Please use the information below to fill the care plan

Please use the information below to fill the care plan below. Name: Millicent Hatfield Age: 83 years Provider: J. Atwood MD Allergies: NKA Code Status: DNR Admit Wt: 132.7 lbs (60.3 kg) BMI: 22.8 NURSING ASSESSMENT & NOTES 10/7 0750 Neuro/Cognitive: Alert, oriented x 4. Speech clear. Disinterested in conversation with staff. Searching room. Respiratory: Lung sounds clear; lung expansion is equal bilaterally Cardiovascular: Regular rhythm. Gastrointestinal: Abdomen soft, non-distended, non-tender; last bowel movement was this morning. Psychsocial: Anxious. Pain: Rates 4/10, stiff, aching pain in joints. 10/7 0900 Nursing Note: Client states not eating breakfast or showering “until Felicia hands over my personal property.” Nursing staff advised of missing item. 10/7 1015 Nursing Note: Client attends bingo session and finds ring sitting in planter beside her regular seat where she eats meals. States, “I must have put it there for some reason.” Client pleasant. Agreeable to having shower. VITAL SIGN TREND Date Temp HR RR BP SpO2 O2 10/7 0750 98.6 °F (37.0 °C) 80 20 126/84 96% RA Adl log Date ADL & Notes 10/7 0800 Feeding: 0% of breakfast 10/7 0800 Hygiene: Refused AM care 10/7 1230 Feeding: 100% of lunch PROVIDER PRESCRIPTIONS & NOTES 10/7 0800 Prescriptions: Lorazepam 1 mg (1mg/tab) by mouth PRN for anxiety MEDICATION ADMINISTRATION RECORD Medication 0810 Medication: Methotrexate Dosage: 15 mg Route: intramuscular Frequency: once weekly Parameters: N/A AFW Medication: Vitamin D Dosage: 1000 IU (1000 IU/cap) Route: By mouth Frequency: Daily Parameters: N/A AFW Medication: Acetaminophen Dosage: 650 mg (325 mg/tab) Route: by mouth Frequency: every 6 hours Parameters: As needed for moderate pain. AFW 10/7 0700 Medical History: Rheumatoid Arthritis General Anxiety Disorder Surgical History: Cholecystectomy 10/7 0800 Plan of Care: Goal: Pain control for Rheumatoid Arthritis. Intervention: Assess and monitor pain. Assess ability to perform ADLs. Administer disease-modifying antirheumatic drugs as prescribed. Encourage range of motion exercises and muscle strengthening. Pace activities for client. 10/7 0900 Facility Missing Item Note: Millicent Hatfield is missing a ring that may be on a metal chain that is gold in color. The ring has a thin gold band with a large red stone surrounded by six smaller white stones. Please contact Lakeview Assisted Living Community if found. 10/7 1300 Client Education: Rheumatoid Arthritis Management Progressive disease – chronic pain management. Pain worse in morning and after periods of inactivity. Warm compresses may alleviate pain. Teach range of motion exercises – thumb stretches, knuckle bends, fist stretching, fingertip touches, finger walking. Daily walks. Weight maintenance – reduces strain on joints. Question: Please use the above information to complete the care plan template below 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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