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LindaMcCartchy.pdf

Name: Linda McCarthy Age: 86 years Provider: K. Townsend MD Codestatus: DNI BMI: 24.1 Allergies: penicillin, atorvastatin, red dye, latex Admitweight: 145 lbs (65.8kg)

Linda McCartchy had a rough night. She was pretty restless and only slept two hours. This morning she was having an issue with her hearing aids not working. They kept whistling. I went to change the batteries, but she was out of them. Her family will be bringing them in later today.

Nursing Assessments and notes

11/1 0700

Neuro/Cognitive: Alert and oriented to person and place. She intermittently confused and called staff by the names of her children. Speech raspy. 4/5 strength in all extremities. Cardiovascular: S1 and S2 heart sound present. Heart rate regular and even. No edema was noted. Pedal pulses +2, radial pulses +3. Capillary refill less than 3 seconds.

Respiratory: Even, regular, unlabored. Lung sounds wheezing through all lung fields. Chronic dry cough. Wears 2 L via nasal cannula chronically.

Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended, non-tender. Last bowel movement 2 days ago.

Genitourinary: Occasional stress incontinence.

Integumentary: Scattered bruising. Various stages of healing.

Sensory: Hard of hearing. Wears hearing aids and glasses.

11/1 0730

ADLs: Independent with utensil holders Activity: Ambulated 100 feet with a roller walker

11/1 0830

Nursing Note: Client resting quietly in bed. Looking out the window, not responding to staff prompts for verbal interaction. Moves all extremities appropriately. Morning medications were administered without difficulty. Able to state name but unsure of her birthday. Up in the hall with physical therapy. Shuffling gait with use of a rolling walker.

11/1 1100

Nursing Note: RN called to bedside. The client stated that the staff took her favorite earrings. Earrings were found in the client’s tissue box at the bedside.

11/1 2015

Nursing Note: Client evening hygiene offered. The client begins yelling, “No! No! No!” as staff offer to assist with teeth brushing and denture care. Attempts were made to deescalate the client and place her hearing aids so that she could hear the conversation. The client begins attempting to hit and bite staff. Client sitting in bed. Staff leave room to reduce stimulation.

11/1 2015

Neuro/Cognitive: Alert, oriented to self only. She believes it is 1965 and that there are strangers in her house. Client calling out for her mother. Extremely hard of hearing with hearing aids in place.

11/2 0700

Nursing Note: The client is awake in bed, staring around her room, rubbing her eyes, and frequently yawning. Noted to have redness and purulent drainage from right eye. Provider notified; prescriptions received.

11/2 0900

Nursing Note: Appetite poor, ate 5 small bites only, Drank a cup of juice. Weight down. Will encourage protein supplement drinks between meals.

Date Intake Source & Amount

11/1 0700 Oral 240 mL

11/1 0900

Client Information: Medical History: Presbyopia, bilateral cataracts, Alzheimer’s dementia, hearing loss, hypertension, hyperlipidemia, osteoarthritis, ambulatory dysfunction, chronic obstructive pulmonary disease

Medications: ● Rivastigmine 6 mg by mouth twice daily ● Lisinopril 20 mg by mouth daily ● Ezetimibe 10 mg by mouth daily ● Simvastatin 40 mg by mouth daily ● Docusate sodium 100 mg by mouth daily ● Polyethylene glycol 17 g by mouth daily – diluted in 8 oz of beverage ● Duloxetine 60 mg by mouth daily ● Artificial tears 1-2 drops into eyes PRN for dry eyes ● Oxygen 2L/NC PRN for difficulty breathing

11/2 0730 Prescriptions: ● Ciprofloxacin ocular ointment 0.5-inch right eye three times

daily

ClinicalJPLC2.docx

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:

N/A

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

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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)

Temp: RR: 12

BP: SpO2:

HR:

Temp: RR:

BP: SpO2:

HR:

CJSim™ Purposeful Clinical Judgment

Clinical Debriefing

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?

3. Prioritize Hypothesis — What could be causing the changes?

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

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?

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?

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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2.

3.

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2.

3.

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3.

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2.

3.

Priority Laboratory Tests/ Diagnostic Cues

Priority Actual & Potential Complications/Cues

Priority Medications

Priority Collaborative Actions

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2.

3.

4.

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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.

© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept23 4

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