Relearning: Clinical Judgment Plan of Care Template

Relearning: Clinical Judgment Plan of Care Template Student Name: Client Initials: J.K Age/DOB: 20 years Allergies: Penicillin BSA/BMI: N/A Code Status: Full Code Date of Admission: 2/28 Date of Care: 2/28 Admitting Diagnosis: preterm labor Comorbidities: N/A Planned Treatments/Procedures: prevent further complications Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders Cultural/Spiritual: Health Promotion/Development: Not discussed in case study. Tertiary care center transfer after discharge. Neurological/Cognition/Coping/Adaptation/Function: Magnesium sulfate IV infusion for seizure precautions Infection/Immunity/Inflammation: Ceftriaxone ordered 1g IV q24h. Bacteria present in urine. Nutrition/Elimination: Indwelling catheter insertion ordered by provider. Mobility: Bed rest with bathroom privileges. Fluid/Electrolytes/Acid-Base: Strict I&O. Pain/Comfort/Tissue Integrity: Cramps off and on since yesterday. Gas Exchange/Perfusion: WDL. Safety: Bed rest with bathroom privilege, fall risk. Glucose Regulation: Glucose and ketones negative in urine. Other: None 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 Hypotheses for Priority Priority Priority Assessments/Cues Nursing Care Interventions/Actions Teaching/Discharge Needs 1. Cramps 1. Fetal kick count 1. FHR assessment 1. Doppler placed 2. Dull Back ache 3. Feels like she’s wetting her pants 2. Cervix assessment 2. Urinalysis collect 3. Social work request 3. Vaginal exam 2. Contraction worsening 3. Take medications as prescribed Priority Laboratory Tests/ Diagnostic Cues 1. Magnesium 1. UTI 1. Magnesium sulfate Priority Collaborative Actions 1. Social work 2. Urinalysis 2. Preterm birth 2. Ceftriaxone 2. OB 3. Prenatal labs 3. Inaccessible transport 3. Betamethasone 3. NICU Priority Actual & Potential Complications/Cues Priority Medications 1 © 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept2023 v1.1 Relearning: Clinical Judgment Plan of Care Template Vital Signs & Pertinent Lab Trends START of the Shift (CJSim™) Analysis (phase 1/Question 1 section) Cramps feeling, feeling like wetting pants, contractions 3-5 minutes 20-40 second mild. (CJSim™) Mid-Shift Purposeful Clinical Judgment (Complete after reviewing EHR/Question 2 section) Answer these questions about today's client: 1. Recognize Cues — In the beginning of the shift client was experiencing cramping 2. Analyze Cues — this is significant because it can be an indicator of preterm labor 3. Prioritize Hypothesis — the uti the client has could have caused this to start 4. Generate Solutions — continuous fetal monitoring and stopping the contractions is important for this 5. Take Action — follow the providers orders and continuously monitor fetus and mother END of the Shift (CJSim™) Analysis (phase 3/Question 3 section) No contractions, cramping not noticeable, dull backache, contractions 3-4 minutes, 20-30 seconds, mild. 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. 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? In clinical I have not seen any mothers go into preterm labor. I did learn about the medications given to stop the contractions and to prevent seizures in the client. Everything matches up to how this scenario went. 2. Compare this client with the "textbook" , what was the same and what was different? Everything matched up from this scenario to the textbook. 6. Evaluate Outcomes —at the end of the scenario the client had no more cramping and all vitals remained stable without any dilated of the cervix. END of Shift (CJSim™) Priorities — How Has Your Client Changed? (phase 3/Question 3 section) Recognize & Analyze Cues Prioritize Hypotheses Priority Assessments/Cues Priority Hypotheses for Nursing Care 1. Cramps 2. Dull Back ache 3. Feels like she’s wetting her pants Generate Solutions & Take Actions Priority Interventions/Actions 1. FHR assessment 1. Doppler placed 2. Cervix assessment 2. Urinalysis collect 3. Social work request 3. Vaginal exam Evaluate Outcomes Priority Teaching/Discharge Needs 1. Fetal kick count 2. Contraction worsening 3. Take medications as prescribed Priority Laboratory Tests/ Diagnostic Cues 1. Magnesium 1. UTI 1. Magnesium sulfate Priority Collaborative Actions 1. Social work 4. Urinalysis 2. Preterm birth 2. Ceftriaxone 2. OB 5. Prenatal labs 3. Inaccessible transport 3. Betamethasone 3. NICU Priority Actual & Potential Complications/Cues Priority Medications 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 2 © 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept2023 v1.1 Relearning: Clinical Judgment Plan of Care Template CONSIDER QUESTIONS Document the Answers to Your Questions Here 1. A number of scoring systems of risk factors associated with preterm birth have been used. Systematic, objective measures can include age, marital status, socio‐economic factors, smoking, threatened miscarriage, previous low birthweight baby, previous stillbirth, maternal weight and height. 2. Risk factors: ethnicity, age of mother, smoking, drinking alcohol, use of illicit drugs, domestic violence. 3. The Hear Her campaign supports CDC's efforts to prevent pregnancyrelated deaths by sharing potentially life-saving messages about urgent warning signs. 1. Therapeutic communication allows the client to feel comfortable and supported while being able to verbalize feelings. 2. Fear of childbirth indicates the need for midwives to intervene with women to help them reshape their expectations and confidence levels, improve their knowledge about labor and childbirth, and empower them to make sound decisions. 3. During admission, using an interpreter will provide more accurate baseline information. 1. Many survivors face a lifetime of disability, including learning disabilities and visual and hearing problems. Globally, prematurity is the leading cause of death in children under the age of 5 years. Inequalities in survival rates around the world are stark. 2. The March of Dimes is important because it strives to ensure that all babies are born healthy and with access to quality care. To do this, they work to promote education and awareness regarding maternal health issues, as well as advocate for policies that support women and families. 3. The Centers for Disease Control and Prevention (CDC) have an array of free resources and a free app for tracking child development milestones. 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? I believe more information about the clients pregnancy could have made it easier to understand what was going on in this case study. - What could you have done better or differently to improve the outcome? Why? Understand the medications and the contraindications for it could have been improved on my part. - Describe what was most challenging for you when caring for the clients in the CJSim™? The most challenging part was not having the full amount of information about the clients pregnancy. - Identify the additional equipment, resources, or assistance needed to improve the care you provided. A full history of this client in the chart is needed to improve the care provided. - Share the key areas of care that were new to you that you had not experienced before. The information provided in this scenario was gone over in class which is why I knew the content. - How will your above reflections impact your future practice and improve your clinical judgment? I can take this new information and apply it to my future clinical experience.      NurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN. 3 © 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept2023 v1.1