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June 2, 2024

Clinical Judgment Plan

Clinical Judgment Plan NURS 481L Advance Medical Surgical Professor_______________ January 1, 2024 Clinical Judgment Plan History of Present Illness Date: Student Name: Instructor: Chief Complaint Pathophysiology of Admitting Diagnosis ( 3-5 Diagnosis with Citations) Admitting Diagnosis Pathophysiology of Medical History ( 3-5 Diagnosis with Citations) Erickson’s Developmental Stage Related to the Patient (w/Citations) Revised 03/2024 CB/LB/DW Surgical History Social History / Social Economics Psychosocial Assessment/Concerns Revised 03/2024 CB/LB/DW Identify and explain abnormal findings related to the patient’s disease process. Test WBC Hgb Hct Platelets Na+ K+ Chloride Co2 Creatinine Blood Glucose BUN Troponins BNP ALT AST Ca+ Albumin Normal Admit Labs Current Labs Cultural Considerations, Ethnicity, Occupation, Religion, Family support, Insurance Explanation of Abnormal 4.40-11 14.0-16.0 36-42 150-450 135-145 3.5-5.0 95-110 23-29 0.6-1.3 76-106 8.0-30.3 0.0-0.4 >125pg/mL 7-56 10-40 8.5-10.5 3.5-5.5 Interprofessional Consults and Collaborative Plan Blood Cultures Cholesterol Triglycerides HDL LDL Lactic Acid Procalcitonin CEA CA 125 Test CT MRI 100-129 40-59 100-129

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