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PLEASE I attached two patient information plus the template you have to use for each patient thank you
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Nan1e: Eleanor Volke Age: 97 years
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Adn1it Wt: 98 lbs
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Provider: K. Childers
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BMI: 17. 9
Allergies: NKDA
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Nan1e: Eleanor Volke Age: 97 years
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Provider: K. Childers .,
MD
BMI: 17.9
Allergies: NKDA
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Cataract surgery (age 71)
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Relearning: Clinical Judgment Plan of Care Template
Student Name:
Client Initials:
Age/DOB:
Allergies:
BSA/BMI:
Date of Admission:
Date of Care:
Admitting Diagnosis:
Comorbidities:
Planned Treatments/Procedures:
Code Status:
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders
Cultural/Spiritual:
Health Promotion/Development:
Neurological/Cognition/Coping/Adaptation/Function:
Infection/Immunity/Inflammation:
Nutrition/Elimination:
Mobility:
Fluid/Electrolytes/Acid-Base:
Pain/Comfort/Tissue Integrity:
Gas Exchange/Perfusion:
Safety:
Glucose Regulation:
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
1.
1.
1.
1.
2.
2.
2.
2.
3.
3.
3.
3.
Priority Laboratory Tests/
Diagnostic Cues
Priority Actual & Potential
Complications/Cues
Priority Medications
Priority Collaborative Actions
1.
1.
1.
1.
2.
2.
2.
2.
3.
3.
3.
3.
1
© 2023 Chamberlain University. All Rights Reserved.
Relearning Clinical Judgment Plan of Care Template-Sept2023 v1.1
Relearning: Clinical Judgment Plan of Care Template
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)
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. Recognize Cues — Explain any assessment changes since the start of shift.
2. Analyze Cues — How are the changes important or significant?
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?
3. Prioritize Hypothesis — What could be causing the changes?
4. Generate Solutions — What can/should you do about these changes?
2. Compare this client with the "textbook" , what was the same and what
was different?
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
1.
1.
1.
1.
2.
2.
2.
2.
3.
3.
3.
3.
Priority Laboratory Tests/
Diagnostic Cues
Priority Actual & Potential
Complications/Cues
Priority Medications
Priority Collaborative Actions
4.
5.
1.
1.
1.
2.
2.
2.
3.
3.
3.
6.
2
© 2023 Chamberlain University. All Rights Reserved.
Relearning Clinical Judgment Plan of Care Template-Sept2023 v1.1
Relearning: Clinical Judgment Plan of Care Template
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
1.
1.
1.
2.
2.
2.
3.
3.
3.
Nurse Think® CJSimTM Reflection Exercise
Assignment: 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 clients in the CJSim™?
•
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?
NurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN.
3
© 2023 Chamberlain University. All Rights Reserved.
Relearning Clinical Judgment Plan of Care Template-Sept2023 v1.1
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