Assignment Prompt & Instructions
– 2 years ago
**files (2)**
– ## Relearning_Clinical_Judgment_Plan_of_Care_Template_July241.docx
– CLEnote.docx
**## Relearning_Clinical_Judgment_Plan_of_Care_Template_July241.docx**
### 
### Relearning: Clinical Judgment Plan of Care Template
| | |
| — | — |
| Student Name: <br>Client Initials: <br>Age/DOB: <br>Allergies: <br>BSA/BMI: Code Status: | Date of Admission: <br>Date of Care: <br>Admitting Diagnosis: <br>Comorbidities: <br>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: <br> <br>Neurological/Cognition/Coping/Adaptation/Function:<br> <br>Nutrition/Elimination:<br> <br>Fluid/Electrolytes/Acid-Base:<br> <br>Gas Exchange/Perfusion:<br> <br>Glucose Regulation: | Health Promotion/Development:<br> <br>Infection/Immunity/Inflammation:<br> <br>Mobility:<br> <br>Pain/Comfort/Tissue Integrity:<br> <br>Safety:<br> <br>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. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| **Priority Laboratory Tests/ Diagnostic Cues** | **Priority Actual & Potential Complications/Cues** | **Priority Medications** | **Priority Collaborative Actions** |
| 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| | |
| — | — |
| 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) |
| **Answer these questions about today's client:**<br>1. <br>**Recognize Cues** — <br>_Explain any assessment changes since the start of shift._<br>2. <br>**Analyze Cues** — <br>_How are the changes important or significant?_<br>3. <br>**Prioritize Hypothesis** — <br>_What could be causing the changes?_<br>4. <br>**Generate Solutions** — <br>_What can/should you do about these changes?_<br>5. <br>**Take Action** — <br>_What did I do about it? What would I do about it?_<br>6. <br>**Evaluate Outcomes** — <br>_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. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| **Priority Laboratory Tests/ Diagnostic Cues** | **Priority Actual & Potential Complications/Cues** | **Priority Medications** | **Priority Collaborative Actions** |
| 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| |
| — |
| 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:**<br>1. <br>_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.?_<br>2. <br>_Compare this client with the "textbook", what was the same and what was different?_ |
| | | |
| — | — | — |
| CONSIDER QUESTIONS Document the Answers to Your Questions Here |
| **Consider Questions from CJSim** ™<br>**Question #1** | **Consider Questions from CJSim** ™ <br>**Question #2** | **Consider Questions from CJSim** ™<br>**Question #3** |
| 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| |
| — |
| Reflection Exercise (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:**<br>1. <br>_What additional information would you need to provide more comprehensive care for the client?_<br>2. <br>_What could you have done better or differently to improve the outcome? Why?_<br>3. <br>_Describe what was most challenging for you when caring for the clients in the CJSim™?_<br>4. <br>_Identify the additional equipment, resources, or assistance needed to improve the care you provided._<br>5. <br>_Share the key areas of care that were new to you that you had not experienced before._<br>6. <br>_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.
Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 1
**image1.png**
**image2.jpg**
**CLEnote.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/clenote-docx-10206051)
**CLEnote.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/clenote-docx-10206051)
**## Relearning_Clinical_Judgment_Plan_of_Care_Template_July241.docx**
### 
### Relearning: Clinical Judgment Plan of Care Template
| | |
| — | — |
| Student Name: <br>Client Initials: <br>Age/DOB: <br>Allergies: <br>BSA/BMI: Code Status: | Date of Admission: <br>Date of Care: <br>Admitting Diagnosis: <br>Comorbidities: <br>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: <br> <br>Neurological/Cognition/Coping/Adaptation/Function:<br> <br>Nutrition/Elimination:<br> <br>Fluid/Electrolytes/Acid-Base:<br> <br>Gas Exchange/Perfusion:<br> <br>Glucose Regulation: | Health Promotion/Development:<br> <br>Infection/Immunity/Inflammation:<br> <br>Mobility:<br> <br>Pain/Comfort/Tissue Integrity:<br> <br>Safety:<br> <br>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. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| **Priority Laboratory Tests/ Diagnostic Cues** | **Priority Actual & Potential Complications/Cues** | **Priority Medications** | **Priority Collaborative Actions** |
| 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| | |
| — | — |
| 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) |
| **Answer these questions about today's client:**<br>1. <br>**Recognize Cues** — <br>_Explain any assessment changes since the start of shift._<br>2. <br>**Analyze Cues** — <br>_How are the changes important or significant?_<br>3. <br>**Prioritize Hypothesis** — <br>_What could be causing the changes?_<br>4. <br>**Generate Solutions** — <br>_What can/should you do about these changes?_<br>5. <br>**Take Action** — <br>_What did I do about it? What would I do about it?_<br>6. <br>**Evaluate Outcomes** — <br>_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. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| **Priority Laboratory Tests/ Diagnostic Cues** | **Priority Actual & Potential Complications/Cues** | **Priority Medications** | **Priority Collaborative Actions** |
| 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| |
| — |
| 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:**<br>1. <br>_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.?_<br>2. <br>_Compare this client with the "textbook", what was the same and what was different?_ |
| | | |
| — | — | — |
| CONSIDER QUESTIONS Document the Answers to Your Questions Here |
| **Consider Questions from CJSim** ™<br>**Question #1** | **Consider Questions from CJSim** ™ <br>**Question #2** | **Consider Questions from CJSim** ™<br>**Question #3** |
| 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| |
| — |
| Reflection Exercise (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:**<br>1. <br>_What additional information would you need to provide more comprehensive care for the client?_<br>2. <br>_What could you have done better or differently to improve the outcome? Why?_<br>3. <br>_Describe what was most challenging for you when caring for the clients in the CJSim™?_<br>4. <br>_Identify the additional equipment, resources, or assistance needed to improve the care you provided._<br>5. <br>_Share the key areas of care that were new to you that you had not experienced before._<br>6. <br>_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.
Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 1
**image1.png**
**image2.jpg**
**CLEnote.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/clenote-docx-10206051)
**## Relearning_Clinical_Judgment_Plan_of_Care_Template_July241.docx**
### 
### Relearning: Clinical Judgment Plan of Care Template
| | |
| — | — |
| Student Name: <br>Client Initials: <br>Age/DOB: <br>Allergies: <br>BSA/BMI: Code Status: | Date of Admission: <br>Date of Care: <br>Admitting Diagnosis: <br>Comorbidities: <br>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: <br> <br>Neurological/Cognition/Coping/Adaptation/Function:<br> <br>Nutrition/Elimination:<br> <br>Fluid/Electrolytes/Acid-Base:<br> <br>Gas Exchange/Perfusion:<br> <br>Glucose Regulation: | Health Promotion/Development:<br> <br>Infection/Immunity/Inflammation:<br> <br>Mobility:<br> <br>Pain/Comfort/Tissue Integrity:<br> <br>Safety:<br> <br>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. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| **Priority Laboratory Tests/ Diagnostic Cues** | **Priority Actual & Potential Complications/Cues** | **Priority Medications** | **Priority Collaborative Actions** |
| 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| | |
| — | — |
| 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) |
| **Answer these questions about today's client:**<br>1. <br>**Recognize Cues** — <br>_Explain any assessment changes since the start of shift._<br>2. <br>**Analyze Cues** — <br>_How are the changes important or significant?_<br>3. <br>**Prioritize Hypothesis** — <br>_What could be causing the changes?_<br>4. <br>**Generate Solutions** — <br>_What can/should you do about these changes?_<br>5. <br>**Take Action** — <br>_What did I do about it? What would I do about it?_<br>6. <br>**Evaluate Outcomes** — <br>_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. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| **Priority Laboratory Tests/ Diagnostic Cues** | **Priority Actual & Potential Complications/Cues** | **Priority Medications** | **Priority Collaborative Actions** |
| 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| |
| — |
| 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:**<br>1. <br>_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.?_<br>2. <br>_Compare this client with the "textbook", what was the same and what was different?_ |
| | | |
| — | — | — |
| CONSIDER QUESTIONS Document the Answers to Your Questions Here |
| **Consider Questions from CJSim** ™<br>**Question #1** | **Consider Questions from CJSim** ™ <br>**Question #2** | **Consider Questions from CJSim** ™<br>**Question #3** |
| 1. <br>2. <br>3. | 1. <br>2. <br>3. | 1. <br>2. <br>3. |
| |
| — |
| Reflection Exercise (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:**<br>1. <br>_What additional information would you need to provide more comprehensive care for the client?_<br>2. <br>_What could you have done better or differently to improve the outcome? Why?_<br>3. <br>_Describe what was most challenging for you when caring for the clients in the CJSim™?_<br>4. <br>_Identify the additional equipment, resources, or assistance needed to improve the care you provided._<br>5. <br>_Share the key areas of care that were new to you that you had not experienced before._<br>6. <br>_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.
Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 1
**image1.png**
**image2.jpg**
**CLEnote.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/clenote-docx-10206051)