1. Research and discuss links between enrolled nursing practice and

Please complete the care plan template below using the information provided. Name: Asti Safar Age: 38 years Provider: M. Patel MD Allergies: NKA Code Status: Full Code Admit Wt: 138 lbs (62.6 kg) BMI: 21.9 NURSING ASSESSMENT & NOTES 3/31 0100 Nursing Note: Client arrived with her husband. Client states having back pain, 9/10 on pain scale. The client refuses to make eye contact with staff. She is crying. Husband is at the bedside. The client requested a female nurse for the assessment. She also requested a female provider. She requested to keep her hijab in place but changed into a hospital gown. Guarded when changing positions. Denies any recent injury or trauma. 3/31 0700 Pain: Client rating back pain as 4/10. 4/1 0800 Pain: Client rating back pain as 3/10. 4/1 1700 Pain: Client rating back pain as 6/10. VITAL SIGN TREND Date Temp HR RR BP SpO2 O2 3/31 0700 98.8 °F (37.1 °C) 98 24 124/78 98% RA 4/1 0800 98.8 °F (37.1 °C) 94 18 118/76 99% RA 4/1 1700 98.8 °F (37.1 °C) 102 20 134/88 98% RA PROVIDER PRESCRIPTIONS & NOTES 4/1 0715 Prescriptions: Continue home medications Normal saline IV continuous 125 mL/hr Acetaminophen 1000 mg q8h PRN for mild pain >4/10 Tramadol 50 mg q4-6h PRN pain >7/10 Activity: up ad lib 4/1 1730 Prescriptions: Diet: Regular as tolerated 3/31 0700 Religious Preferences: Practicing Muslim 4/1 0800 Home Medications: Multivitamin daily Vitamin D3 supplement daily 4/1 1745 Client Education: Provided education regarding pain medication and safe administration. Question Please complete the care plan below using the information provided above 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 (CJSimâ„¢) 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 Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions Vital Signs & Pertinent Lab Trends START of the Shift (CJSimâ„¢) Analysis (phase 1/Question 1 section) END of the Shift (CJSimâ„¢) Analysis (phase 3/Question 3 section) (CJSimâ„¢) MID-SHIFT Purposeful Clinical Judgment (Complete after reviewing EHR/Question 2 section) 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? END of Shift (CJSimâ„¢) 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 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: 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? CONSIDER QUESTIONS Document the Answers to Your Questions Here Consider Questions from CJSimâ„¢ Question #1 Consider Questions from CJSimâ„¢ Question #2 Consider Questions from CJSimâ„¢ Question #3 Reflection Exercise (After providing care during the CJSimâ„¢ and completing the plan of care template for your assigned client, answer the following reflection questions focusing on the care you provided for this CJSimâ„¢ client.) CJSimâ„¢ 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 CJSimâ„¢? 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?

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