Real Due
QueenBee2
3 years ago
40
files (4)CaraJett.pdf
LindaMcCartchy.pdf
ClinicalJPLC.docx
- Template2.docx
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.
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
ClinicalJPLC.docx
Relearning: Clinical Judgment Plan of Care Template
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Student Name: CJSim™ Client Initials: Age/DOB: Allergies: BSA/BMI: Code Status: |
Date of Admission: Date of Care: Admitting Diagnosis: Comorbidities: Planned Treatments/Procedures: |
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Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders |
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Cultural/Spiritual: N/A
Neurological/Cognition/Coping/Adaptation/Function:
Nutrition/Elimination:
Fluid/Electrolytes/Acid-Base:
Gas Exchange/Perfusion:
Glucose Regulation:
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Health Promotion/Development:
Infection/Immunity/Inflammation:
Mobility:
Pain/Comfort/Tissue Integrity:
Safety:
Other: |
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START of Shift (CJSim™) Priorities |
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Recognize & Analyze Cues |
Prioritize Hypotheses |
Generate Solutions & Take Actions |
Evaluate Outcomes |
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Priority Assessments/Cues |
Priority Hypotheses for Nursing Care |
Priority Interventions/Actions |
Priority Teaching/Discharge Needs |
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1. 2. 3. |
1. 2. 3. |
1. 2. 3. |
1. 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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1. 2.
3. |
1. 2. 3.
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1. 2. 3. |
1. 2. 3. |
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Vital Signs & Pertinent Lab Trends |
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START of the Shift (CJSim™) Analysis (phase 1) |
END of the Shift (CJSim™) Analysis (phase 3) |
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Temp: RR: 12 BP: SpO2: HR: |
Temp: RR: BP: SpO2: HR:
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CJSim™ Purposeful Clinical Judgment |
Clinical Debriefing |
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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? |
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END of Shift (CJSim™) Priorities — How Has Your Client Changed? |
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Recognize & Analyze Cues |
Prioritize Hypotheses |
Generate Solutions & Take Actions |
Evaluate Outcomes |
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Priority Assessments/Cues |
Priority Hypotheses for Nursing Care |
Priority Interventions/Actions |
Priority Teaching/Discharge Needs |
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1. 2. 3. |
1. 2. 3. |
1. 2. 3. |
1. 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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1. 2.
3. |
4. 5. 6.
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1. 2. 3. |
1. 2. 3. |
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CONSIDER QUESTIONS Document the Answers to Your Questions Here |
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Consider Questions from CJSim™ Question #1 |
Consider Questions from CJSim™ Question #2 |
Consider Questions from CJSim™ Question #3 |
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1. 2. 3. |
1. 2. 3. |
1. 2. 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.
© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept23 4
