Clinical Judgment Plan of Care Template

need one care plan done
need one care plan done 1 Relearning: Clinical Judgment Plan of Care Template

Student 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 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

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

Priority Laboratory Tests/ Diagnostic Cues

Priority Actual & Potential Complications/Cues

Priority Medications

Priority Collaborative Actions

Vital Signs & Pertinent Lab Trends

START of the Shift (CJSim™) Analysis (phase 1)

END of the Shift (CJSim™) Analysis (phase 3)

CJSim™ Purposeful Clinical Judgment

Clinical Debriefing

Answer these questions about today’s client:

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

Analyze Cues — How are the changes important or significant?

Prioritize Hypothesis — What could be causing the changes?

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

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

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:

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?

Compare this client with the “textbook”. What was the same and different?

END of Shift (CJSim™) Priorities — How Has Your Client Changed?

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

Priority Laboratory Tests/ Diagnostic Cues

Priority Actual & Potential Complications/Cues

Priority Medications

Priority Collaborative Actions

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

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 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?

Reference

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

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