just conmplete the template.

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:

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

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?

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 from CJSim™ Question #1

Consider Questions from CJSim™ Question #2

Consider Questions from CJSim™ Question #3