Please complete the template below using the scenario provided. Larry Shortz 69-years-old CJSim Over

Please complete the template below using the scenario provided. Larry Shortz 69-years-old CJSim Overview: Client at an ambulatory care setting with armpit infection and pain. Transcript: Larry Shortz Age 69 Larry Shortz came to the ED after having pain in his right armpit last week. He was discharged 2 weeks ago after a 2-day admission due to an episode of hypoglycemia. He has a lump under his arm. His past medical history includes diabetes type 2, hyperlipidemia, hypertension, and a history of deep vein thrombus. Name: Larry Shortz Age: 69 years Provider: C. Mason MD Allergies: NKDA Code Status: Full Code Admit Wt: 179 lbs (81.2 kg) BMI: 25.7 NURSING ASSESSMENT & NOTES 9/21 1100 Nursing Note: Alert and oriented x 4 and reports pain in the right armpit x1 week. Reports 8/10 pain with movement or direct touch to the site. The client stated it started with a little pimple under my arm, and “I popped the one I had last.” Right axilla tender to touch, erythematous and warm with 4 cm abscess with yellow center. Redness and swelling extending down the right posterior arm, stopping 2 inches from the elbow—skin warm and tight to touch. The inflamed area is outlined with a skin marker. VITAL SIGN TREND Date Temp HR RR BP SpO2 O2 9/21 1100 101.6 °F (38.6 °C) 105 22 134/72 98% RA 9/21 1130 101.6 °F (38.6 °C) 108 22 144/72 98% RA blood glucose log Date Glu 9/21 1100 245 PRESCRIPTIONS & NOTES 9/21 1230 Provider Prescriptions: Admit to the medical care unit Place on contact isolation Insert peripheral IV Vital signs q4h 1800 kcal ADA diet Consult wound and ostomy nurse Prepare for incision and drainage, culture and sensitivity of exudate Cleanse wound and pack with iodoform gauze daily Apply a warm compress to the area twice daily Glipizide 5 mg by mouth daily Simvastatin 20 mg by mouth daily at bedtime Carvedilol 3.125 mg by mouth twice daily Enoxaparin 40 mg subcutaneous daily Morphine 2 mg IVP now and q4h PRN for pain >5 Hydrocodone acetaminophen 5/325 1-2 tabs PRN for pain 3-5 Vancomycin 1 g q12h for 7 days Vancomycin peak and trough after 4th dose LAB RESULTS Date Lab Normal Result 9/21 1615 WBC 4,000-10,000 mm3 15,000 H Hct 36-51% 47 Hgb 12-17 g/dL 16 Platelets 150,000-350,000 mm3 150,000 Na 136-145 mEq/L 137 K 3.5-5.0 mEq/L 4.0 Creatinine 0.7-1.3 mg/dL 0.8 BUN 8-20 mg/dL 25 H DIAGNOSTIC TEST RESULTS Date Diagnostic Test Findings 9/21 1615 Microbiology: Culture, Aerobic Bacteria Preliminary Report Light growth of Methicillin-resistant staphylococcus Levofloxacin: Resistant Gentamicin: Sensitive Ceftriaxone: Resistant Vancomycin: Sensitive Ampicillin: Resistant MEDICATION ADMINISTRATION RECORD Medication 9/21 1135 9/21 1245 Carvedilol 3.125 mg by mouth twice daily SDT Enoxaparin 40 mg subcutaneous daily SDT Glipizide 5 mg by mouth daily before breakfast SDT Simvastatin 20 mg by mouth daily at bedtime SDT Vancomycin 1 g SDT Hydrocodone/acetaminophen 5/325 by mouth 1-2 tabs PRN for pain >5 Morphine 2 mg IV q4h PRN for pain 3-5 SDT 9/21 2100 Discharge Teaching Plan: Encourage the client to take all prescribed medication after discharge. Washing hands with soap and warm water before and after touching the affected area or touching bandages. Educate client on keeping infected skin areas covered with a clean, dry bandage. Change bandage whenever drainage seeps through. Place soiled bandages in a plastic bag. Please complete the template below Using the information 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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