelling of the faceDifficulty breathingMonitor For: (Wagner, 2023)AST & ALTBUN LevelsHepatotoxicityAssess pain levelsFever ReductionHeparin SodiumPorcine5000units/1mLSUBQBIDTreat thrombosis associated with patient’s pulmonary embolism.Heparin increases the rate of the neutralization of certain activated coagulation factors by antithrombin.Abdominal PainBack PainHematuriaConstipation HeadachesHemorrhage Monitor For: (Wayne, 2023)aPTTAssess for any bleedingBruisingBlack Tarry StoolHematuriaCalcium AcetatePhoslo667mgPOTIDWith MealsCalcium Acetate combines with dietary phosphate to form an insoluble calcium phosphate complex, which is excreted in the feces decreasing phosphorus concentration.NauseaVomitingConstipationLoss of appetiteItching Monitor For: (Pharmaceutics, 2021)Encourage Fluid IntakeAmbulateCalcium levelsSodium Levels Potassium Levels
Clinical Judgement PlanInstructor: Professor TarangoDATE Care Provided and UNIT: 4 WestASSESSMENT/History of Present Illness /REVIEW OF SYTEMSTIME OUT!!! Student instructions: Physical Assessment Findings including presenting signs and symptoms that you will complete for this patient supported with Evidence Based CitationsVital Signs (4)BP: 151/70 HR: 67RR: 18 Temp: 98.2 O2: 96% with 2L Nasal CannulaPain: 3/10Ht: 190.5 cmWt: 100.7 kg BMI:Neurological (5) Patient is Alert & Oriented to person, place, situation, and time (X4)Cranial Nerves II to XII are all intact.Normal SpeechNormal Mental StatusNormal Strength Respiratory (7) Upon auscultation patient has coarse crackled.TachypneaLabored BreathingPatient has shortness of breath present Musculoskeletal (8)Upper and lower extremities are cool and clammy to touch.Edema is present on lower extremities.Juglar Vein Distention presentRest/ Exercise (11) Patient ambulates very minimally with Physical Therapist twice a week.Has compression device on bilaterally.Uses bedside commode.GI/Hydration/Nutrition (9)Diet is low sodiumFluid Deficit Intake: 240ml/Output 2400= Balance: – 2160GU (10)NocturiaUrge Incontinence MISC: Attends all doctor appointments.Supported by family members.Has a positive mindset Think about his futureEndocrine (13)HepatomegalyLymph nodes are not palpable.Cardiovascular (6) S3 is present upon auscultationRate and Rhythm are irregular.Juglar Vein Distention is not present.Cap Refill < 3Psychosocial (14)Patient denies any suicidal ideations.Prays and uses the beliefs of God as a coping mechanism.Integumentary (12) Patient has no lesions or wounds.Skin is intact and moist
Clinical Judgement PlanInstructor: Professor TarangoDATE Care Provided and UNIT: 4 West 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?AssessmentAnalysis PlanningImplementObservationInterpretingRespondingRecognize Cues 1.Fluid Overload2.Chest-Xray pleural effusion3. Delirium/Changed Mental status4. Elevated TroponinAnalyze Cues1. Fluid overload indicates heart failure is occurring, leading to kidney failure as the kidney fails to excrete sodium hence water retention.2. Pleural effusion indicates the presence of fluid overload and congestive cardiac failure.3. Confusion is caused by cerebral edema due to the acute fluid and electrolyte shifts during dialysis, and infection caused by UTI.4. Increased troponin levels due to cardiac injury associated with congestive heart failure.Prioritize Hypotheses1.Initiate dialysis treatments to balance fluid in the body by taking out excess fluids from blood. 2.Administer diuretics medications to treat pleural effusion and thoracentesis.3.Initiate a hyperventilation and surgical decompression procedure to decrease. Patient given antibiotics to help with infection causing confusion.4.Provide aspirin and intravenous blood thinners to increase contractibility of the heart and decrease elevated troponin.Generate Solutions1.Perform routine dialysis to create a functioning kidney effort.2.Perform thoracentesis administer medications to reduce inflammation.3. Patient will be given antibiotics to treat main cause of UTI and continue with diuretics for decrease fluids.4. Diagnostic tests will be taken to see if there is an adequate amount of oxygen that is provided through therapy, to decrease complications.Take Action1. Monitor fluids given, put on fluid deficit, check for JVD presence, and inspect BP changes.2.High fowlers will be initiated, encourage breathing exercises, monitoring blood gases. Increase daily activity3.Increase perfusion to the brain and reduce infection in the blood stream to avoid increase confusion.4. Perform ECG, continue administering a statin to increase contractibility and reduce heart failure.Evaluation Patient was able to regain consciousness after the administration of diuretics. In addition to a decrease in chest paint with the appropriate medication administered.EvaluateReflectingClinical Judgement (The expected/anticipated outcomes or SMART GOALS)The patient will display improved consciousness after excess fluid has decreased by the end of the 12-hour shift.Patient will have a decrease of chest pain within the end of a 12 hour shift due to the Isosorbide Mononitrate given in AM.
Clinical Judgement PlanInstructor: Professor TarangoDATE Care Provided and UNIT: 4 WestReferencesBalasubramanian, S. (2023, May 16). Isosorbide – StatPearls – NCBI Bookshelf. Isosorbide. https://www.ncbi.nlm.nih.gov/books/NBK557839/Donis, P., Ayoka, M. Z., Sam, Sophat, M., Zam, Kelleher, S., & Vera, M. (2023, April 30). 11 chronic renal failure nursing care plans. Nurseslabs. https://nurseslabs.com/chronic-renal-failure-nursing-care-plans/#h-nursing-goalsGil Wayne BSN, R. N. (2023, July 1). Metoprolol nursing considerations and patient teaching [drug guide]. Nurseslabs. https://nurseslabs.com/metoprolol-nursing-considerations-and-patient-teaching-drug-guide/Luke’s, S. (n.d.). Discharge instructions for heart failure. Saint Luke’s Health System. https://www.saintlukeskc.org/health-library/discharge-instructions-heart-failureMalik, A. (2022, November 7). Congestive heart failure – statpearls – NCBI bookshelf. NCBI. https://www.ncbi.nlm.nih.gov/books/NBK430873/Maree, J. G. (2021). The psychosocial development theory of Erik Erikson: critical overview. Early Child Development and Care, 191(7-8), 1107-1121.Matt Vera BSN, R. N. (2023, July 1). Aspirin nursing considerations and patient teaching [drug guide]. Nurseslabs. https://nurseslabs.com/aspirin-nursing-considerations-and-patient-teaching-drug-guide/McIver, L. A. (2022, November 13). Atorvastatin – StatPearls – NCBI Bookshelf. Atorvastatin. https://www.ncbi.nlm.nih.gov/books/NBK430779/Monomil Elantan. (2021, July 1). Isosorbide mononitrate and isosorbide dinitrate. NHS choices. https://www.nhs.uk/medicines/isosorbide-mononitrate-dinitrate/Pharmaceutics International, Inc. (2021, March). Gelcaps (calcium acetate): 667 mg. DRUGS@FDA data files. https://www.fda.gov/drugs/drug-approvals-and-databases/drugsfda-data-filesProfessional, C. C. Medical. (2023, May 12). Esophagitis. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/10138-esophagitisPonikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129-2200
Clinical Judgement PlanInstructor: Professor TarangoDATE Care Provided and UNIT: 4 WestRnpedia. (2019, February 12). Folic acid (folate) nursing considerations & management. RNpedia. https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/folic-acid-folate/ Smilde, T. D., Damman, K., van der Harst, P., Navis, G., Daan Westenbrink, B., Voors, A. A., … & Hillege, H. L. (2009). Differential associations between renal function and “modifiable” risk factors in patients with chronic heart failure. Clinical Research in Cardiology, 98, 121-129.Wagner, M. (2023, February 26). Aspirin Nursing Considerations & Patient teachings. NurseTogether. https://www.nursetogether.com/aspirin-nursingconsiderations/#:~:text=Routinely%20monitor%20the%20effectiveness%20of,confusion%2C%20lethargy%2C%20and%20anaphylaxis Wayne, G. (2023, July 1). Heparin nursing considerations and patient teaching [drug guide]. Nurseslabs. https://nurseslabs.com/heparin-nursing-considerations-and-patient-teaching-drug-guide/#:~:text=Assess%20for%20signs%20of%20bleeding,is%20crucial%20before%20administering%20heparin.
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