Clinical Judgment / Patient Assessment

Overview: This assignment is designed to help students grow their nursing clinical judgment by working through
the clinical judgement models. Students will complete this activity weekly on each patient they are assigned to in
clinical. The responses in this assignment must reflect the individual patient, not generic information. Per
the course schedule, students will submit their Clinical Judgment Assignment(s) that will summatively evaluate
their clinical judgment.

Directions:
1. Noticing/Assessment/Recognizing Cues
a. Collect data from the chart to complete (collect trends for labs).
b. Pathophysiology should represent the relationships between the patient’s comorbidities and the
admitting diagnosis. Must be patient specific and explained at a cellular level in your own words.
2. Interpreting/Analysis/Analyze Cues
a. Appropriately analyze the patient cues/ data collected on your patient.
b. Determine what information is the most significant, (i.e., need to know, as a nurse). Findings may
be a normal or abnormal finding.
c. Discuss the nursing relevance (how will this influence care?).
3. Interpreting/Analysis/Prioritize Hypothesis (Problem)
a. Analyze the significant data/results to identify three priority hypotheses (problems).
b. Prioritize the three most important Provider Orders, explain the rationale, and what the
desired/expected outcomes for those orders.
c. Based on the patient’s specific situation,
hypothesize the three mostly likely
complications and their clinical relevance.
d. Identify age-specific concerns, as applicable.
4. Interpreting/Planning/Generate Solutions
a. Identify which hypothesis (problem) has the
highest priority and must be addressed first.
b. Plan and generate solutions with five nursing
interventions (what can the nurse actively do
for the patient, not just monitor or assess)
and explain your rationale.
c. Explain the desired/expected outcome for
each intervention.
d. Determine which members of the health care team can assist in meeting the patient’s needs and
why?
e. Identify the patient’s discharge needs.
5. Interpreting/Implementation/Take Action
a. Identify which hypothesis (problem) requires immediate response.
b. Which intervention(s) can be implemented via delegation?
c. Which medication(s) address the identified priority hypothesis (problem).
d. Complete medication chart. Discuss pharmacological age-specific concerns, if appropriate.
6. Reflecting/Evaluation/Evaluate Outcomes
a. Answer the questions listed.
 Clinical Judgment / Patient Assessment

Student: Evangeline Da Vera Date: 09/16/23 Instructor Name: Cynthia Gutierrez

Pt. Initials: MK M F Age: 62 Years Allergies/Reaction:

Allergic to Ciproflaxacin
Date of Admission: 09/15/23 Code Status: Full status
Admitting Diagnosis: Bilateral pneumonia, AKI, UTI
Comorbidities: Morbid obesity, Atrial fibrillation, CKD, Candida auris, MRSA, Vancomycin resistant enterococcus,
impaired skin integrity.
General appearance: Patient brought to the hospital ER with altered level of consciousness and with severe
respiratory distress.

Immunizations not up to date: Yes/No Immuno-compromised: Isolation Precautions Type(s):

Influenza Describe: Patient is MRSA positive, so she Patient is MRSA positive, so she is
is immuno-compromised. immunocompromised and should be
separated in a single room.
Pneumococcal
COVID-19
Varicella
Other:

Noticing/Assessment/Recognizing Cues
History of Present Problem Patient is suffering from altered level of consciousness and severe respiratory distress with
hypotension, hyperthermia, bradycardia and oliguria .
Significant PMH Morbid Obesity, Atrial fibrillation, CKD, Candida auris, MRSA, Vancomycin resistant enterococcus,
impaired skin integrity.
Vital Signs: Time: 1200 HRS Time: 1400 HRS Time: 1600 HRS Height:
Temp 101F 98F 98F 164 cm
HR 62 bpm 82 bpm 78 bpm
Resp. 34 /min 20 /min 20 /min Weight(k
g):
BP 80/60 mmhg 100/70 mmhg 110/70 mmhg 150 kg
O2sat 78% at room air 98% on ventilatory support 98% on ventilatory support
Pain Restlessness, irritable patient Patient is sedate and paralyze Patient is sedate and BMI:
paralyze 56.1

Chemistry/Electrolytes CBC with

Differential
Result/Critical Value/Trend
Date: Re Result/Critical
L L Ref. Range
Date: Date: f. Value/Trend Date:
a a
Ran Date:
b b
ge
Na+ 144↑ ↓ ↔ 146↑ ↓ ↔ 136-144 WBC 15.7 12.4↑ ↓ ↔ 4.5-11.0
mmol/l
Cl- 110↑ ↓ ↔ 114↑ ↓ ↔ 97-105 Hemoglobin 8.3 7.6↑ ↓ ↔ 10-14
mmol/l
K + 3.9↑ ↓ ↔ 4.6↑ ↓ ↔ 3.7-5.1 Hematocrit 28.4 23.2↑ ↓ ↔ 36-48%
mmol/l
CO2 19↑ ↓ ↔ 16↑ ↓ ↔ 23-29 Platelets 131 109.4↑ ↓ ↔ 150-400
mm0l/l
Glucose 129↑ ↓ ↔ 90↑ ↓ ↔ 74-140 RBC 2.46 2.12↑ ↓ ↔ 3.5-5.5m/mm3
mg/dl
Mg ++ 2.6↑ ↓ ↔ 3.4↑ ↓ ↔ 2.41-3.44 Lymphocyte 10.3 33.0↑ ↓ ↔ 21-51
s
mmol/l
Ca ++ 13.0↑ ↓ ↔ 11.7↑ ↓ ↔ 0.75-2.27 Neutrophils 5.7 7.8↑ ↓ ↔ 4.2-7.5
 mmol/l
Phos. 2.6↑ ↓ ↔ 2.8↑ ↓ ↔ 2.4-4.5 Pancreatic
Function
mg/dl
Cardiac Amylase 160 138↑ ↓ ↔ 0-90 U/L
Function
Troponin 0.03↑ ↓ ↔ O.O4↑ ↓ ↔ 0-0.04ng/ 187 154 0-70 U/L
Lipase ↑↓
m
BNP 88 pg/ml↑ ↓ ↔ 93↑ ↓ ↔ ↔
<100pg/ml
Clotting and Hepatic Function Urinaly Urine Culture
sis
PTT 46↑ ↓ ↔ 38↑ ↓ ↔ 30-34/S Protein 2t(A) Organism(s
)
PT 23↑ ↓ ↔ 28↑ ↓ ↔ 11-14/S Glucose trace Sensitivity Y/Pending
INR 3.7↑ ↓ ↔ 3.2↑ ↓ ↔ 2.0-3.0 Ketones NIL ABx sensitive to:
ALT 32↑ ↓ ↔ 26↑ ↓ ↔ 4-36U/L Bilirubin NIL
AST 18↑ ↓ ↔ 14↑ ↓ ↔ 10-40 U/L Blood 2t(A)
ALP 128↑ ↓ ↔ 88↑ ↓ ↔ 44-147 WBC NIL What Abx is patient on:
IU/L
Ammonia 22↑ ↓ ↔ 25↑ ↓ ↔ 15-45 u/dl Nitrate NIL
Albumin 3.3↑ ↓ ↔ 3.1↑ ↓ ↔ 3.5-5.5
u/dl
 Wound Culture
Renal (Source Location): NIL
Function Organism:
BUN 60↑ ↓ ↔ 32↑ ↓ ↔ 6-24 mg/dl Sensitivity (ABx Sensitive to):
Creatinine 32.4↑ ↓ ↔ 14.4↑ ↓ ↔ 6.0-8.3g/dl What ABx is patient on:
GFR ↑↓↔ ↑↓↔
ABGs
Organism
pH: 7.29 Acidosis /
Alkalosis pCO2: 38 Respiratory / Sensitivity (ABx Sensitive to):
Metabolic Misc. Lab Work
HCO3: 18 Compensated / Lactate 1.0 ↑↓ 0-2 mmol/l
Uncompensated pO2: 95 ↔
O2 settings: ventilatory support Procalcitonin NOT ↑↓
REQUIRED ↔
Diagnostic Tests (Date and Type) & Result:

Date Type Result

09/15/23 CBC Raised TLC

09/15/23 RFT’S Raised Creatinine range

09/15/23 Chest X-ray X-ray shows abnormal lung opacity and loss of clarity of diaphragm.

09/15/23 HRCT Chest HRCT Chest shows bilateral pneumonia with atelectasis , ground glass
opacities and consolidation with interlobular septal thickening.

09/15/23 USG KUB USG KUB shows chronic kidney disease with large size and increased
cortical echogenicity.

NEUROLOGIC
AL
Normal: A&Ox4. Behavior appropriate to situation. Active ROM of all extremities. Symmetry of strength & movement. No paresthesias. Speech clear. Swallowing intact. EOM
intact. PERRLA. LT & ST memory intact.
Orientation: Person Pl Date/Time Situatio
ac n
e
Level of Awake Drowsy/Lethargic Stuporous Comat
Consciousness ose
:
GCS Eyes Hearing Sensation Pain Primary Verbal
Total: 11 Language: Scale
PERRLA No Normal Charac spanish Level: /10
Eyes # mm Deficits Numbne ter Location:
4 Spontaneous AD Sharp/
3 To speech ss Tingling
12345678 AS Dull
2 To pain Absent
Tinnitus Burning Non-
1 None Location: Speech:
Motor HOH/ Pin Verbal
Articulate
6 Obey Deaf Prick Pain Cues
Slurred
Hearing Heavy/Cramp Moaning
Commands 5 Pupils Garbled
Aids Ache Crying
Localized Brisk Aphasic
pain to Sluggis Slow to Grimacin
stimuli h Fixed Respond g
4 Withdraws from Clenched Teeth
stimuli Vision Tight Closed
3 Abnormal No Eyes
flexion Restlessness
2 Deficit
Guarding
s OD ↑ HR/BP
Abnorm OS Gait Coordination Gross Movement Fine Movement
al Glasses/ Steady Intact Intact
extensio Contacts Unsteady Absent Absent
n Cataracts
1 No response Glaucoma
Verbal Blind
5 Oriented
4 Confused
3
Inappropr
iate
words
2
Incomprehensible
sounds
1 None
 CARDIOVASCULAR
Normal: Regular rhythm. No JVD or edema. Peripheral pulses 2+ bilat. Capillary refill <3 secs. Skin pink, warm, dry, no numbness or paresthesia. Denies chest pain. No activity
intolerance or SOB.

GASTROINTESTINAL/ENDOCRINE
Normal: Abdomen soft, non-distended, non-tender, no diarrhea, constipation. No tubes, drains, stomas, diabetes, pituitary, thyroid, thymus or adrenal gland
disorders.
Bowel Sounds Abdomen Stool NGT/GT/JT Decompression
Active / Hyperactive / Hypoactive / Soft Formed NGT / GT/PEG / JT
Firm Soft Suction: Intermittent / Continuous
Absent Location: Distended Hard 150 mmHg Drainage Color:
Non- Liquid
Flatus: Yes / No Ostomy: Yes / No Goiter: Yes / No
distended # /24 hr.
Color: Location:
Tender Neck Surgical
Mucous Membranes Type:
Non-tender Scar:
M Last BM: Ileostomy Yes / No
oi Date: Colostomy
Incontinence Stoma Exophthalmos:
st Yes / No
Dr Yes / No Color:
Red / Pink / Dusky
y

RENAL/
URINARY
Uri Catheter Voiding Frequency Urgenc Incontinenc Dysuria Nocturi Dialysis
ne Per: y e a
Clear N Uri Yes / No Yes / No Yes / No Yes / Yes / No Hemodial
Cloudy on nal No ys
Sedim eI BR is
Periton
ent & BS eal
Straw O C Mucous Membranes: Skin Turgor Shunt/Fistula:
Yellow External BP Moist/Dry Tenting/Non-Tenting Location: NIL
Amber Indwelling Bruit +/- Thrill
Pink Suprapubi +/-
Red c
 SKIN INTEGRITY
Normal: Skin color appropriate to ethnicity. Turgor within normal limits. Skin warm, dry & intact. Oral mucous membranes moist & intact. No bruising or Petechiae, no rashes or
skin lesions. No dermal ulcers.

MUSCULOSKELETAL
 OBSTETRIC
AL NOT
REQUIRED
Hist Type of Delivery Infant Post-Delivery/Op Breasts
ory
o LMP o FHT o SVD o Live o LMP o Breastfeedin
o EDD o FH o C/S 1°, X o Single o EDD g
o GA o FHR o VBAC o Demise o Full
o Gravida • Deceleration o Forceps/Vacuum o Twins o GA o Filling
o Para s o Episiotomy o Multiple o Gravida o Engorged
o SAB • Variables o Laceration o Para o Nipples
o TAB o PROM o SAB o Flat
o EAB o SROM o Fundus o TAB o Inverted
o Lochia amt. o EAB o Other
o Rubra o Surgical Site
o Serosa o Staples
o Alba o Sutures
o Clots o Approximated
o Other
 PSYCHOLOGICAL
ASSESSMENT
Patient’s perceived health status and expectations of How does patient usually manage stressors (coping
care: skills)?
Patient is unconscious, so I can't do her psychological
assessment.

History of psychiatric illness (on any psychotropic Patient’s perception of self-esteem and body image:
medications)? Describe:
NIL

Identify actual and potential stressors (internal & external), losses and strengths:
NIL
 SOCIAL ASSESSMENT
Patient’s occupation: Housewife Significant relationships (circle one): S M W D
If retired, previous occupation:
Highest level of education: MA
English
Tobacco products: No / Yes Quit? No / Yes Living arrangements/Support system: Husband
Type: Cigarette Years: 20 years
Alcohol consumption: No / Yes Quantity: Recreational drugs: No / Yes Quit? No /
Quit? No / Yes Years: Yes Type: Years:

Conflicts at work, school, home, or community? Describe:

NIL
 Significant Lab(s): Why are these important to the nurse? If abnormal, TREND
interpret the cause? Improving/Worsening/Stable:
Raised TLC TLC denotes infection and points towards human immune After hemodialysis,
Deranged RFTS response. trracheostomy and treatment
Proteinuria Deranged RFTS indicate chronic kidney injury. of disease, the patient's
Proteinuria is associated with an increased risk of kidney condition is improving.
function loss.

Significant Diagnostics: Nursing Relevance:

HRCT Chest HRCT Chest shows bilateral pneumonia with atelectasis , ground glass opacities and
USD Abdomen consolidation with interlobular septal thickening
USG KUB shows chronic kidney disease with large size and increased cortical echogenicity.

Significant Assessment Nursing Relevance:

Findings:
Hyperthermia Hyperthermia is due to infection or inflammation.
Bradycardia AF causes bradycardia.
Severe respiratory distress severe respiratory distress is due to atelectasis and inflammation of alveoli
Hypotension Hypotension is due to nausea and vomiting and lower intake. It can be the cause of AKI.

What age-specific concerns Aging is associated with decline of lung function.

that need to be considered Decrease in glomerular filtration rate and renal blood flow occur with age.
and why?

Interpreting/Analysis/Prioritize Hypothesis (Problem)

Hypothesize which THREE findings from histories, VS, labs, diagnostics, and assessment must be recognized as priority
concerns to the nurse and why?

1. Impaired gaseous exchange related to bilateral pneumonia as evidenced by severe respiratory distress.

2. Ineffective airway clearance related to mechanical ventilation as evidenced by excessive secretions and abnormal breath
sounds.

3 Fluid volume excess related to acute kidney injury as evidenced by pitting edema.

.
Hypothesize which THREE Provider Orders are a priority that must be recognized as clinically significant to the nurse?

Provider Orders: Rationale: Expected Outcome of the order:

1. Promote airway clearance. 1. Patient is on mechanical 1. Patient airway will be cleared and there
ventilation and she can’t clear the will be no secretions in the airway.

2. hemodialysis
3. Promote patient comfort
airway, so intermittent suctioning is
needed.
2.Hemodialysis is needed 2. Patients RFT’S will be in normal range.
because the patient's kidney is not
working properly.
3.Patient is on mechanical 3. Patient will be comfortable.
ventilation, so promotes patient
comfort by keeping her sedate and
paralyzed.

Hypothesize the complications the patient is at greatest risk to develop?

The patient is at risk for developing barotrauma related to mechanical ventilation.

The patient is at risk for developing permanent kidney damage related to AKI.

The patient is at risk for developing emphysema related to mechanical ventilation.

 Interpreting/Planning/Generate Solutions
What is the priority nursing diagnosis and should be Goal(s) (SMART): Short-term / Long-term
managed first? Why?
Ineffective airway clearance:
Short term goals Long term goals
Effective airway clearance is important because if the
airway is not cleared gaseous exchange is impaired. Manage severe Maintain skin integrity
respiratory distress

Manage hyperthermia Maintain balanced diet

Manage fluid electrolytes Manage pressure ulcers

balance

Manage oliguria provide knowledge

Based on your analysis of cues, what are FIVE
appropriate nursing interventions, in order of priority and
why?
1. Manage impaired gaseous exchange
2. Effective airway clearance
What is the desired/expected outcome of the intervention?
1. After mechanical ventilation patients gaseous
exchange will improve as evidenced by O2
saturation is >90%.
2. It will enhance the mucus mobilization,reduce
airway resistance and improve ventilation.

3.Manage fluid electrolytes balance

3. Pitting edema will be reduced.

4. Manage hyperthermia
4.Hyperthermia will be settled.

5.Manage oliguria 5.Urine output will be increased.

Which interprofessional Female Dresser helps me in meeting patients' needs because she came to do the dressing of the patient.
healthcare team
member(s) can assist
in meeting this
patient’s needs and
why?
What discharge
needs do you NO,
anticipate your
patient will have?
 3. 3.

Patient Medications (Medications relevant to primary problem - scheduled and PRN):

*This will be used in conjunction with the Medication Worksheet

Drug name Dose/Route/ How will medication help with Evaluation – Patient response to
(trade & generic) Time Due prioritized hypothesis(es) (problem)? administration (not what the drug is expected
to do)
Inj. Merem (Meropenem) 1g* Iv* TDS Meropenem will treat the Patient will be fine and lab investigations are in
infection. normal range.

Inj. Bofalgan ( paracetamol) 1g* Iv* TDS Paracetamol will settle the hyperthermia Vital signs were indicative of no hyperthermia at
the
end of shift.

Inj. lasix (furosemide) 60* Iv* TDS Furosemide will increase the urine Urine output will be increased and pitting edema
output. will be reduced.

Tab. sildenafil (Revatio, 1tab*BD Sildenafil reduces the Pulmonary arterial Pulmonary arterial hypertention is reduced.
Viagra) hypertention.

IV Fluid 500ml*IV*TDS Patient is NPO, so IV fluid should be Vital signs were indicative of fluid electrolytes
Inj. dextrose saline 500ml*IV*BD given to maintain fluid electrolyte balance.
Inj. normal saline balance. Skin integrity is also indicative of hydration status.

Inj. ventolin TDS Ventolin relaxes muscles and increases Respiratory distress is reduced.
air flow in the lungs.
Age-specific
considerations: NIL

Reflecting/Evaluation/Evaluate Outcomes
Was the YES
desired/expecte Patient condition is somehow better after mechanical ventilation and dialysis but still critical.
d outcome for
the patient
achieved?
Explain.
What findings would Interventions are effective because Patients' labs improve after interventions.
indicate whether the
interventions were
effective?

Did the patient YES

respond as Patients' condition is better after interventions. Patients' respiratory distress is reduced and patient will be weaned off
expected? from the ventilator.
Explain.

What cues should Patients Vitals signs, capillary refill and RFT’S should be assessed and reassessed.
be assessed/re-
assessed?

What did you learn I learned how to ventilate patients and settings of the ventilator and management of ventilatory patients.
from caring for your
patient today?

How can you use In the future, I can easily manage the patient on mechanical ventilation.
what you learned
today in the future?

What could have I think the patient was properly managed.

gone better?
What could have
gone differently?

What are your goals Next week I will learn modes of ventilation according to the condition and need of the patient.
next week?

- 143
-
 Summative Clinical Judgment / Patient Assessment Activity Grading Rubric
Criteria Accomplished - 5
Points
Noticing/ Cues include patient
Assessment/ specific significant
Recognizing Cues subjective data (history
of present problem,
Points Earned: personal & social
history, pain) and
objective data (history,
VS, lab & diagnostic
results, assessment
findings) are identified
and described
completely and are
significant to the clinical
patient. Pathophysiology
is patient specific and
thoroughly explains how
the patient’s
comorbidities
contributed to the
disease process.
Explained at a cellular
level.
Interpreting/ Comprehensively
Analysis/ Analyze identifies patient specific
Cues significant history, VS,
lab & diagnostic results,
Points Earned: assessment findings.
Thoroughly explains
why they are clinically
significant to the nurse
and the patient’s
condition.
Interpreting/ Accurately identifies
Analysis/ the three patient
Prioritize specific priorities based
Hypothesis on significant history,
VS, lab & diagnostic
Points Earned: results, assessment
findings.
Accurately identifies the
three priority Provider
Orders and potential
complications.
Interpreting/ Accurately identifies the
Planning/ patient specific priority.
Generate Provides five
Solutions appropriate active
Acceptable - 3
Points
Many of the cues
including subjective
data (history of present
problem, personal &
social history, pain) and
objective data (history,
VS, lab & diagnostic
results, assessment
findings,
pathophysiology) are
identified and
described completely
and are significant to
the clinical patient.
Pathophysiology is
partially patient specific
and partially explains
how the patient’s
comorbidities
contributed to the
disease process. Not
fully
explained at a cellular
level.
Partially identifies
significant history, VS,
lab & diagnostic
results, assessment
findings.
Does not completely
explain why they are
clinically significant to
the
nurse and the patient’s
condition.
Partially identifies two
priorities based on
significant history, VS,
lab & diagnostic
results, assessment
findings.
Partially identifies (either
incorrectly or less than
three) priority Provider
Orders and potential
complications.
Identifies a potential
patient priority.
Provides four to three
appropriate active
Needs improvement - 1
Point
Cues including subjective
data (history of present
problem, personal & social
history, pain) and/or
objective data (history, VS,
lab & diagnostic results,
assessment findings,
pathophysiology) are
incomplete and/or not
relevant. Pathophysiology
is not patient specific.
Patient’s comorbidities are
incomplete and/or not
relevant. Not explained at
a cellular level.
Does not identify the
significant history, VS, lab
& diagnostic results,
assessment findings.
Explain of why they are
clinically significant to the
nurse and the patient’s
condition is incomplete
and/or not
relevant.
Identifies two or less
priorities based on
significant history, VS, lab
& diagnostic results,
assessment findings are
not identified or incorrect.
Priority Provider Orders
and potential complications
are not identified or
incorrect.
Does not identify, identifies
two or less, or incorrectly
identifies patient priorities.
Interventions are
 nursing interventions nursing interventions insufficient to address
Points Earned: with thorough with some explanation patient needs and/or are
explanation of clinical of relevance. Or only inappropriate.
relevance. partially explains
relevance.

Instructor’s Signature: Date:

Revised 8/23/23 -Approved: 06/06/2023