| 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 |
| 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.
