Clinical Judgment Plan- OB (1) (1)

Student Name Clinical Judgement Plan West Coast University Professor Name Date SK/DW 2/22 pg. 1

Clinical Judgement Plan Instructor: DATE Care Provided and UNIT: Final Version 3/10/22 DW/ss & MS Team OB History GTPAL G1, T0, P0, A0, L0 Prenatal Panel Blood Type/Rh: A positive GBS: negative Hep B: Negative HIV: negative Rubella: Equivocal RPR: Nonreactive Chlamydia: NO Gonorrhea: NO HSV: NO Delivery Summary Delivery Type & Time: C-section at 4:01 PDT Placenta Delivery Time: 04:03 PDT Lacerations/Episiotomy: N/A EBL: N/A Hemorrhage Medications Given: N/A APGAR Score:1 minute: 6>100 bpm slow, some flexion, cough or sneeze or blue/pale, pulls away. 5 minute: 8>100 bpm, good cry, active motion, cough or sneeze or blue/pale, pulls away Patient Information (1) Patient Initials: C.W Age & Gender: 34 y.o Height/Weight: 61.5 / 139 Code Status: Full code Living Will/ DPOA: with her boyfriend EDC: 08/26/23 EGA: 40.3 Chief Complaint Primipara pregnancy, high BP, 40 weeks, contraction Admitting Diagnosis & Admission Date Post term, C-section and the reason was nonreassuring fetal status. Admitted on 08/29/2023 History of Present Illness (HPI) C.W is a 34-year old female who was admitted at the hospital on 08/29/2023 because induction of labor, other postterm, gest. She had C-section at 4:01 PDT, pattern normal 5 contraction in 10 minutes, indication for induction is HTN/ Preeclampsia/ Eclampsia. Through C-section, she was able to deliver a baby boy weighing 8 pounds and 5 ounces. After delivery, the client received 30 units oxytocin IB bolus. The blood that she lost during the delivery is about 300 ml. Medical History : (SEE RUBRIC REQUIREMENTS) PAST DIAGNOSED MEDICAL PROBLEMS Bipolar disorder on medication (depression and anxiety since age 24- on Prozac 40 mg po daily). Bipolar disorder is a mental health issue or disorder that brings about a lot of mood swings such as emotional lows (depression) and emotional highs (hypomania). Substance abuse- on Subutex. This is a mental health issue that affects the behavior and brain of a person making them to be unable to tame their substance use such as illegal and legal drugs. Hypothyroidism- on levothyroxine 100 mcg PO daily. This condition is also known as underactive thyroid, a condition where the thyroid glands fails to manufacture sufficient thyroid hormones that can be able to meet the needs of the body. Surgical History : (SEE RUBRIC REQUIREMENTS) PAST DIAGNOSED SURGICAL PROBLEMS Appendectomy in 2013. This is appendix removal through surgery. The surgery is normally carried out only if it is an emergency while treating appendicitis. Social History: Tabacco/cocaine/crack use not specified, Methamphetamine since age 23, Positive marijuana use, Positive Illicit drug use, History of substance abuse. Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic /Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns : include the following Social Determinants of Health (SDOH) (SEE RUBRIC REQUIREMENTS) ❋ Economic Stability ❋ Education: Diploma ❋ Social and Community Context ❋ Health and Health Care ❋ Neighborhood and Built Environment Erickson’s Developmental Stage Related to pt. & Cite References (1) * List and Discuss specific stage (based on objective assessment) (SEE RUBRIC REQUIREMENTS ) According to the stages of development by Erickson, C.W lies within the stage of intimacy versus isolation. The people found in this stage are of the ages between 18-40 years (Mcleoud, 2018). The stage put its much focus on the aspect of love. After establishing a firm identity sense, people in this stage now gives such for love, companion and intimacy a priority. C.W has found love and companion. This is because she has a boyfriend whom they have gotten the baby together. It is during this stage that most people usually find a reason to love and be loved. Individuals usually developed strongly love feelings such that if not directed to a person who will be carefully with it, they will end up feeling isolated.

Clinical Judgement Plan Instructor: DATE Care Provided and UNIT: Final Version 3/10/22 DW/ss & MS Team TIME OUT!!! Student instructions: Medications & Allergies (2) Medication Name Dos e Route Freq. NOTE: PRN ‘alone’ ≠ Freq Indications (PRN meds must include MD ordered Indication ) Mechanism of Action Side Effects/ Adverse Reactions Nursing Considerations specific to this patient with citations What cues will you observe for? What will you monitor (labs, vitals, etc?) Fluoxetine (Prozac) 40 mg Valacyclovir 1 gram Levothyroxine (Synthroid) 100 mcg Buprenorphine HCL (Buprenex) 8 mg Amoxicillin 875 mg Quetiapine (Seroquel) 200 mg Seroquel 100 mg Clotrimazole 2 % Oxycodone 5 mg PRN

Clinical Judgement Plan Instructor: DATE Care Provided and UNIT: ASSESSMENT/History of Present Illness /REVIEW OF SYTEMS TIME OUT!!! Student instructions: Physical Assessment Findings including presenting signs and symptoms that you will complete for this patient supported with Evidence Based Citations Final Version 3/10/22 DW/ss & MS Team Cardiovascular Color: Cap Refill: Tele Rhythm: Peripheral Edema: Heart Sounds: Pulses: Episiotomy/Laceration Location: Stitches: Edema: Redness: Approximation: Neurological LOC: PMS: PERRLA: Vision: Face: Strength: Vital Signs Temperature: 98.2 Pulse: 70 Respirations: 18 Blood Pressure: 141/92 Pain Level: 0/10 Ht (cm) 156.21 Wt. (Kg) 63.1 BMI: 23.9 O2: 96% Breasts Size: Nipple: Shape: Engorgement: Colostrum: Uterus Location: Midline: Firm/Boggy: Contractions: Bladder BR: Incontinence: Indwelling Catheter: Urine Color/Consistency: Urine Output: Bowel Bowel Sounds: Abdomen: Last BM: Incontinence: Bedpan: Abd. Pain: Ostomy: Drains: Respiratory Lung Fields: Breathing Pattern: Sputum: Cough: Suctioning: Pulse Oximetry: Supplemental O2: Emotional Bonding: Support: Emotional State: Maternal Phase: Homan’s Sign Redness: Tenderness: Pain: Swelling: Homan’s: Lochia Amount: Odor: Color: Clots: Pad Changes: EBL:

Clinical Judgement Plan Instructor: DATE Care Provided and UNIT: TIME OUT!!! Student instructions: To be sure your clinical judgement statements written below are accurate. You need to review the defining characteristics and related factors associated with and see how your patient data match. Do you have an accurate match or are additional data required, or does another cue from abnormal assessment findings need to be investigated? Final Version 3/10/22 DW/ss & MS Team Reflecting Evaluate Evaluation 1.Goal Not MET: BP 141/92 2. Goal Not Met: H&H 10.6/30.3 3. Goal Met: Blood screen drug clear. 4. Goal Met: Follow up with the social worker appointment. 5. Goal Met: Stable Mood & Condition. Generate Solutions Follow up by medication and psychological counseling (psychotherapy). Provide safe environment. No harming object inside the room. Give erythropoietin- stimulating drugs. Start chemotherapy. Responding Interpreting Observation Implement Planning Analysis Assessment Clinical Judgement (The expected/anticipated outcomes or SMART GOALS) 1.by end of the shift, pt BP is less than 170/80. 2. by end of the shift, pt H&H more than 9.8/30.1. 3. by end of the shift, pt drug screen negative prior discharge. 4. by end of the shift, pt follow up with social worker a week after the discharge. 5. pt discharge with stable condition. Take Action observe the pt manic and behavior, treatment received and result. Monitor VS, tachycardia, hypertension. Assesses the pt for any signs of bleeding, bruising. Assess the vaginal bleeding & sign of infection. inject Intravenous iron, transfusions or medications. Teach the pt about protein & iron rich foods. Provide supplemental oxygen. Keep educate the pt about each prosses. Teach medication side effect and No breastfeeding during chemotherapy. Recognize Cues Bipolar disorder Depression and Anxiety since age 24 on prozac. Psychiatric disorder. History of substance abuse. Thyroid dysfunction & Hypothyroidism in pregnancy. Long term drug therapy. Positive marijuana use Positive Illicit drug use Tabacco/cocaine/crack use not specified. Methamphetamine since age 23- start rehab 07/22/2022 BP: 174/82, H&H: 9.5/29.4 Hx surgery, anemia, cancer age2 Prioritize Hypotheses postpartum bipolar disorder put the baby at risk. Baby can be effected by depression. Increased HR from anxiety may result complication with surgery. Anemia could have decreased perfusion to tissues and major organs and making feel very tired & week & multiple variable decals of baby. Vaginal bleeding can cause infection and low RBC. Analyze Cues Appetite & sleep changes from bipolar disorder (BP 174/82) Increased HR from anxiety. Hypothyroidism can cause anemia, low birth weight, rarely congestive HF (H&H 9.5/29.4). Personality change of long-term drug therapy. Criminal or anti-social behavior occurs of marijuana or illicit drug use, body toxicity. Previous surgery put the pt at risk for bleeding. Stage2 cancer put her at risk for vaginal bleeding, abdominal pain swelling.

Clinical Judgement Plan Instructor: DATE Care Provided and UNIT: References Use APA format and hanging indents for all references. If you have any questions, please consult the APA 7 th Edition. Final Version 3/10/22 DW/ss & MS Team