JUST COMPLETE THE TEMPLATE

Student Name: Mame Sy

CJSim™ Client Initials: Floyd Dunmire

Age/DOB: 58 years old

Allergies: NKA

BSA/BMI: 30.1 Code Status: Full Code

Date of Admission: 10/19/1630

Date of Care: 10/19/1630

Admitting Diagnosis: Hepatics ascites

Comorbidities: alcoholism, hypertension

Planned Treatments/Procedures: Medications, smoking cessation

Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders

Cultural/Spiritual: Client is a recent immigrant from Mexico and practices Catholicism. Nursing will ensure care accommodates client's spiritual practices and beliefs. Translator services will be utilized as needed. Provider aware of potential effects of stress from immigration on health and will screen for additional social services if indicated.

Neurological/Cognition/Coping/Adaptation/Function: Client recently recovered from brief encephalopathic episode, now neuro back to baseline. Nursing reinforcing teaching on symptom reporting and medication adherence. Provider monitoring for recurring confusion and will adjust treatment if needed.

Nutrition/Elimination: Soft diet ordered to prevent gastrointestinal stress. Nursing assessing intake, weight and stool patterns. Provider will modify restrictions or add supplements as client's condition requires.

Fluid/Electrolytes/Acid-Base: Intravenous fluids prescribed for dehydration upon admission. Nursing adhering to intake/output metrics and labs. Provider overseeing fluid management plan and replacing electrolytes as indicated.

Gas Exchange/Perfusion: Client recovering from pulmonary edema related to liver dysfunction. O2 administration continuing until stable off supplementary support. Nursing monitoring respiratory status via vital signs, assessments. Provider weaning oxygen as tolerated and arranging follow up CXR prior to discharge.

Glucose Regulation: Diabetes newly diagnosed, client learning self-care. Nursing reinforcing education on medications, monitoring, prevention of complications. Provider collaborating with diabetes educator for outpatient referrals.

Health Promotion/Development: Cirrhosis lead to osteopenia, risk of fractures from falls. Nursing discussing dietary and lifestyle modifications like exercise to improve bone health. Provider referred client to hepatology and nutritionist for long-term management counseling.

Infection/Immunity/Inflammation: Immunocompromised due to liver disease, high infection risk. Nursing screening for symptoms and reinforcing hygiene. Provider expedited testing if fever arises and administering targeted antibiotics.

Mobility: Weak from encephalopathy, but regaining strength. Nursing assisting until independent and instructing on safety and activity pacing. Provider referred to physical therapy for evaluation.

Pain/Comfort/Tissue Integrity: Discomfort managed with scheduled pain medication. Nursing vigilant for distress and side effects, ensuring comfort strategies applied. Provider alternating types of analgesics to balance efficacy and tolerability.

Safety: Fall precaution in effect, padded floors, rails, low bed. Nursing conducting rounds, range of motion. Provider discussing modification of home environment prior to discharge planning.

Other: Anemia present due to blood loss from varices. Nursing administering iron supplements and observing for signs of intolerance. Client made aware variceal bleeding risks in future. Provider scheduled for banding of varices to reduce chances of hemorrhage and arranging hematology consult for ongoing monitoring of blood counts.

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. Neurologic status - assess alertness, orientation, cognitive function for signs of worsening encephalopathy.

2. Abdominal assessment - inspect for swelling, palpate for pain/tenderness, measure girth to monitor ascites.

3. Lower extremity exam - check pedal pulses, capillary refill, measure edema and assess skin integrity.
   

1. Fluid overload - ascites may be recurrent or worsening despite treatment

2. Infection - susceptible due to cirrhosis, watch for developing SIRS cues

3. Electrolyte imbalance - monitor for signs of hypokalemia from diuretic use

1. Daily weights and assessment for fluid retention signs

2. Targeted neuro checks and infection monitoring for temp, WBC count

3. Reinforce education on diet, medications, symptom reporting

1. Review low sodium diet and fluid restrictions

2. Demonstrate medication administration techniques

3. Assess understanding of warning signs and follow up instructions

Priority Laboratory Tests/ Diagnostic Cues

Priority Actual & Potential Complications/Cues

Priority Medications

Priority Collaborative Actions

1. CBC with diff - monitor for developing infection or bleeding issues

2. Liver panel - trend liver enzymes and synthetic function to track response to treatment

3. Electrolytes - observe potassium, sodium levels with diuretic use to prevent complications

1. Bleeding - esophageal varices at high risk of hemorrhage in this population

2. Encephalopathy - past episode indicates recurrent episodes are possible

3. Non-adherence - challenge with lifestyle changes, assess understanding

1. Diuretics - assess effects and ensure dosing as prescribed

2. Supplements - administer electrolyte replacements properly

3. Antibiotics - continue course if infection treated, monitor for tolerance
   

1. Cross-check provider orders with care plan

2. Communicate changes in status promptly to healthcare team

3. Ensure discharge preparations (equipment, transportation) complete

Vital Signs & Pertinent Lab Trends

START of the Shift (CJSim™) Analysis (phase 1)

END of the Shift (CJSim™) Analysis (phase 3)

Vital signs and labs stable upon initial assessment. No new cues noted. Will continue scheduled cares and monitoring per plan of care.

Client condition unchanged over shift. Vitals, exams, labs within normal limits. Teaching reinforced adherence with diet, meds, symptom reporting. Ready for continued management at home following discharge preparations.

CJSim™ Purposeful Clinical Judgment

Clinical Debriefing

Answer these questions about today's client:

1. Recognize Cues - No notable changes in assessment findings between shifts. Vital signs stable, abdominal exam unchanged.

2. Analyze Cues - Stable presentation is reassuring, suggests treatment plan effective in managing ascites without complication.

3. Prioritize Hypothesis - N/A, no changes observed to hypothesize about.

4. Generate Solutions - Continue current monitoring and interventions per orders. Reinforce education and prepare for imminent discharge.

5. Take Action - Carried out scheduled cares and assessments. Discussed plan with team and reinforced teaching for home.

6. Evaluate Outcomes - Client progressing well without issues over shift. Goals of therapy seem achieved - ascites controlled without adverse events. No need to modify or intensify treatment at this time based on stability.

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?
   Client presentation and protocol similar to an older adult with hepatic cirrhosis I cared for previously, though they had more advanced disease with complications.

2. Compare this client with the "textbook". What was the same and different?

Client course aligned with textbook description of typical ascites management: therapeutic paracentesis, sodium restriction, diuretics and albumin for volume resuscitation. Labs did not demonstrate severe synthetic dysfunction or portal hypertension variants seen in later stages.

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. No change in level of alertness or orientation from admission.

2. Abdominal exam unchanged without increased swelling or pain.

3. Skin intact without new edema or discoloration in legs.

1. Stable clinical condition suggests effective management of ascites and liver dysfunction.

2. No new issues identified based on lacking assessment changes.

3. On track for discharge with home treatment plan in place.

1. Continue scheduled assessments per policy.

2. Reinforce teaching and support preparation for discharge.

3. Coordinate safe transition of care as outpatient.

1. Verify comprehension of diet and medication adherence

2. Review warning signs and instructions for follow up contact

3. Finalize discharge arrangements and equip client for independence

Priority Laboratory Tests/ Diagnostic Cues

Priority Actual & Potential Complications/Cues

Priority Medications

Priority Collaborative Actions

1. CBC with diff remains stable without suspect findings.

2. Liver function tests show consistent results without decline.

3. Electrolyte panel within normal limits on latest labs from today.
   

1. Absence of complications indicates controlled ascites without recurrence.

2. Continued stability makes hypothesizing complications unwarranted.

3. Client demonstrating understanding of self-care to continue as an outpatient.

1. Maintain current medical regimen and monitor for effects.

2. Ensure clear understanding of post-discharge medication plan.

3. Provide prescriptions and counseling for uninterrupted treatment.

1. Communicate stability and preparedness for discharge to team

2. Coordinate safe handoff of care through discharge summary

3. Ensure smooth transition by addressing any loose ends

Consider Questions from CJSim™ Question #1

Consider Questions from CJSim™ Question #2

Consider Questions from CJSim™ Question #3

1. What are the patient's goals for self-care at home?

2. How confident does the patient feel in managing symptoms and medications independently?

3. What additional education or resources would help ensure the patient's safe transition to home?

1. How can the care team best support the patient after discharge?

2. What factors may interfere with the patient's ability to follow the treatment plan as prescribed?

3. What arrangements need to be made for follow-up monitoring or access to care if issues arise?

1. What are the early signs that the treatment plan may not be effectively controlling the ascites?

2. What steps should the patient take if they notice worsening symptoms?

3. How often should the patient expect follow-up contact or visits after being discharged?