please fill out the entire blank clinical judgement no plagiarism. fill our clinical judgement based on the sample
do clinical judgement plan based off of the example and put it all in your own words
my constructive feedback is as follows: – Good HPI. ROS needs more detailed and specific pt assessment data overall – Good diagnosis pathophysiology. No medical history/patho listed – Good psychsocial/socioeconomics – Good pt education/DC planning – Within medical/collaborative plan section, you need to list the treatment team/interprofessional consults (e.g., Endocrinology, Diabetes Educator RN, PT/OT, Social Work, etc.) and their specific necessity within the pt’s plan of care – Vital signs need to be specific – Good RN considerations for meds – Given how this pt presented to the ED, lab/diagnostic data should include urinalysis for ketones, specific gravity and osmolarity, and ABGs (pH and HCO3) to assess for DKA, as well as Hgb A1c. Creatinine/BUN/electrolytes need to be monitored as well to assess renal function. Was there any infection with this pt? – Remember, all adverse pt data should be listed within Recognize Cues section, which are then grouped into several issues/problems within Analyze Cues section, and then these are given priority within Prioritize Cues section. More of these are needed in these sections, with deeper analyses overall – More interventions are needed overall. Remember, after you have analyzed your list of cues to form and prioritize several issues/problems to address, these issues need to then be given sets of specific interventions – And remember, all goals each need to be specific, measurable, and reasonably timed (e.g., end of shift, 24 hrs, etc.) to establish expected outcomes from corresponding interventions applied – As discussed, the Evaluation section needs to align with the goals section to establish whether each specific goal was met/not met – More specific and pt-related detail is needed within these sections A more complex pt would be needed for your next CJP. Please feel free to contact me or see me in person if you have any questions or concerns. Happy to provide any assistance needed.
