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Home>Homework Answsers>Nursing homework helpgoodBest2 years ago24.10.202340Report issuefiles (4)CaraJett.pdfLindaMcCartchy.pdfClinicalJPLC.docxTemplate2.docxCaraJett.pdfName: Cara Jett
Age: 34 years
Provider: R. Mcbride NP
Allergies: NKA
Admit weight: 102 Ibs (46.3kg)
BMI: 17.5
Code status: full codeI just can’t eat. Every time I do, I have horrible pain in my stomach. My family keeps
accusing me of having an eating disorder. It’s not that I don’t want to eat. It’s that I can’t
without pain and diarrhea!4/12
1345Nursing Note: Client presents for ongoing stomach pain after eating. Current BMI of
17.5. Last recorded BMI from 3 years ago was 22.2. States pain has been ongoing for
several years, more severe as of late yesterday. Client skipped lunch today. Current
abdominal pain is 2/10. States that she has tried using over-the-counter pain relievers to
help with the abdominal pain, but this has not been successful. Rates 2/10 RLQ
abdominal pain.4/12
1355Neuro/Cognitive: Alert and oriented x4.Cardiovascular: Regular heartbeat with S1 and S2 heard. No edema present. Capillary
refill <3 seconds. Bilateral pedal and radial pulses +3.Respiratory: Lungs clear bilaterally.Gastrointestinal: Abdomen flat, firm, hyperactive bowel sounds x 4 quadrants. Tender in RLQ. Denies nausea. Last bowel movement was 1045 today. Loose, brown, mucous looking – per client. Three loose stools today so far.Genitourinary: Continent. No pain or burning when urinatingMusculoskeletal: Muscle atrophy present. +5 strengths for all extremities. Tenting present on arm and collarbone.Psychosocial: Anxious. Becomes tearful several times during visit. States her family is accusing her of having an eating disorder.5/7 1435Nursing Note: Follow-Up Appointment with Gastrointestinal SpecialistDiagnosis: New Crohn’s disease.Follow-up appointment after colonoscopy and upper GI procedure. Had a CT scan of the abdomen completed after the procedure. Rates 4/10 abdominal pain. Client is taking prednisone and metronidazole as prescribed by primary care provider for Crohn's disease.Date Temp HR RR BP SpO2 O24/12 1345 96.8 °F(36.0 °C)78 18 102/54 100% RA5/1 0945 97.2 °F(36.2 °C)64 12 94/45 89% RA5/1 1000 97.2 °F(36.2 °C)69 12 104/50 92% RA5/1 1015 97.2 °F(36.2 °C)72 14 110/52 94% RA5/7 1430 98.6 °F(37.0 °C)88 18 138/78 99% RADate Diagnostic Test Findings5/1 1015Upper GI ColonoscopyNo abnormal findings.Small ulcer found in the transverse portion of the large intestine with evidence of more in the small intestine. Further testing, including an MRI, is highly suggested.5/5 1500CT Scan of AbdomenImpression: Thickening of the wall of the small intestine present. Three small abscesses noted by entrance to the colon correlating with recent gastric studies. No fistula apparent.5/1 0945Endoscopy Center Nursing Note:Client has completed an upper GI study and a colonoscopy with no noticeable complications. Vitals stable. Drowsy but easily woken. Oriented x4.5/1 1000Endoscopy Center Nursing Note:Vitals remain stable. Client drank 60mL of clear soda and two bites of graham cracker. Swallow and gag reflex present. Mild 2/10 throat discomfort present. Driver present and atbedside.5/1 1015Endoscopy Center Nursing Note:Client discharged to home in care of mother, Nancy. Follow-up appointment made.LindaMcCartchy.pdfName: Linda McCarthy Age: 86 years Provider: K. Townsend MD Codestatus: DNI BMI: 24.1 Allergies: penicillin, atorvastatin, red dye, latex Admitweight: 145 lbs (65.8kg)Linda McCartchy had a rough night. She was pretty restless and only slept two hours. This morning she was having an issue with her hearing aids not working. They kept whistling. I went to change the batteries, but she was out of them. Her family will be bringing them in later today.Nursing Assessments and notes11/1 0700Neuro/Cognitive: Alert and oriented to person and place. She intermittently confused and called staff by the names of her children. Speech raspy. 4/5 strength in all extremities. Cardiovascular: S1 and S2 heart sound present. Heart rate regular and even. No edema was noted. Pedal pulses +2, radial pulses +3. Capillary refill less than 3 seconds.Respiratory: Even, regular, unlabored. Lung sounds wheezing through all lung fields. Chronic dry cough. Wears 2 L via nasal cannula chronically.Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended, non-tender. Last bowel movement 2 days ago.Genitourinary: Occasional stress incontinence.Integumentary: Scattered bruising. Various stages of healing.Sensory: Hard of hearing. Wears hearing aids and glasses.11/1 0730ADLs: Independent with utensil holders Activity: Ambulated 100 feet with a roller walker11/1 0830Nursing Note: Client resting quietly in bed. Looking out the window, not responding to staff prompts for verbal interaction. Moves all extremities appropriately. Morning medications were administered without difficulty. Able to state name but unsure of her birthday. Up in the hall with physical therapy. Shuffling gait with use of a rolling walker.11/1 1100Nursing Note: RN called to bedside. The client stated that the staff took her favorite earrings. Earrings were found in the client’s tissue box at the bedside.11/1 2015Nursing Note: Client evening hygiene offered. The client begins yelling, “No! No! No!” as staff offer to assist with teeth brushing and denture care. Attempts were made to deescalate the client and place her hearing aids so that she could hear the conversation. The client begins attempting to hit and bite staff. Client sitting in bed. Staff leave room to reduce stimulation.11/1 2015Neuro/Cognitive: Alert, oriented to self only. She believes it is 1965 and that there are strangers in her house. Client calling out for her mother. Extremely hard of hearing with hearing aids in place.11/2 0700Nursing Note: The client is awake in bed, staring around her room, rubbing her eyes, and frequently yawning. Noted to have redness and purulent drainage from right eye. Provider notified; prescriptions received.11/2 0900Nursing Note: Appetite poor, ate 5 small bites only, Drank a cup of juice. Weight down. Will encourage protein supplement drinks between meals.Date Intake Source & Amount11/1 0700 Oral 240 mL11/1 0900Client Information: Medical History: Presbyopia, bilateral cataracts, Alzheimer’s dementia, hearing loss, hypertension, hyperlipidemia, osteoarthritis, ambulatory dysfunction, chronic obstructive pulmonary diseaseMedications: ● Rivastigmine 6 mg by mouth twice daily ● Lisinopril 20 mg by mouth daily ● Ezetimibe 10 mg by mouth daily ● Simvastatin 40 mg by mouth daily ● Docusate sodium 100 mg by mouth daily ● Polyethylene glycol 17 g by mouth daily – diluted in 8 oz of beverage ● Duloxetine 60 mg by mouth daily ● Artificial tears 1-2 drops into eyes PRN for dry eyes ● Oxygen 2L/NC PRN for difficulty breathing11/2 0730 Prescriptions: ● Ciprofloxacin ocular ointment 0.5-inch right eye three timesdailyClinicalJPLC.docxRelearning: Clinical Judgment Plan of Care TemplateStudent Name:CJSim™ 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 ordersCultural/Spiritual:N/ANeurological/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:STARTof Shift (CJSim™) PrioritiesRecognize & Analyze CuesPrioritize HypothesesGenerate Solutions & Take ActionsEvaluate OutcomesPriority Assessments/CuesPriority Hypotheses for Nursing CarePriority Interventions/ActionsPriority Teaching/Discharge Needs1.2.3.1.2.3.1.2.3.1.2.3.Priority Laboratory Tests/ Diagnostic CuesPriority Actual & Potential Complications/CuesPriority MedicationsPriority Collaborative Actions1.2.3.1.2.3.1.2.3.1.2.3.Vital Signs & Pertinent Lab TrendsSTARTof the Shift (CJSim™) Analysis (phase 1)ENDof the Shift (CJSim™) Analysis (phase 3)Temp: RR: 12BP: SpO2:HR:Temp: RR:BP: SpO2:HR:CJSim™ Purposeful Clinical JudgmentClinical DebriefingAnswer 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?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 different?ENDof Shift (CJSim™) Priorities — How Has Your Client Changed?Recognize & Analyze CuesPrioritize HypothesesGenerate Solutions & Take ActionsEvaluate OutcomesPriority Assessments/CuesPriority Hypotheses for Nursing CarePriority Interventions/ActionsPriority Teaching/Discharge Needs1.2.3.1.2.3.1.2.3.1.2.3.Priority Laboratory Tests/ Diagnostic CuesPriority Actual & Potential Complications/CuesPriority MedicationsPriority Collaborative Actions1.2.3.4.5.6.1.2.3.1.2.3.CONSIDER QUESTIONS Document the Answers to Your Questions HereConsider Questions from CJSim™ Question #1Consider Questions from CJSim™ Question #2Consider Questions from CJSim™ Question #31.2.3.1.2.3.1.2.3.Nurse Think® CJSimTM Reflection ExerciseAssignment: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:· What additional information would you need to provide more comprehensive care for the client?· What could you have done better or differently to improve the outcome? Why?· Describe what was most challenging for you when caring for the client(s).· Identify the additional equipment, resources, or assistance needed to improve the care you provided.· Share the key areas of care that were new to you that you had not experienced before.· How will your above reflections impact your future practice and improve your clinical judgment?ReferenceNurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN.© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept23 4image1.pngTemplate2.docxThis file is too large to display.View in new windowTemplate2.docxThis file is too large to display.View in new windowCaraJett.pdfName: Cara Jett Age: 34 years Provider: R. Mcbride NP Allergies: NKA Admit weight: 102 Ibs (46.3kg) BMI: 17.5 Code status: full codeI just can’t eat. Every time I do, I have horrible pain in my stomach. My family keeps accusing me of having an eating disorder. It’s not that I don't want to eat. It's that I can’t without pain and diarrhea!4/12 1345Nursing Note: Client presents for ongoing stomach pain after eating. Current BMI of 17.5. Last recorded BMI from 3 years ago was 22.2. States pain has been ongoing for several years, more severe as of late yesterday. Client skipped lunch today. Current abdominal pain is 2/10. States that she has tried using over-the-counter pain relievers to help with the abdominal pain, but this has not been successful. Rates 2/10 RLQ abdominal pain.4/12 1355Neuro/Cognitive: Alert and oriented x4.Cardiovascular: Regular heartbeat with S1 and S2 heard. No edema present. Capillary refill <3 seconds. Bilateral pedal and radial pulses +3.Respiratory: Lungs clear bilaterally.Gastrointestinal: Abdomen flat, firm, hyperactive bowel sounds x 4 quadrants. Tender in RLQ. Denies nausea. Last bowel movement was 1045 today. Loose, brown, mucous looking – per client. Three loose stools today so far.Genitourinary: Continent. No pain or burning when urinatingMusculoskeletal: Muscle atrophy present. +5 strengths for all extremities. Tenting present on arm and collarbone.Psychosocial: Anxious. Becomes tearful several times during visit. States her family is accusing her of having an eating disorder.5/7 1435Nursing Note: Follow-Up Appointment with Gastrointestinal SpecialistDiagnosis: New Crohn’s disease.Follow-up appointment after colonoscopy and upper GI procedure. Had a CT scan of the abdomen completed after the procedure. Rates 4/10 abdominal pain. Client is taking prednisone and metronidazole as prescribed by primary care provider for Crohn's disease.Date Temp HR RR BP SpO2 O24/12 1345 96.8 °F(36.0 °C)78 18 102/54 100% RA5/1 0945 97.2 °F(36.2 °C)64 12 94/45 89% RA5/1 1000 97.2 °F(36.2 °C)69 12 104/50 92% RA5/1 1015 97.2 °F(36.2 °C)72 14 110/52 94% RA5/7 1430 98.6 °F(37.0 °C)88 18 138/78 99% RADate Diagnostic Test Findings5/1 1015Upper GI ColonoscopyNo abnormal findings.Small ulcer found in the transverse portion of the large intestine with evidence of more in the small intestine. Further testing, including an MRI, is highly suggested.5/5 1500CT Scan of AbdomenImpression: Thickening of the wall of the small intestine present. Three small abscesses noted by entrance to the colon correlating with recent gastric studies. No fistula apparent.5/1 0945Endoscopy Center Nursing Note:Client has completed an upper GI study and a colonoscopy with no noticeable complications. Vitals stable. Drowsy but easily woken. Oriented x4.5/1 1000Endoscopy Center Nursing Note:Vitals remain stable. Client drank 60mL of clear soda and two bites of graham cracker. Swallow and gag reflex present. Mild 2/10 throat discomfort present. Driver present and atbedside.5/1 1015Endoscopy Center Nursing Note:Client discharged to home in care of mother, Nancy. Follow-up appointment made.LindaMcCartchy.pdfName: Linda McCarthy Age: 86 years Provider: K. Townsend MD Codestatus: DNI BMI: 24.1 Allergies: penicillin, atorvastatin, red dye, latex Admitweight: 145 lbs (65.8kg)Linda McCartchy had a rough night. She was pretty restless and only slept two hours. This morning she was having an issue with her hearing aids not working. They kept whistling. I went to change the batteries, but she was out of them. Her family will be bringing them in later today.Nursing Assessments and notes11/1 0700Neuro/Cognitive: Alert and oriented to person and place. She intermittently confused and called staff by the names of her children. Speech raspy. 4/5 strength in all extremities. Cardiovascular: S1 and S2 heart sound present. Heart rate regular and even. No edema was noted. Pedal pulses +2, radial pulses +3. Capillary refill less than 3 seconds.Respiratory: Even, regular, unlabored. Lung sounds wheezing through all lung fields. Chronic dry cough. Wears 2 L via nasal cannula chronically.Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended, non-tender. Last bowel movement 2 days ago.Genitourinary: Occasional stress incontinence.Integumentary: Scattered bruising. Various stages of healing.Sensory: Hard of hearing. Wears hearing aids and glasses.11/1 0730ADLs: Independent with utensil holders Activity: Ambulated 100 feet with a roller walker11/1 0830Nursing Note: Client resting quietly in bed. Looking out the window, not responding to staff prompts for verbal interaction. Moves all extremities appropriately. Morning medications were administered without difficulty. Able to state name but unsure of her birthday. Up in the hall with physical therapy. Shuffling gait with use of a rolling walker.11/1 1100Nursing Note: RN called to bedside. The client stated that the staff took her favorite earrings. Earrings were found in the client’s tissue box at the bedside.11/1 2015Nursing Note: Client evening hygiene offered. The client begins yelling, “No! No! No!” as staff offer to assist with teeth brushing and denture care. Attempts were made to deescalate the client and place her hearing aids so that she could hear the conversation. The client begins attempting to hit and bite staff. Client sitting in bed. Staff leave room to reduce stimulation.11/1 2015Neuro/Cognitive: Alert, oriented to self only. She believes it is 1965 and that there are strangers in her house. Client calling out for her mother. Extremely hard of hearing with hearing aids in place.11/2 0700Nursing Note: The client is awake in bed, staring around her room, rubbing her eyes, and frequently yawning. Noted to have redness and purulent drainage from right eye. Provider notified; prescriptions received.11/2 0900Nursing Note: Appetite poor, ate 5 small bites only, Drank a cup of juice. Weight down. Will encourage protein supplement drinks between meals.Date Intake Source & Amount11/1 0700 Oral 240 mL11/1 0900Client Information: Medical History: Presbyopia, bilateral cataracts, Alzheimer’s dementia, hearing loss, hypertension, hyperlipidemia, osteoarthritis, ambulatory dysfunction, chronic obstructive pulmonary diseaseMedications: ● Rivastigmine 6 mg by mouth twice daily ● Lisinopril 20 mg by mouth daily ● Ezetimibe 10 mg by mouth daily ● Simvastatin 40 mg by mouth daily ● Docusate sodium 100 mg by mouth daily ● Polyethylene glycol 17 g by mouth daily – diluted in 8 oz of beverage ● Duloxetine 60 mg by mouth daily ● Artificial tears 1-2 drops into eyes PRN for dry eyes ● Oxygen 2L/NC PRN for difficulty breathing11/2 0730 Prescriptions: ● Ciprofloxacin ocular ointment 0.5-inch right eye three timesdailyClinicalJPLC.docxRelearning: Clinical Judgment Plan of Care TemplateStudent Name:CJSim™ 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 ordersCultural/Spiritual:N/ANeurological/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:STARTof Shift (CJSim™) PrioritiesRecognize & Analyze CuesPrioritize HypothesesGenerate Solutions & Take ActionsEvaluate OutcomesPriority Assessments/CuesPriority Hypotheses for Nursing CarePriority Interventions/ActionsPriority Teaching/Discharge Needs1.2.3.1.2.3.1.2.3.1.2.3.Priority Laboratory Tests/ Diagnostic CuesPriority Actual & Potential Complications/CuesPriority MedicationsPriority Collaborative Actions1.2.3.1.2.3.1.2.3.1.2.3.Vital Signs & Pertinent Lab TrendsSTARTof the Shift (CJSim™) Analysis (phase 1)ENDof the Shift (CJSim™) Analysis (phase 3)Temp: RR: 12BP: SpO2:HR:Temp: RR:BP: SpO2:HR:CJSim™ Purposeful Clinical JudgmentClinical DebriefingAnswer 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?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 different?ENDof Shift (CJSim™) Priorities — How Has Your Client Changed?Recognize & Analyze CuesPrioritize HypothesesGenerate Solutions & Take ActionsEvaluate OutcomesPriority Assessments/CuesPriority Hypotheses for Nursing CarePriority Interventions/ActionsPriority Teaching/Discharge Needs1.2.3.1.2.3.1.2.3.1.2.3.Priority Laboratory Tests/ Diagnostic CuesPriority Actual & Potential Complications/CuesPriority MedicationsPriority Collaborative Actions1.2.3.4.5.6.1.2.3.1.2.3.CONSIDER QUESTIONS Document the Answers to Your Questions HereConsider Questions from CJSim™ Question #1Consider Questions from CJSim™ Question #2Consider Questions from CJSim™ Question #31.2.3.1.2.3.1.2.3.Nurse Think® CJSimTM Reflection ExerciseAssignment: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:· What additional information would you need to provide more comprehensive care for the client?· What could you have done better or differently to improve the outcome? Why?· Describe what was most challenging for you when caring for the client(s).· Identify the additional equipment, resources, or assistance needed to improve the care you provided.· Share the key areas of care that were new to you that you had not experienced before.· How will your above reflections impact your future practice and improve your clinical judgment?ReferenceNurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN.© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept23 4image1.pngTemplate2.docxThis file is too large to display.View in new windowCaraJett.pdfName: Cara Jett Age: 34 years Provider: R. Mcbride NP Allergies: NKA Admit weight: 102 Ibs (46.3kg) BMI: 17.5 Code status: full codeI just can’t eat. Every time I do, I have horrible pain in my stomach. My family keeps accusing me of having an eating disorder. It’s not that I don't want to eat. It's that I can’t without pain and diarrhea!4/12 1345Nursing Note: Client presents for ongoing stomach pain after eating. Current BMI of 17.5. Last recorded BMI from 3 years ago was 22.2. States pain has been ongoing for several years, more severe as of late yesterday. Client skipped lunch today. Current abdominal pain is 2/10. States that she has tried using over-the-counter pain relievers to help with the abdominal pain, but this has not been successful. Rates 2/10 RLQ abdominal pain.4/12 1355Neuro/Cognitive: Alert and oriented x4.Cardiovascular: Regular heartbeat with S1 and S2 heard. No edema present. Capillary refill <3 seconds. Bilateral pedal and radial pulses +3.Respiratory: Lungs clear bilaterally.Gastrointestinal: Abdomen flat, firm, hyperactive bowel sounds x 4 quadrants. Tender in RLQ. Denies nausea. Last bowel movement was 1045 today. Loose, brown, mucous looking – per client. Three loose stools today so far.Genitourinary: Continent. No pain or burning when urinatingMusculoskeletal: Muscle atrophy present. +5 strengths for all extremities. Tenting present on arm and collarbone.Psychosocial: Anxious. Becomes tearful several times during visit. States her family is accusing her of having an eating disorder.5/7 1435Nursing Note: Follow-Up Appointment with Gastrointestinal SpecialistDiagnosis: New Crohn’s disease.Follow-up appointment after colonoscopy and upper GI procedure. Had a CT scan of the abdomen completed after the procedure. Rates 4/10 abdominal pain. Client is taking prednisone and metronidazole as prescribed by primary care provider for Crohn's disease.Date Temp HR RR BP SpO2 O24/12 1345 96.8 °F(36.0 °C)78 18 102/54 100% RA5/1 0945 97.2 °F(36.2 °C)64 12 94/45 89% RA5/1 1000 97.2 °F(36.2 °C)69 12 104/50 92% RA5/1 1015 97.2 °F(36.2 °C)72 14 110/52 94% RA5/7 1430 98.6 °F(37.0 °C)88 18 138/78 99% RADate Diagnostic Test Findings5/1 1015Upper GI ColonoscopyNo abnormal findings.Small ulcer found in the transverse portion of the large intestine with evidence of more in the small intestine. Further testing, including an MRI, is highly suggested.5/5 1500CT Scan of AbdomenImpression: Thickening of the wall of the small intestine present. Three small abscesses noted by entrance to the colon correlating with recent gastric studies. No fistula apparent.5/1 0945Endoscopy Center Nursing Note:Client has completed an upper GI study and a colonoscopy with no noticeable complications. Vitals stable. Drowsy but easily woken. Oriented x4.5/1 1000Endoscopy Center Nursing Note:Vitals remain stable. Client drank 60mL of clear soda and two bites of graham cracker. Swallow and gag reflex present. Mild 2/10 throat discomfort present. Driver present and atbedside.5/1 1015Endoscopy Center Nursing Note:Client discharged to home in care of mother, Nancy. Follow-up appointment made.LindaMcCartchy.pdfName: Linda McCarthy Age: 86 years Provider: K. Townsend MD Codestatus: DNI BMI: 24.1 Allergies: penicillin, atorvastatin, red dye, latex Admitweight: 145 lbs (65.8kg)Linda McCartchy had a rough night. She was pretty restless and only slept two hours. This morning she was having an issue with her hearing aids not working. They kept whistling. I went to change the batteries, but she was out of them. Her family will be bringing them in later today.Nursing Assessments and notes11/1 0700Neuro/Cognitive: Alert and oriented to person and place. She intermittently confused and called staff by the names of her children. Speech raspy. 4/5 strength in all extremities. Cardiovascular: S1 and S2 heart sound present. Heart rate regular and even. No edema was noted. Pedal pulses +2, radial pulses +3. Capillary refill less than 3 seconds.Respiratory: Even, regular, unlabored. Lung sounds wheezing through all lung fields. Chronic dry cough. Wears 2 L via nasal cannula chronically.Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended, non-tender. Last bowel movement 2 days ago.Genitourinary: Occasional stress incontinence.Integumentary: Scattered bruising. Various stages of healing.Sensory: Hard of hearing. Wears hearing aids and glasses.11/1 0730ADLs: Independent with utensil holders Activity: Ambulated 100 feet with a roller walker11/1 0830Nursing Note: Client resting quietly in bed. Looking out the window, not responding to staff prompts for verbal interaction. Moves all extremities appropriately. Morning medications were administered without difficulty. Able to state name but unsure of her birthday. Up in the hall with physical therapy. Shuffling gait with use of a rolling walker.11/1 1100Nursing Note: RN called to bedside. The client stated that the staff took her favorite earrings. Earrings were found in the client’s tissue box at the bedside.11/1 2015Nursing Note: Client evening hygiene offered. The client begins yelling, “No! No! No!” as staff offer to assist with teeth brushing and denture care. Attempts were made to deescalate the client and place her hearing aids so that she could hear the conversation. The client begins attempting to hit and bite staff. Client sitting in bed. Staff leave room to reduce stimulation.11/1 2015Neuro/Cognitive: Alert, oriented to self only. She believes it is 1965 and that there are strangers in her house. Client calling out for her mother. Extremely hard of hearing with hearing aids in place.11/2 0700Nursing Note: The client is awake in bed, staring around her room, rubbing her eyes, and frequently yawning. Noted to have redness and purulent drainage from right eye. Provider notified; prescriptions received.11/2 0900Nursing Note: Appetite poor, ate 5 small bites only, Drank a cup of juice. Weight down. Will encourage protein supplement drinks between meals.Date Intake Source & Amount11/1 0700 Oral 240 mL11/1 0900Client Information: Medical History: Presbyopia, bilateral cataracts, Alzheimer’s dementia, hearing loss, hypertension, hyperlipidemia, osteoarthritis, ambulatory dysfunction, chronic obstructive pulmonary diseaseMedications: ● Rivastigmine 6 mg by mouth twice daily ● Lisinopril 20 mg by mouth daily ● Ezetimibe 10 mg by mouth daily ● Simvastatin 40 mg by mouth daily ● Docusate sodium 100 mg by mouth daily ● Polyethylene glycol 17 g by mouth daily – diluted in 8 oz of beverage ● Duloxetine 60 mg by mouth daily ● Artificial tears 1-2 drops into eyes PRN for dry eyes ● Oxygen 2L/NC PRN for difficulty breathing11/2 0730 Prescriptions: ● Ciprofloxacin ocular ointment 0.5-inch right eye three timesdailyClinicalJPLC.docxRelearning: Clinical Judgment Plan of Care TemplateStudent Name:CJSim™ 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 ordersCultural/Spiritual:N/ANeurological/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:STARTof Shift (CJSim™) PrioritiesRecognize & Analyze CuesPrioritize HypothesesGenerate Solutions & Take ActionsEvaluate OutcomesPriority Assessments/CuesPriority Hypotheses for Nursing CarePriority Interventions/ActionsPriority Teaching/Discharge Needs1.2.3.1.2.3.1.2.3.1.2.3.Priority Laboratory Tests/ Diagnostic CuesPriority Actual & Potential Complications/CuesPriority MedicationsPriority Collaborative Actions1.2.3.1.2.3.1.2.3.1.2.3.Vital Signs & Pertinent Lab TrendsSTARTof the Shift (CJSim™) Analysis (phase 1)ENDof the Shift (CJSim™) Analysis (phase 3)Temp: RR: 12BP: SpO2:HR:Temp: RR:BP: SpO2:HR:CJSim™ Purposeful Clinical JudgmentClinical DebriefingAnswer 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?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 different?ENDof Shift (CJSim™) Priorities — How Has Your Client Changed?Recognize & Analyze CuesPrioritize HypothesesGenerate Solutions & Take ActionsEvaluate OutcomesPriority Assessments/CuesPriority Hypotheses for Nursing CarePriority Interventions/ActionsPriority Teaching/Discharge Needs1.2.3.1.2.3.1.2.3.1.2.3.Priority Laboratory Tests/ Diagnostic CuesPriority Actual & Potential Complications/CuesPriority MedicationsPriority Collaborative Actions1.2.3.4.5.6.1.2.3.1.2.3.CONSIDER QUESTIONS Document the Answers to Your Questions HereConsider Questions from CJSim™ Question #1Consider Questions from CJSim™ Question #2Consider Questions from CJSim™ Question #31.2.3.1.2.3.1.2.3.Nurse Think® CJSimTM Reflection ExerciseAssignment: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:· What additional information would you need to provide more comprehensive care for the client?· What could you have done better or differently to improve the outcome? Why?· Describe what was most challenging for you when caring for the client(s).· Identify the additional equipment, resources, or assistance needed to improve the care you provided.· Share the key areas of care that were new to you that you had not experienced before.· How will your above reflections impact your future practice and improve your clinical judgment?ReferenceNurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN.© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept23 4image1.pngTemplate2.docxThis file is too large to display.View in new window1234Bids(73)Miss DeannaDr. Ellen RMMISS HILLARY A+abdul_rehman_Emily ClareSTELLAR GEEK A+Sheryl HoganProf Double RDoctor.NamiraProWritingGuruYoung NyanyaDr. Adeline ZoeDr M. 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