| 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: |
| 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 |
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| Priority Laboratory Tests/ Diagnostic Cues | Priority Actual & Potential Complications/Cues | Priority Medications | Priority Collaborative Actions |
| 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: Recognize Cues — Explain any assessment changes since the start of 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 are why not? What should have been done differently? | Answer these questions about today’s client: 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? 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 |
| | |||
| Priority Laboratory Tests/ Diagnostic Cues | Priority Actual & Potential Complications/Cues | Priority Medications | Priority Collaborative Actions |
| 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 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.
