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Clinical Judgment Plan of Care

Clinical Judgment Plan of Care

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:

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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
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Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions
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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:

1.   Recognize CuesExplain any assessment changes since the start of shift.

2.   Analyze CuesHow are the changes important or significant?

3.   Prioritize HypothesisWhat could be causing the changes?

4.   Generate SolutionsWhat can/should you do about these changes?

5.   Take ActionWhat did I do about it? What would I do about it?

6.   Evaluate OutcomesDid 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?

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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
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Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions
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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?
  • 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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