| Student Name:
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: |
Nursing and HCP Collaborative Plan for Care
| 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.
2. 3. |
1.
2. 3. |
1.
2. 3. |
1.
2. 3. |
| Priority Laboratory Tests/ Diagnostic Cues | Priority Actual & Potential Complications/Cues | Priority Medications | Priority Collaborative Actions |
| 1.
2.
3. |
1.
2. 3.
|
1.
2. 3. |
1.
2. 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) | 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:
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 what was different? |
| 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.
2. 3. |
1.
2. 3. |
1.
2. 3. |
1.
2. 3. |
| Priority Laboratory Tests/ Diagnostic Cues | Priority Actual & Potential Complications/Cues | Priority Medications | Priority Collaborative Actions |
| 1.
2.
3. |
4.
5. 6.
|
1.
2. 3. |
1.
2. 3. |
| 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 |
| 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 clients in the CJSim™?
· 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?
NurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN.
Nursing and HCP Collaborative Plan for Care
1
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### Clinical Integration Care Plan Template
#### Student Information
**Student Name:** [Your Name]
**Client Initials:** [Client’s Initials]
**Age/DOB:** [Client’s Age/DOB]
**Allergies:** [Client’s Allergies]
**BSA/BMI:** [Client’s BSA/BMI]
**Code Status:** [Client’s Code Status]
**Date of Admission:** [Date]
**Date of Care:** [Date]
**Admitting Diagnosis:** [Admitting Diagnosis]
**Comorbidities:** [List of Comorbidities]
**Planned Treatments/Procedures:** [List of Planned Treatments/Procedures]
### Nursing and HCP Collaborative Plan for Care
**Priority Client Specific Information:**
– Patient’s primary health concerns and presenting symptoms.
**Nursing Actions:**
– Regular monitoring of vital signs.
– Administering prescribed medications.
– Providing patient education.
**Provider Orders:**
– Diagnostic tests (e.g., blood tests, imaging).
– Medications.
– Specific nursing interventions (e.g., wound care).
### Cultural/Spiritual Considerations
– Understand and respect the patient’s cultural beliefs and practices.
– Provide culturally appropriate education and support.
### Neurological/Cognition/Coping/Adaptation/Function
– Assess cognitive function and coping mechanisms.
– Provide support for neurological or psychological needs.
### Nutrition/Elimination
– Monitor dietary intake and nutritional status.
– Assess elimination patterns and address any issues.
### Fluid/Electrolytes/Acid-Base Balance
– Monitor fluid intake and output.
– Assess for signs of electrolyte imbalances.
### Gas Exchange/Perfusion
– Monitor respiratory status.
– Assess for adequate tissue perfusion.
### Glucose Regulation
– Monitor blood glucose levels.
– Administer medications as needed to control blood sugar.
### Health Promotion/Development
– Educate the patient on healthy lifestyle choices.
– Promote preventive care and regular health screenings.
### Infection/Immunity/Inflammation
– Monitor for signs of infection.
– Implement infection control measures.
### Mobility
– Assess mobility and provide support to maintain or improve function.
### Pain/Comfort/Tissue Integrity
– Assess pain levels and provide appropriate pain management.
– Monitor skin integrity and provide wound care as needed.
### Safety
– Implement fall prevention strategies.
– Ensure a safe environment for the patient.
### Other
– Any additional specific considerations relevant to the patient’s care.
—
### START of Shift (CJSim™) Priorities
**Recognize & Analyze Cues**
**Priority Hypotheses for Nursing Care**
**Generate Solutions & Take Actions**
**Evaluate Outcomes**
#### Priority Assessments/Cues
#### Priority Hypotheses for Nursing Care
#### Priority Interventions/Actions
#### Priority Teaching/Discharge Needs
#### Priority Laboratory Tests/ Diagnostic Cues
#### Priority Actual & Potential Complications/Cues
#### Priority Medications
#### Priority Collaborative Actions
#### Vital Signs & Pertinent Lab Trends
– Record relevant vital signs and laboratory results.
### START of the Shift (CJSim™) Analysis
### END of the Shift (CJSim™) Analysis
### (CJSim™) Mid-Shift Purposeful Clinical Judgment
#### Clinical Debriefing
**Recognize Cues:**
– Explain any assessment changes since the start of the shift.
**Analyze Cues:**
– How are the changes important or significant?
**Prioritize Hypothesis:**
– What could be causing the changes?
**Generate Solutions:**
– What can/should you do about these changes?
**Take Action:**
– What did I do about it? What would I do about it?
**Evaluate Outcomes:**
– Did my actions make a difference? Why or why not? What should have been done differently?
**Compare with Previous Client:**
– Similarities and differences in condition, assessment findings, provider prescriptions, medications, etc.
**Compare with Textbook:**
– Similarities and differences in condition and treatment.
### END of Shift (CJSim™) Priorities
**Recognize & Analyze Cues**
**Priority Hypotheses for Nursing Care**
**Generate Solutions & Take Actions**
**Evaluate Outcomes**
#### Priority Assessments/Cues
#### Priority Hypotheses for Nursing Care
#### Priority Interventions/Actions
#### Priority Teaching/Discharge Needs
#### Priority Laboratory Tests/ Diagnostic Cues
#### Priority Actual & Potential Complications/Cues
#### Priority Medications
#### Priority Collaborative Actions
### CONSIDER QUESTIONS
**Consider Questions from CJSim™ Question #1**
**Consider Questions from CJSim™ Question #2**
**Consider Questions from CJSim™ Question #3**
### Nurse Think® CJSim™ Reflection Exercise
#### Reflection Questions
**Additional Information Needed:**
– What additional information would you need to provide more comprehensive care for the client?
**Improvements:**
– What could you have done better or differently to improve the outcome? Why?
**Challenges Faced:**
– Describe what was most challenging for you when caring for the clients in the CJSim™.
**Additional Resources:**
– Identify the additional equipment, resources, or assistance needed to improve the care you provided.
**New Areas of Care:**
– Share the key areas of care that were new to you that you had not experienced before.
**Impact on Future Practice:**
– How will your above reflections impact your future practice and improve your clinical judgment?
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