Chat with us, powered by LiveChat Fill out my clinical judgement plan Postpartum Spinal Headache Patient: Jane Doe Age: 27 years Gravida/Para: G1P1 PMH: None Allergies: NKDA Date of del - EssayAbode

Fill out my clinical judgement plan Postpartum Spinal Headache Patient: Jane Doe Age: 27 years Gravida/Para: G1P1 PMH: None Allergies: NKDA Date of del

 Fill out my clinical judgement plan

Postpartum Spinal Headache

Patient: Jane Doe
Age: 27 years
Gravida/Para: G1P1
PMH: None
Allergies: NKDA
Date of delivery: 06/15/2025
Delivery type: Vaginal /
Anesthesia: Epidural
Postpartum Day: 06/16/2025

Clinical Judgement Plan

Instructor:

DATE Care Provided and UNIT:

Student Name

Clinical Judgement Plan

West Coast University

Professor Name

Date

OB History

GTPAL:

Prenatal Panel

Blood Type/Rh: GBS: Hep B: HIV: Rubella: RPR: Chlamydia: Gonorrhea: HSV:

Delivery Summary

Gestational age:

Delivery Type:

Delivery Time:

Postpartum Day: Placenta Delivery Time: Lacerations/Episiotomy: QBL: APGAR Score:

ROM type and time:

Complications:

Social History

Patient Information

Patient Initials:

Admission Date:

Chief Complaint:

Age & Gender:

Admission Weight:

Allergies:

Code Status:

Living Will/ DPOA:

History of Present Illness (HPI)

Admitting Diagnosis & Pathophysiology

Medical History & Pathophysiology

Surgical History & Pathophysiology

Erikson’s Developmental Stage Related to Patient (1) *List and discuss specific stage (based on objective assessment)

Social Determinants of Health

Ethnicity

Occupation

Religion

Family support

Insurance

3 Psychosocial Considerations/Concerns

Teaching Assessment and Client Education

Discharge Planning

Interprofessional Consults and Multidisciplinary Plan

Lab Tests with Values

(Include normal ranges, dates, and rationales of abnormal results)

Lab Tests or

Diagnostic Tests

Normal Ranges

Admission Lab Values

Current Lab Values

Explain Abnormal Results R/T Your Patient

(USE additional pages at the end of template WHEN NEEDED)

Diagnostics

(3) Relevant Diagnostic Procedures with Results

(2) Medications

Medication Name

Include Generic name, Trade name, and Medication Class.

Include OTC, herbal (non-pharmacological items) and PRN medications given during clinical

Dose

Route

Frequency

Purpose of Medication for Your Patient

Mechanism of Action

Side Effects/

Adverse Reactions

Nursing Considerations Specific to Your Patient/Teaching

Physical Assessment/Review of Systems

Postpartum BUBBLE Assessment

Time of care: ____________________________________

Labor Assessment

Episiotomy/Laceration/

Incision

Vital Signs/Height/Weight

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:

Bowel

Bladder

Uterus

Breasts

Respiratory

Cardiovascular

Neurological

Emotional

DVT

Lochia

Time of care: ____________________________________

HEENT

Psychosocial

Hydration/Nutrition

Vital Signs/Height/Weight

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:

Genitourinary (GU)

Vaginal Exam/Leopold’s

Lines/Drains/Tubes

Gastrointestinal (GI)

Safety

Respiratory

Cardiovascular

Neurological

Musculoskeletal and Activity

Integumentary

Endocrine

Responding

Observation

Interpreting

Implement

Planning

Analysis

Assessment

Take Action

Generate Solutions

Prioritize Hypotheses

Analyze Cues

Recognize Cues

Evaluate

Evaluation

Reference Page

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