NCSBN Clinical Judgment Measurement Model (Care Plan)

NCSBN Clinical Judgment Measurement Model (Care Plan) Image transcription text Recognizing Cues Analyzing Cues Prioritize Hypotheses Generate Solutions Take Actions Evaluate Outcomes Fill out like care plan. Recognize Cues=Assessment Analyzing Cues=Diagnosis/Analysis Prioritize Hypotheses=Diagnosis/Analysis Generate Solutions=Planning Take Actions=Implementation Evaluate Outcomes=Evaluation CJMM Scenario #2 RN to RN Report: Our patient is Adam Garcia, a 35 year old male with a history of type 1 diabetes. He was admitted to the medical-surgical unit yesterday due to a right leg ulcer that resulted from a fall 6 months ago and has gotten progressively worse. He is now unable to bear weight on his right leg. He is noted to have poor circulation in both legs with bilateral leg edema. Past medical history includes: Cardiac surgery 5 years ago due to a congenital heart defect. Right deep vein thrombosis 3 years ago Social History: Adam works as a truck driver so it is difficult for him to follow up with his primary care provider since he is on the road a lot. It is also hard for him to adhere to his medication regimen as well as taking his blood glucose regularly. Patient states he often skips meals throughout the day or buys food at gas stations or rest stops while he’s working. Drinks 3 energy drinks a day. He also has a history of alcohol and drug misuse – patient states he drinks about 5 to 6 beers a day. He also states injecting “street drugs” into his feet. Adam is single and lives alone. Current Medications: Insulin, sliding scale Metoprolol – 100mg once a day Lasix – 80mg once a day Physical Exam: General Survey: alert and oriented x4; patient appears tired; skin color even and consistent with genetic background (except for the right leg – see below for right leg exam); patient is sitting upright in bed, no distress noted. Facial expression and mood appropriate for situation. Heart: Sinus rhythm; heart sounds normal; no presence of murmur or extra heart sounds Lungs: lung sounds clear bilaterally Abdomen: soft, non-tender; bowel sounds present in all four quadrants Genitourinary System: voiding regularly using bedside urinal Peripheral Vascular System: bilaterally lower leg edema present; lower legs warm to touch with right leg warmer around wound. Pedal pulse 2+ on left foot, diminished on right foot. Hyperpigmentation noted to right leg, surrounding the wound. Capillary refill sluggish bilaterally. Musculoskeletal: patient able to move all extremities but unable to bear weight on right leg. Wound: Right medial lower leg open ulcer, measuring 3cm x 2cm. Wound is shallow with irregular borders. Wound bed is bright red and appears to show inflammation of the subcutaneous tissue. Hyperpigmentation noted around wound. Slough present over 25% of wound. Various dilated vessels around the ankle. Purulent drainage noted when dressing was removed. Foul odor from wound noted. Image transcription text Decision 6 Vital Signs: Pain: 8/10 on lower right leg BP: 138/90 (right arm) HR: 106 Respirations: 20 Temp: 103 F O2 saturation: 99% on room air SCIENCE HEALTH SCIENCE NURSING HEALTH ASSESSMENT 114

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