4 Care plans based on virtual patient scenarios

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