NR 226 week 8

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Relearning: Clinical Judgment Plan of Care Template

 

Student Name:

Client Initials:

Age/DOB:

Allergies:

BSA/BMI: Code Status:

 Date of Admission:

Date of Care:

Admitting Diagnosis:

Comorbidities:

Planned Treatments/Procedures:

 

 

Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders
Cultural/Spiritual:

 

 

Neurological/Cognition/Coping/Adaptation/Function:

 

 

Nutrition/Elimination:

 

 

Fluid/Electrolytes/Acid-Base:

 

 

Gas Exchange/Perfusion:

 

 

Glucose Regulation:

 

 Health Promotion/Development:

 

 

Infection/Immunity/Inflammation:

 

 

Mobility:

 

 

Pain/Comfort/Tissue Integrity:

 

 

Safety:

 

 

Other:

 

 

 

START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase 1/Question 1 section)
Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions & Take Actions Evaluate Outcomes
Priority Assessments/Cues Priority Hypotheses for Nursing Care Priority Interventions/Actions Priority Teaching/Discharge Needs
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Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions
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Vital Signs & Pertinent Lab Trends
START of the Shift (CJSim™) Analysis (phase 1/Question 1 section) END of the Shift (CJSim™) Analysis (phase 3/Question 3 section)
   

 

 

(CJSim™) MID-SHIFT Purposeful Clinical Judgment (Complete after reviewing EHR/Question 2 section)
Answer these questions about today’s client:

1. Recognize Cues — Explain any assessment changes since the start of shift.

2. Analyze Cues — How are the changes important or significant?

3. Prioritize Hypothesis — What could be causing the changes?

4. Generate Solutions — What can/should you do about these changes?

5. Take Action — What did I do about it? What would I do about it?

6. Evaluate Outcomes — Did my actions make a difference? Why are why not? What should have been done differently?

 

 

END of Shift (CJSim™) Priorities — How Has Your Client Changed? (phase 3/Question 3 section)
Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions & Take Actions Evaluate Outcomes
Priority Assessments/Cues Priority Hypotheses for Nursing Care Priority Interventions/Actions Priority Teaching/Discharge Needs
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Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions
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Clinical Debriefing (Complete these questions after completely caring for the client and answering the questions for the client)
Answer these questions about today’s client:

1. Compare this client with one that you’ve cared for previously in clinical, simulation, or a class case study. What things were the same and what was different related to their condition, assessment findings, provider prescriptions, medications, etc.?

2. Compare this client with the “textbook”, what was the same and what was different?

 

 

 

CONSIDER QUESTIONS Document the Answers to Your Questions Here
Consider Questions from CJSim™ Question #1 Consider Questions from CJSim™ Question #2 Consider Questions from CJSim™ Question #3
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Reflection Exercise (After providing care during the CJSim™ and completing the plan of care template for your assigned client, answer the following reflection questions focusing on the care you provided for this CJSim™ client.)
CJSim™ Reflection Questions:

 

1. What additional information would you need to provide more comprehensive care for the client?

 

2. What could you have done better or differently to improve the outcome? Why?

 

3. Describe what was most challenging for you when caring for the clients in the CJSim™?

 

4. Identify the additional equipment, resources, or assistance needed to improve the care you provided.

 

5. Share the key areas of care that were new to you that you had not experienced before.

 

6. How will your above reflections impact your future practice and improve your clinical judgment?

 

 

 

NurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN.

 

 

 

Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 1

 

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