Please complete with a mixture of the information given and online resources:
patient name: Laura V
age: 33
G 2 P1
Hospitalized at 33 weeks with history of precamplsia, diabetes and gestational diabetes. Bed rest and trying to hold off until past term 37 weeks.
at week 35 ruptured membrane at 2am and went into labor.
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 Diagnostic Tests |
Normal Ranges |
Admission Lab Values |
Current Lab Values |
Explain Abnormal Results R/T Your Patient (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