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CaraJett.pdf

Name: Cara Jett Age: 34 years Provider: R. Mcbride NP Allergies: NKA Admit weight: 102 Ibs (46.3kg) BMI: 17.5 Code status: full code

I just can’t eat. Every time I do, I have horrible pain in my stomach. My family keeps accusing me of having an eating disorder. It’s not that I don't want to eat. It's that I can’t without pain and diarrhea!

4/12 1345

Nursing Note: Client presents for ongoing stomach pain after eating. Current BMI of 17.5. Last recorded BMI from 3 years ago was 22.2. States pain has been ongoing for several years, more severe as of late yesterday. Client skipped lunch today. Current abdominal pain is 2/10. States that she has tried using over-the-counter pain relievers to help with the abdominal pain, but this has not been successful. Rates 2/10 RLQ abdominal pain.

4/12 1355

Neuro/Cognitive: Alert and oriented x4.

Cardiovascular: Regular heartbeat with S1 and S2 heard. No edema present. Capillary refill <3 seconds. Bilateral pedal and radial pulses +3.

Respiratory: Lungs clear bilaterally.

Gastrointestinal: Abdomen flat, firm, hyperactive bowel sounds x 4 quadrants. Tender in RLQ. Denies nausea. Last bowel movement was 1045 today. Loose, brown, mucous looking – per client. Three loose stools today so far.

Genitourinary: Continent. No pain or burning when urinating

Musculoskeletal: Muscle atrophy present. +5 strengths for all extremities. Tenting present on arm and collarbone.

Psychosocial: Anxious. Becomes tearful several times during visit. States her family is accusing her of having an eating disorder.

5/7 1435

Nursing Note: Follow-Up Appointment with Gastrointestinal Specialist

Diagnosis: New Crohn’s disease.

Follow-up appointment after colonoscopy and upper GI procedure. Had a CT scan of the abdomen completed after the procedure. Rates 4/10 abdominal pain. Client is taking prednisone and metronidazole as prescribed by primary care provider for Crohn's disease.

Date Temp HR RR BP SpO2 O2

4/12 1345 96.8 °F

(36.0 °C)

78 18 102/54 100% RA

5/1 0945 97.2 °F

(36.2 °C)

64 12 94/45 89% RA

5/1 1000 97.2 °F

(36.2 °C)

69 12 104/50 92% RA

5/1 1015 97.2 °F

(36.2 °C)

72 14 110/52 94% RA

5/7 1430 98.6 °F

(37.0 °C)

88 18 138/78 99% RA

Date Diagnostic Test Findings

5/1 1015

Upper GI Colonoscopy

No abnormal findings.

Small ulcer found in the transverse portion of the large intestine with evidence of more in the small intestine. Further testing, including an MRI, is highly suggested.

5/5 1500

CT Scan of Abdomen

Impression: Thickening of the wall of the small intestine present. Three small abscesses noted by entrance to the colon correlating with recent gastric studies. No fistula apparent.

5/1 0945

Endoscopy Center Nursing Note:

Client has completed an upper GI study and a colonoscopy with no noticeable complications. Vitals stable. Drowsy but easily woken. Oriented x4.

5/1 1000

Endoscopy Center Nursing Note:

Vitals remain stable. Client drank 60mL of clear soda and two bites of graham cracker. Swallow and gag reflex present. Mild 2/10 throat discomfort present. Driver present and atbedside.

5/1 1015

Endoscopy Center Nursing Note:

Client discharged to home in care of mother, Nancy. Follow-up appointment made.

Template2.docx

Relearning: Clinical Judgment Plan of Care Template

Student Name: OA

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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2.

3.

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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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2.

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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6.

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2.

3.

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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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