Please complete the care plan template below using the below

Please complete the care plan template below using the below information. Name: Simon Andrews Age: 68 years Provider: Dr. S. Woodsen MD Allergies: NKA Code Status: Full Code Admit Wt: 150 lbs (68.2 kg) BMI: 19.9 NURSING ASSESSMENT & NOTES 10/24 1300 Nursing Note: Client ate 50% of a piece of toast, apple juice, and a bowl of chicken broth for lunch. Teeth brushed, and mouthwash used after lunch. Client vomited about one hour after lunch. Client was given half a cup of ice chips. Client states he is thirsty, and mouth feels dry. Urine in urinal appears dark amber, concentrated with no foul odor. 10/25 2010 Nursing Note: Placement confirmed. Tube feeding initiated. 10/27 0945 Nursing Note: The client states his mouth feels dry. There has been no nausea or vomiting since 10/24. Tolerating feedings well. VITAL SIGN TREND Date Temp HR RR BP SpO2 O2 10/24 1300 99.0° F (37.2° C) 106 18 108/68 99% RA 10/27 0730 98.6° F (37° C) 82 16 118/78 99% RA intake and output Date Intake Source & Amount Output Source & Amount Total 10/25 2030 Bowl of chicken broth, 250 mL Water in cup, 12 oz Urine in bedside commode, 550 mL Urine in bedside urinal, 610 mL Emesis, 170 mL Ice chips, 16 oz cup PROVIDER PRESCRIPTIONS & NOTES 10/24 1300 Prescriptions: Insert nasogastric tube Clamp and measure strict I &O and monitor food intake for 24 hours 10/25 1930 Prescriptions: Feeding tube: Lactose-reduced food supplement formula with fiber 1.2 cal – 1260 mL per 12 hours. Discontinue for 12 hours. Free water flush 200 mL q4h Begin nocturnal feedings at 2000 COLLABORATIVE CARE 10/27 0900 Wound Care Note: Skin breakdown on client’s nose and around tape. Tape changed to non-allergenic plastic tape with plastic skin adhesive. Taping moved off previous breakdown site. Will continue to monitor skin integrity. Supplies left at bedside. Please complete the template below Relearning: Clinical Judgment Plan of Care 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: 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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