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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
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Priority Laboratory Tests/
Diagnostic Cues
Priority Actual & Potential
Complications/Cues
Priority Medications
Priority Collaborative Actions
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© 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.
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3.
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Priority Laboratory Tests/
Diagnostic Cues
Priority Actual & Potential
Complications/Cues
Priority Medications
Priority Collaborative Actions
4.
5.
1.
1.
1.
2.
2.
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3.
3.
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6.
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© 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
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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?
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What could you have done better or differently to improve the outcome? Why?
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Describe what was most challenging for you when caring for the clients in the CJSim™?
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Identify the additional equipment, resources, or assistance needed to improve the care you provided.
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Share the key areas of care that were new to you that you had not experienced before.
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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
Name: Trevor Simbly
Age: 34 years
Provider: S. Young MD
Allergies: penicillin, lisinopril
Code Status: Full Code
Admit Wt: 236.06 lbs (107.3 kg)
BMI: 33.9
Neuro/Cognitive: Sleepy but arousable. Partner says he was confused about the time and place during
the night. He is currently oriented to person, place, and day, but not to time.
Respiratory: Lung sounds are clear, and lung expansion is equal bilaterally. Deep, labored breathing
without accessory muscle use.
Cardiovascular: Tachycardia with a normal rhythm. No S3 or S4 sounds were heard. Radial and pedal
pulse +2. Cap refills < 3 seconds. Extremities cool to touch. Gastrointestinal: Abdomen large, tender, soft. The client has had 3 emesis since the admission of small amounts of clear fluid - abdominal pain 5/10 with palpation to LUQ and RUQ. Bowel sounds hypoactive and audible in all quadrants. He hasn't had anything to eat or drink since last night. Date 7/26 0900 Temp 99.2 °F VITAL SIGN TREND HR RR 115 24 BP 108/74 SpO2 96% (37.3 °C) Date 7/26 0900 OTHER TRENDING DATA Glucose 600 mg/dL COLLABORATIVE CARE 7/26 0900 Medical History: Hypertension, diagnosed 6 years ago, Diabetes type 2 diagnosed 14 years ago and became insulin dependent 5 years ago, GERD diagnosis 3 years ago. Surgical History: Appendectomy at age 16. O2 RA Date Lab Normal Result 7/26 0915 Arterial Blood Gas (ABG) pH-7.35-7.45 pO2-80-100 mmHg pCO2-35-45 mmHg HCO3-22-26 mEq/L 7.28 L 83 35 18 L 7/26 0915 Potassium 3.5-5.0 mEq/L 5.6 H Sodium 136-145 mEq/L 147 Calcium 9.0-10.5 mg/dL 10.0 Chloride 98-106 mEq/L 99 Magnesium 1.5-2.4 mEq/L 1.9 Phosphorus 3.0-4.5 mg/dL 3.3 Glucose 70-100 mg/dL 615 H Arterial Blood Gas (ABG) pH-7.35-7.45 pO2-80-100 mmHg pCO2-35-45 mmHg HCO3-22-26 mEq/L 7.38 L 87 32 L 25 7/26 1130 7/26 0930 Provider Prescriptions: • Insert peripheral IV • 0.9% Normal saline 1000 mL bolus IV – infusion rate 1000 mL/hour • After bolus, infuse D5/.45 NS at 150 mL/hr • Ondansetron 4 mg IV q4h PRN for nausea • Regular insulin IV – titrate per sliding scale • Glargine insulin infusion as per protocol • Blood glucose checks q15 minutes. • Regular diet • Bed rest with bathroom privileges 7/26 1000 Provider Prescriptions: • 0.9% NaCl at 150 mL/hour after bolus. • Hold glargine insulin infusion • Nothing by mouth OTHER TRENDING DATA Date Glucose 7/26 0900 600 mg/dL 7/26 0930 615 mg/dL 7/26 1130 490 mg/dL Name: Jake Abbott Age: 28 years Provider: A. Nichols MD Allergies: NKA Code Status: Full Code Admit Wt: 190 lbs (86.2 kg) BMI: 25.1 Nursing Note: Client was playing basketball, injured his right ankle, “I made this great jump shot, and when I landed, I felt something pop in my right ankle.” Right ankle with slight swelling, no obvious deformity, toes warm with capillary refill less than 3 seconds. +active ROM in toes and denies increased numbness or change in tingling. Has had numbness and tingling in both feet for the past year. Reports doing daily capillary blood glucose monitoring but does not always follow a diet plan. “It’s hard, I don’t want my friends to think of me as sick, so I eat what they eat. I take about the same amount of insulin every day.” Neuro/Cognitive: Alert and oriented x 4, pupils 4 mm and PERRLA. Grips equal and strong. Right lower extremity, non-weight-bearing, toes wiggle, full weight-bearing with left leg. Bilateral foot numbness and tingling x 1 year. Cardiovascular: S1/S2, regular rhythm. Respiratory: Lungs clear, no cough noted or reported. Gastrointestinal: Abdomen soft with active bowel sounds x 4 quadrants. Last bowel movement was today. Integumentary: Skin appears intact. +blue bruising, +swelling to right lateral ankle. Nursing Note: Client inquiring about snacks, “I haven’t eaten today, and I feel dizzy. I get like this if I don’t eat.” Blood glucose: 82. Client took NPH insulin at approximately 0800, did not eat. Client unsure how much insulin he took, “I was in a hurry, but took about the same number on the syringe as I usually do.” Snack of turkey sandwich and milk, client, ate 100%. Nursing Note: Client reports seeing a provider on the other side of town for diabetes management every six months. Has not had blood drawn in the past year, “I couldn’t get to the lab.” Completes capillary blood glucose checks about once a day, time varies, sometimes before he eats and sometimes after. “I didn’t know that it mattered; my mom never did that. Maybe that is why I sometimes feel so weak and dizzy.” Denies ever having diabetic education as a teen or an adult, saying it was never offered and he didn’t know he needed it. Provider informed of client conversation. Nursing Note: Client return demonstrates safe crutch walking and elastic bandage application. Discharge instructions reviewed with the client. Client verbalized understanding of discharge instructions and will make appointments with clinic dietitian and diabetic educator. Blood glucose 135 on discharge. VITAL SIGN TREND Date Temp HR RR BP SpO2 O2 4/3 1000 98.5 °F (36.9 °C) 80 16 140/82 99% RA BLOOD GLUCOSE LOG Date Result Notes 4/3 1000 224 Fasting, last food was ice cream at 4/2 2230 4/3 1145 84 PROVIDER PRESCRIPTIONS & NOTES 4/3 1100 Prescriptions: • X-ray left lower extremity, including foot - R/O fracture Diagnoses: Soft tissue injury, unmanaged diabetes Discharge Instructions: • No weight-bearing on right foot until seen by primary provider next week • Nurse to provide crutches and teach crutch walking, assess safety • Client to do capillary blood glucose before eating and taking insulin • Client to keep record of capillary blood glucose and food diary • Client to return to this clinic next week if unable to see provider • Referral to clinic dietitian and diabetic educator for teaching • Make appointment with clinic neurologist for evaluation of tingling in feet • Client to elevate foot to decrease swelling • Ibuprofen 400 mg by mouth q8h PRN for ankle pain • Nurse to demonstrate proper use of elastic bandage to foot/ankle, client to do return demonstration of wrapping • Nurse to do blood glucose and instruct on signs and symptoms of high and low blood sugar and when to contact EMS Purchase answer to see full attachment