Executive Solution Overview
complete the attached file – 2 years ago **files (1)** – ## NURS223L-ClinicalJudgmentPlan.docx **## NURS223L-ClinicalJudgmentPlan.docx** **Clinical Judgement Plan** **Instructor:** **DATE Care Provided and UNIT:** Student Name Clinical Judgement Plan West Coast University Professor Name Date **Socia…
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complete the attached file
– 2 years ago
**files (1)**
– ## NURS223L-ClinicalJudgmentPlan.docx
**## NURS223L-ClinicalJudgmentPlan.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:
Age & Gender:
Admission Weight:
Allergies:
Code Status:
Legal status:
Living Will/ DPOA:
**History of Present Psychiatric Illness (HPI)**
**Psychiatric Diagnosis and DSM 5 Diagnostic Criterion**
**Psychiatric Admitting Psychopathology**
**Medical 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
**Substance Abuse and Other Addictions**
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
**Involuntary Movements**
Code: 0 = None 1 = Minimal 2 = Mild 3 = Moderate 4 = Severe
**I: Facial and Oral Movements:**(movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,
grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth)
Code:
**II: Extremity Movements:**
**Upper (arms, wrists, hands, fingers)** Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements.)
**Lower (legs, knees, ankles, toes)** Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot
Code:
**III: Trunk Movements:**(Rocking, twisting, squirming, pelvic gyrations)
Code:
**IV: Global Judgment:**(Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.)
Code:
**V: Dental Status:**(Current problems with teeth and/or dentures/Endentia?)
Yes/No
**C.A.G.E. Questionnaire**
Have you ever felt you should cut down on your drinking?
Yes / No
Have people annoyed you by criticizing your drinking?
Yes / No
Have you ever felt bad or guilty about your drinking?
Yes / No
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
Yes / No
**Teaching Assessment and Client Education**
**Discharge Planning**
**Risk Assessment**
**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**
**Vital Signs/Height/Weight (4)**
Temp:
HR:
BP:
RR:
SpO2:
Pain:
Height:
Weight:
**Level of Participation in Program/Activity**
**Gait and Motor Coordination**
**Presenting Appearance**
**Behavioral Approach**
**Speech**
**Interpersonal Characteristic and Approach to Evaluation**
**Recall and Memory/Orientation**
**Judgement and Insight**
**Hallucinations and Delusions**
**Rapport and Expressions**
**Response to Failure/Impulsivity/ Anxiety**
**Mood and Affect**
**Concentration and Attention**
**Alertness/Coherence**
**Thought Process**
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**
**## NURS223L-ClinicalJudgmentPlan.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:
Age & Gender:
Admission Weight:
Allergies:
Code Status:
Legal status:
Living Will/ DPOA:
**History of Present Psychiatric Illness (HPI)**
**Psychiatric Diagnosis and DSM 5 Diagnostic Criterion**
**Psychiatric Admitting Psychopathology**
**Medical 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
**Substance Abuse and Other Addictions**
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
**Involuntary Movements**
Code: 0 = None 1 = Minimal 2 = Mild 3 = Moderate 4 = Severe
**I: Facial and Oral Movements:**(movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,
grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth)
Code:
**II: Extremity Movements:**
**Upper (arms, wrists, hands, fingers)** Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements.)
**Lower (legs, knees, ankles, toes)** Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot
Code:
**III: Trunk Movements:**(Rocking, twisting, squirming, pelvic gyrations)
Code:
**IV: Global Judgment:**(Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.)
Code:
**V: Dental Status:**(Current problems with teeth and/or dentures/Endentia?)
Yes/No
**C.A.G.E. Questionnaire**
Have you ever felt you should cut down on your drinking?
Yes / No
Have people annoyed you by criticizing your drinking?
Yes / No
Have you ever felt bad or guilty about your drinking?
Yes / No
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
Yes / No
**Teaching Assessment and Client Education**
**Discharge Planning**
**Risk Assessment**
**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**
**Vital Signs/Height/Weight (4)**
Temp:
HR:
BP:
RR:
SpO2:
Pain:
Height:
Weight:
**Level of Participation in Program/Activity**
**Gait and Motor Coordination**
**Presenting Appearance**
**Behavioral Approach**
**Speech**
**Interpersonal Characteristic and Approach to Evaluation**
**Recall and Memory/Orientation**
**Judgement and Insight**
**Hallucinations and Delusions**
**Rapport and Expressions**
**Response to Failure/Impulsivity/ Anxiety**
**Mood and Affect**
**Concentration and Attention**
**Alertness/Coherence**
**Thought Process**
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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