clinical judgment plan 306 Notes that I took from professor explaining the assig

clinical judgment plan 306
Notes that I took from professor explaining the assignment:::::
page 1: pt info –
OB History: if you have NICU baby might night have the info,
history and illness 5 points: put citation for that.
past med surgery history: make stuff up or put not applicable.
Social History: do they work? insurance type? are in shelter? have home?. for NICU baby – parents’ cultural history. Rubric – identify 3 or more psycho concerns: substance abuse, violence, if they are homeless, going from 1 kid to 2 kids and need to keep balance the attention to give baby, having new baby in general, breast feeding, bonding
medications:
assessment and history, present illness pp5:
uterus: for babies it is applicable too – diapers.
next to labs the colab: physical therapy, social worker, lactation therapy, psych for any reason
equipment: pads,
pp 6 – put 4 clients needs as in the rubric to get full point and have to put in order which one is the most important to start to. Put one action
learning barrier, education barrier, cultural barrier. don’t put not applicable for NICU babies or babies. Put G-tube feeding, how to hold the baby, diaper change, teach how to feed.
LABS: CBC, platelets, hem.,
Clinical judgment and smart goals pg 7: Ex: hemorrhage – pt will not saturate a pad in 2 hours. ex: pain – use number scale and say pt will have 3/10 pain at the end of my shift. Infection – pt temp will be less than 100F at the end of my shift.
Examples:
post c/s
assessment: readiness on the incision site (possible infection)
prioritize hypothesis:
low bp:
assessment 80/60
prioritize hypothesis: