relearning clinical judgement plan of care templat
alain king 54 year old alllergy nitroglycerin
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NURS MISC (NURSMISC)
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Relearning: Clinical Judgment Plan of Care Template
CLIENT 1; Alain King
Student Name: Date of Admission: N/A
Client Initials: A.K Date of Care: N/A
Age/DOB: 54 years old Admitting Diagnosis: N/A
Allergies: Nitroglycerin, Sulfa drugs Comorbidities: N/A
BSA/BMI: 24.5 Code Status: Full Code Planned Treatments/Procedures: Increase dosage of
furosemide for two days
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and
provider orders
Cultural/Spiritual: N/A Health Promotion/Development: N/A
Nutrition/Elimination: Provide education on dietary choices to Mobility: N/A
manage fluid intake.
Pain/Comfort/Tissue Integrity: N/A
Fluid/Electrolytes/Acid-Base: Monitor fluid intake and output,
especially with increased furosemide dosage.
Safety: No changes
Gas Exchange/Perfusion: Monitor for dyspnea on exertion and
signs of respiratory distress. Other: N/A
Glucose Regulation: No changes
START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase 1/Question 1
section)
Generate Solutions & Take
Recognize & Analyze Cues Prioritize Hypotheses Evaluate Outcomes
Actions
Priority Priority Hypotheses for Priority Priority
Assessments/Cues Nursing Care Interventions/Actions Teaching/Discharge Needs
1. Educate the patient on
1. Assess vital signs, 1. Administer prescribed medication management,
including blood pressure, 1. Exacerbation of heart failure medications such as including proper use and
heart rate, respiratory diuretics or potential side effects.
rate, and oxygen 2. Exacerbation of chronic bronchodilators. 2. Teach self-monitoring
saturation. obstructive pulmonary 2. Provide oxygen therapy if techniques for weight, fluid
2. Auscultate lung sounds for disease (COPD). indicated. intake, and symptoms.
crackles or wheezing. 3. Assist with activities of 3. Provide dietary education
3. Monitor fluid intake and 3. daily living to conserve to manage sodium intake
output. energy. and fluid retention
, Relearning: Clinical Judgment Plan of Care Template
START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase 1/Question 1
section)
1. Educate the patient on 1. Furosemide (diuretic) to
4. Fluid overload leading to reduce fluid volume.
medication management,
including proper use and worsening edema or 1. Fluid overload leading to
2. Beta-agonists or
potential side effects. pulmonary congestion. worsening edema or
anticholinergics
5. Electrolyte imbalances, pulmonary congestion.
2. Teach self-monitoring (bronchodilators) to
2. Electrolyte imbalances,
techniques for weight, particularly hypokalemia due alleviate respiratory
particularly hypokalemia
to diuretic use. symptoms.
fluid intake, and due to diuretic use.
symptoms. 6. Respiratory distress or 3. Respiratory distress or
3. ACE inhibitors or ARBs exacerbation of COPD
exacerbation of COPD
3. Provide dietary education (angiotensin receptor symptoms
to manage sodium intake symptoms blockers) to manage heart
and fluid retention failure symptoms
, Relearning: Clinical Judgment Plan of Care Template
Vital Signs & Pertinent Lab Trends
START of the Shift (CJSim™) Analysis (phase 1/Question 1 END of the Shift (CJSim™) Analysis (phase 3/Question 3
section) section)
1. Recognize & Analyze Cues: For Alain King at the close of the shift, focusing on
Alain reports occasional shortness of breath assessing the patient's response to treatment, evaluating
with exertion. outcomes, and preparing for discharge or ongoing care.
Recent weight gain from 175.8 lbs to 180.2
lbs.
Chronic dry cough.
2. Prioritize Hypotheses for Nursing Care:
Exacerbation of heart failure.
Exacerbation of chronic obstructive
pulmonary disease (COPD).
3. Generate Solutions & Take Actions:
Assess vital signs including blood pressure,
heart rate, respiratory rate, and oxygen
saturation.
Auscultate lung sounds to assess for
crackles or wheezing.
Monitor fluid intake and output.
4. Evaluate Outcomes:
Monitor changes in vital signs, weight, and
symptoms throughout the shift.
Assess the effectiveness of prescribed
medications.
Evaluate the patient's response to
interventions and adjust the plan of care
accordingly.
(CJSim™) Mid-Shift Purposeful Clinical Judgment (Complete after Clinical Debriefing (Complete these questions after completely
reviewing EHR/Question 2 section) caring for the client and answering the questions for the client)
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