Please complete the Clinical judgment Plan using the fake patient I have attached to the CJP TEMPLATE I have also attached. Please go into complete detail and use citations throughout. Also, try to fill up all the boxes as much as possible. I also provided an EXAMPLE of what it should look like. Keep in mind that this is just an example and has nothing to do with the patient information I have provided to you. Thank you dearly!
Madlena Armoutian
Clinical Judgement Plan
West Coast University
Chanpen Blackard
July 12, 2023
LB/DW/CB revised 3/30/23
History of Present Illness (HPI)
Date: 07/09/2023
Student Name: Madlena Armoutian
Instructor: Chanpen Blackard
Patient Information (1)
Name: MH
Age: 72
Gender: Female
Code Status: Unspecified
DPOA: Unspecified
Living Will: Unspecified
Allergies: NKDA
Chief Complaint
– Pt has weakness and dizziness.
– She has sharp chest pain when coughing
rated 6/10.
– Shortness of breath with exertion
Admitting Diagnosis
Sepsis; Pneumonia
Erickson’s Developmental Stage Related
to pt. & Cite References (1)
Integrity vs Despair
During the integrity versus despair stage, individuals review their life
experiences and evaluate whether they have lived a fulfilling and
meaningful life. They may reflect on their accomplishments,
relationships, and overall contentment with their life choices. This
stage involves the integration of previous developmental stages and
the resolution of any unsettled conflicts or challenges (Chen et al.,
2021). Integrity refers to the positive outcome of this stage, where
individuals develop a sense of satisfaction, wisdom, and acceptance.
despair represents the negative outcome of this stage. If individuals
have not successfully resolved conflicts from previous stages or are
overwhelmed by feelings of regret, they may experience a sense of
despair.
M.H. is leaning more toward despair because she mentioned that her
children don’t visit her anymore, and the last time someone visited her
was 3 months ago. She lives by herself with 5 cats. She wants to go to
church but doesn’t have anyone to take her. Her neighbor helps her get
groceries, but not often. She seems like she’s alone often and doesn’t
have meaningful relationships.
M.H. is a 72-year-old Hispanic female who was admitted to the medical surgical unit yesterday afternoon with a diagnosis of pneumonia in her right lobe. EMS was called by her
neighbor who was concerned regarding her worsening mental status. M.H. was experiencing symptoms of dry cough, fever, and malaise and was diagnosed with influenza 10 days
ago. Her symptoms got progressively worse yesterday and she developed a temperature of 38.4 °C (101.2 °F). She was shaking, had the chills, and a productive cough of rust-colored
sputum. She saw her primary care provider yesterday who decided to admit her for the treatment of pneumonia.
Pathophysiology of Admitting Dx (minimum of 3-5) (Cite References)
Congestive Heart Failure
A complex syndrome in which the heart cannot pump enough blood to meet the body’s requirements, and results from any disorder that impairs ventricular filling or ejection of blood
to the systemic circulation (Malik et al., 2022). Heart failure can develop from a myriad of cardiovascular conditions, such as chronic hypertension, valvular disease, and coronary
artery disease. The adaptive mechanisms that maintain the contractile performance of the heart at normal levels become maladaptive when attempting to maintain sufficient cardiac
performance. As such, the heart tries to adapt to systemic demands using several compensatory mechanisms, such as cardiac remodeling, the renin-angiotensin-aldosterone system
(RAAS), and the neuroendocrine system with the release of epinephrine and norepinephrine to improve contractility. These compensatory mechanisms work for a little while before
exacerbating the problem resulting in more hypertension, myocardial hypertrophy, and decreased cardiac output (Malik et al., 2022).
Diabetes Mellitus Type II
A chronic metabolic disorder characterized by persistent hyperglycemia due to impaired insulin secretion, resistance to peripheral actions of insulin, or both (Goyal & Jialal, 2022).
Pancreatic beta-cell dysfunction arises due to the malfunctioning of the feedback loops between insulin secretion and action resulting in abnormally high glucose levels in the blood
(Galicia-Garcia et al., 2020). When insulin attaches to the cell receptors to open up the cell and let glucose in, the cells resist the insulin, which results in elevated serum glucose levels.
Also, the pancreas that produces insulin begins to have trouble making enough insulin to keep serum glucose levels in check, as a result, glucose levels become elevated in the blood.
Hyperlipidemia
A genetic or acquired disorder characterized by elevated levels of lipids in the body that can lead to serious illnesses (Hill & Bordoni, 2022). The pathophysiology of hyperlipidemia
involves disturbances in lipid metabolism, transport, and clearance, which can lead to the accumulation of lipids in the bloodstream and tissues. As fats are broken down and turned
into lipoproteins, when circulating in the blood, depending on their density, they can get stuck on the walls of arteries causing irritation. If they become stuck, plaquing can begin to
form in the vessel causing atherosclerosis, which can have a detrimental effect on the heart and cardiovascular system.
Gastric Ulcer
Gastric ulcers are a break in the mucosa of the stomach lining that penetrate through the muscularis mucosa and are greater than 5 mm in diameter (Woolf & Rose, 2019). Gastric
ulcers form when the stomach’s hydrochloric acid is diffused back into the gastric mucosa, which results in cellular damage and inflammation. Histamine is then released by the
damaged mucosa, which results in vasodilation and more stomach acid secretion causing further damage (Harding et al., 2020). Gastric ulcers are generally caused by Helicobacter
pylori, a bacterium that buries itself inside the stomach lining and causes the stomach to produce more acid, which damages the stomach lining causing ulceration. It can also be
caused by excessive NSAID use, which also irritate the lining of the stomach making it more susceptible to ulceration.
Pathophysiology of Medical History (minimum of 3-5)
Pneumonia
A common acute respiratory infection of one or both of the lungs that causes inflammation in the alveoli and distal airway (Torres et al., 2021). Many microorganisms can cause the
development of pneumonia. When pathogens enter into the lungs, an inflammatory response is triggered. Inflammation occurs with increased blood flow and vascular permeability
bringing in neutrophils that begin to engulf and kill the pathogens. As the killing ensues, more neutrophils are attracted to site of inflammation and edema begins to develop in the
airways, and fluid begins to leak from within the capillaries into the alveoli causing difficult breathing and hypoxia (Harding et al., 2020).
Sepsis
Sepsis is a clinical syndrome that takes place when the body’s response to an infection damages its tissues and organs due to a dysregulated host response to the infection (Bullock &
Benham, 2020). When the immune system discovers a pathogen in the body, it triggers an inflammatory response to get rid of the pathogen. However, the inflammatory response
becomes excessive and dysregulated triggering an inflammatory response throughout the body, which can damage the tissues and organs leading to septic shock (Bullock & Benham,
2020).
Surgical History
Coronary artery bypass grafting (CABG) – X2 2019
A surgical procedure performed on the coronary artery to improve the rate of blood flow coming into the heart. Blood flow to the heart can be impaired due to an obstruction or
narrowing of the coronary arteries due to plaque buildup. The procedure consists of taking healthy blood vessels from another part of the body and connecting them to the vessels
above and below the obstructed artery (Bachar & Manna, 2020). This creates a new path for the blood to flow past the obstructed arteries and get to the heart, which relieves anginal
symptoms, restores heart function, and prevents ischemia (Bachar & Manna, 2020). Patient has had two CABG procedures done in 2019.
Cholecystectomy – 08/2021
A surgical procedure that consists of removing the gallbladder. Cholecystectomies are performed laparoscopically most of the time but can also be performed as an open
cholecystectomy. Four incisions are usually made onto the abdomen, and a tiny video camera is inserted along with surgical equipment to excise the gallbladder (Hassler & Jones,
2019). The patient had a cholecystectomy in August of 2021.
Social History
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Not specified if patient uses cigarettes, tobacco products, alcohol, or illicit drugs.
Medical Management/ Orders/ Medications & Allergies (2)
Medication Name
Dose
RT
Freq.
MOA
Indications
Side Effects/Adverse
RN Considerations
Acetaminophen
(Tylenol)
650 mg
PO
Q6 hours
To relieve mild to moderate pain.
To reduce fever.
blocks pain by inhibiting the
synthesis of prostaglandin, a natural
substance in the body that initiates
inflammation.
Rash, hives, itching, swelling of face and extremities,
hoarseness, difficulty breathing, difficulty
swallowing, diarrhea, nausea, vomiting
* Monitor kidney function since her creatinine and BUN levels are
elevated. “Use acetaminophen cautiously in patients with…severe renal
impairment” (Jones & Bartlett Learning, 2021).
* Monitor liver function since acetaminophen is hepatotoxic and patient
has sepsis* Assess if fever and/or pain is relieved using this medication.
Guaifenesin
(Mucinex)
100 mg/5mL
PO
Q4 hours
To relieve chest congestion
A xanthine derivative that acts as
a bronchodilator by directly
relaxing smooth muscle of the
bronchial airway and pulmonary
blood vessels.
Diarrhea, dizziness, headache, nausea, vomiting, skin
rash, stomach pain
* Assess respiratory status to see if patient is breathing better due to use of
medication.
* Assess cough characteristics
* Encourage hydration to help medication loosen mucus and phlegm in
lungs.
Hydrochlorothiazide
(Microzide)
25 mg
PO
Daily
To manage hypertension. To reduce
edema caused by liver cirrhosis, heart
failure, and renal disease.
Inhibits sodium chloride transport in
the distal convoluted tubule
Back, leg, or stomach pain, black, tarry stools,
bleeding gums, bloating, blood in urine, blue lips and
fingernails, pins and needles tingling
Furosemide
(Lasix)
20 mg
IV
BID
To reduce edema caused by liver
cirrhosis, heart failure, and renal
disease.
To treat acute pulmonary edema
Inhibits sodium and water
reabsorption in the loop of Henle and
increases urine formation.
Increased urination, feeling thirsty, dry mouth,
headaches, feeling confused or dizzy, nausea,
vomiting
Potassium chloride
(KCL)
20 mg
PO
BID w/meals
To prevent or treat hypokalemia.
Acts as the major cation in
intracellular fluid, activating many
enzymatic reactions essential for
physiologic processes.
Stomach bloating, severe vomiting, severe stomach
pain, weakness, chest pain, irregular heart rate, loss of
movement, bloody stools, coughing up blood,
hematemesis
* “Monitor patient’s blood pressure, daily weight, fluid intake and output,
and serum electrolytes, especially potassium”. This medication lowers
potassium, which can cause heart dysrhythmias.
* Check blood glucose levels often since pt is diabetic and blood glucose
levels can rise on this med.
* Monitor BUN and creatinine levels because this med can cause renal
failure. Check for elevated creatinine levels to discontinue (Jones &
Bartlett Learning, 2021).
* Monitor blood pressure as this medication can lower BP significantly.
* Monitor hepatic and renal function while on med. Monitor BUN,
creatinine, and electrolytes as this med can cause dehydration and makes
the kidneys work, and her BUN and creatinine are already high.
* Monitor patient for hypokalemia, which can occur on this med and cause
dysrhythmias and weakness. Pt already not taking her K+ tablet (Jones &
Bartlett Learning, 2021).
*Assess patient for signs of hypokalemia and hyperkalemia.
*Monitor BUN and creatinine levels as adequate renal function is needed
for potassium supplementation
* Monitor patient for abdominal pain, distention, or bleeding as patient is
also on heparin (Jones & Bartlett Learning, 2021).
Moxifloxacin
(Avelox)
400 mg
IVPB
Daily
To treat mild to moderate communityacquired pneumonia caused by
Staphylococcus aureus.
Interferes with bacterial survival by
binding to DNA gyrase
(topoisomerase II) and topoisomerase
IV.
Severe diarrhea, rash, hives, itching, fever, swelling
of the face and extremities, bleeding gums, bloating,
weakness, trouble sleeping
Heparin sodium
(Heparin)
5000 units
Subcut.
Q8 hours
To prevent and treat peripheral arterial
embolism, pulmonary embolism,
thromboembolic complications.
Binds with antithrombin III,
enhancing antithrombin III’s
inactivation of the coagulation
enzymes thrombin and factors Xa and
Xla.
Vancomycin
(Firvanq)
750 mg
IVPD
Q12 hours
To treat serious or severe infections
caused by susceptible strains of
methicillin-resistant Staphylococci.
Inhibits bacterial RNA and cell wall
synthesis.
Insulin Lispro
(Humalog)
Sliding Scale
Subcut.
AC/HS
To improve glycemic control in
patients with diabetes mellitus.
Stimulates peripheral glucose uptake
by fat and skeletal muscle and
inhibiting hepatic glucose production.
Albuterol
(Proair HFA)
360 mg
HHN
To prevent or treat bronchospasm.
Acts on beta-2 adrenergic receptors
to relax the bronchial smooth muscle.
Tachycardia, palpitations, headache, shakiness, throat
and nasal irritation, muscle aches
Metoprolol
(Toprol)
50 mg
PO
BID; hold for HR 12
in 6 hours
Increase platelets
>150 in 6 hours
Decrease glucose to
< 100 in 24 hours
•
•
•
•
•
•
•
•
•
•
•
•
Titrate oxygen to maintain
SpO2 < 94% on room air
Withhold the use of heparin
due to GI bleed
Notify provider about GI
bleed and the need for
alternate therapy to prevent
clotting since pt is currently
bleeding
Encourage coughing, deep
breathing exercises, and use
of incentive spirometer every
x 10 every hour while awake
Administer Vancomycin 750
mg IVPB every 12 hours for
sepsis
Administer Moxifloxacin 400
mg IVPB daily to treat
pneumonia
Administer potassium
chloride 20 mg BID w/meals
to prevent hypokalemia
Administer acetaminophen
650 mg PO PRN to reduce
pain and fever
Administer Guaifenesin 100
mg/5mL PO every 4 hours to
relieve chest congestion
Check vitals every hour
Turn patient every 2 hours
and assess for pressure ulcers
Use of sequential
compression device to
prevent DVT
Evaluation:
The effectiveness of treatment was evaluated by performing a thorough physical assessment, monitoring patient’s heart rate, blood pressure, respirations, O2 sat, fever, pain, electrolyte imbalance, urine output,
glucose levels in the blood, CMP, CBC, chest X-Ray. Compare baseline results with the results after treatment. In summary, patient’s temperature is now 98.9°F, lactic acid is 0.9, O2 sat is 96%, pCO2 is 37,
Hgb is 14, platelets are at 155, and glucose is at 99. Patient states pain is currently 0/10, and she is resting comfortably. She is no longer septic, and her pneumonia is under control and resolving through
antibiotic regimen.
References:
Bachar, B. J., & Manna, B. (2020). Coronary Artery Bypass Graft. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK507836/
Braveman, P., & Gottlieb, L. (2014). The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public
Health Reports, 129(2), 19–31. https://doi.org/10.1177/00333549141291s206
Bullock, B., & Benham, M. D. (2020). Bacterial Sepsis. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK537054/
Caraballo, C., & Jaimes, F. (2019). Organ Dysfunction in Sepsis: An Ominous Trajectory From Infection To Death. The Yale Journal
of Biology and Medicine, 92(4), 629–640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913810/
Chen, P.-Y., Ho, W.-C., Lo, C., & Yeh, T.-P. (2021). Predicting Ego Integrity Using Prior Ego Development Stages for Older Adults
in the Community. International Journal of Environmental Research and Public Health, 18(18), 9490.
https://doi.org/10.3390/ijerph18189490
Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., Ostolaza, H., & Martín, C. (2020).
Pathophysiology of type 2 diabetes mellitus. International Journal of Molecular Sciences, 21(17), 1–34.
https://doi.org/10.3390/ijms21176275
Godin, M., Murray, P., & Mehta, R. L. (2015). Clinical Approach to the Patient With AKI and Sepsis. Seminars in Nephrology, 35(1),
12–22. https://doi.org/10.1016/j.semnephrol.2015.01.003
Goyal, R., & Jialal, I. (2022). Diabetes Mellitus Type 2. NCBI; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513253/
Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-Surgical Nursing: Assessment and
management of clinical problems (11th ed.). Elsevier, Inc.
Hassler, K. R., & Jones, M. W. (2019, March 22). Laparoscopic Cholecystectomy. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK448145/
Hill, M. F., & Bordoni, B. (2022). Hyperlipidemia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559182/
Hoen, L., Pfeffer, D., Zapf, R., Raabe, A., Hildebrand, J., Kraft, J., & Kalkhof, S. (2021). Association of Drug Application and
Hydration Status in Elderly Patients. Nutrients, 13(6), 1929. https://doi.org/10.3390/nu13061929
Jones & Bartlett Learning. (2021). 2022 Nurse’s Drug Handbook. Jones & Bartlett Learning.
Lien, A. S.-Y., Hwang, J.-S., & Jiang, Y.-D. (2017). Diabetes related fatigue sarcopenia, frailty. Journal of Diabetes Investigation,
9(1), 3–4. https://doi.org/10.1111/jdi.12752
Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2022, November 7). Congestive heart failure. National Library of Medicine; StatPearls
Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/
Mushtaq, R., Shoib, S., Shah, T., & Mushtaq, S. (2014). Relationship Between Loneliness, Psychiatric Disorders and Physical Health?
A Review on the Psychological Aspects of Loneliness. Journal of Clinical and Diagnostic Research, 8(9).
https://doi.org/10.7860/jcdr/2014/10077.4828
Suzuki, T., Palus, S., & Springer, J. (2018). Skeletal muscle wasting in chronic heart failure. ESC Heart Failure, 5(6).
https://doi.org/10.1002/ehf2.12387
Tchounwou, P., & Udensi, U. (2017). Potassium homeostasis, oxidative stress, and human disease. International Journal of Clinical
and Experimental Physiology, 4(3), 111. https://doi.org/10.4103/ijcep.ijcep_43_17
Torres, A., Cilloniz, C., Niederman, M. S., Menéndez, R., Chalmers, J. D., Wunderink, R. G., & van der Poll, T. (2021). Pneumonia.
Nature Reviews Disease Primers, 7(1). https://doi.org/10.1038/s41572-021-00259-0
Warnock, L. B., & Huang, D. (2020). Heparin. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538247/
Woolf, A., & Rose, R. (2019, January 28). Gastric Ulcer. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK537128/
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date:
LB/DW/CB revised 3/30/23
Date:
Student Name:
Instructor:
Patient Information (1)
Name:
Age: Age in years/not DOB
Gender:
Code Status:
DPOA:
Living Will:
Allergies:
History of Present Illness (HPI)
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED
WHEN THEY GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE
ATTACHED WORD DOC → WHEN NEEDED) (SEE RUBRIC REQUIREMENTS)
Pathophysiology of Admitting Dx (minimum of 3-5) (Cite References)
For each disease identified, describe pathophysiology, and any potential complications & cite source.
Chief Complaint
Pathophysiology of Medical History (minimum of 3-5)
For each disease identified, describe pathophysiology, and any potential complications & cite source.
Admitting Diagnosis
Erickson’s Developmental Stage Related
to pt. & Cite References (1)
Surgical History
For each procedure identified, define & describe it; include year of procedure & cite source.
Social History
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Medical Management/ Orders/ Medications & Allergies (2)
Medication Name
Dose
RT
Freq.
MOA
Indications
Side Effects/Adverse
RN Considerations
Identify and explain abnormal findings related to Patient’s disease process
Test
Normal
WBC
4.40-11
Hgb
Hct
Platelets
Na+
K+
Chloride
Co2
Creatinine
Blood
Glucose
BUN
Troponins
BNP
ALT
Ca+
Albumin
AST
Blood
cultures
Cholesterol
Triglycerides
HDL
LDL
Lactic Acid
Procalcitonin
CEA
CA 125
14.0- 16.0
36-42
150-450
135-145
3.5-5.0
95-110
23-29
0.6-1.3
76-106
Pt labs
Cultural considerations, ethnicity, occupation, religion, family
support, insurance.
Medical Management and Collaborative Plan
8.0-30.0
0.0-0.4
>125pg/mL
7 to 56
8.5 – 10.5
3.5 – 5.5
10- 40
100 to 129
40 – 59
100 -129
0.5 – 1
0-0.5
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