Relearning: Clinical Judgment Plan of Care Template
Student Name: Lindsey McCammon Date of Admission: 04/21
CJSim™ Client Initials: S.P. Date of Care: 04/21
Age/DOB: 43 years/DOB not given Admitting Diagnosis: Myocardial Infarction
Allergies: acetaminophen Comorbidities: type 1 diabetes, hyperlipidemia, GERD,
BSA/BMI:25.7 Code Status: FULL peripheral vascular disease
Planned Treatments/Procedures: ECG, CBC, CMP, Cardiac
enzymes, INR, chest x-ray, cardiac interventional radiology
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider
orders
Cultural/Spiritual: respect SP’s beliefs and remain unbiased Health Promotion/Development: smoking cessation, daily
exercise to improve cardiovascular health, adhere to a heart
Neurological/Cognition/Coping/Adaptation/Function: assess LOC healthy diet, schedule follow up visit with HCP
and cranial nerves, speak with SP about how they are feeling
about the situation and communicate therapeutically, ask SP Infection/Immunity/Inflammation: monitor peripheral for any
about their support system and if she has any concerns that she edema, redness, or warmth (especially the legs) for DVT
would like to discuss, assess ADL functionality
Mobility: up ad-lib
Nutrition/Elimination: NPO, monitor urine output
Pain/Comfort/Tissue Integrity: 9/10, chest tightness, arm pain,
Fluid/Electrolytes/Acid-Base: Hgb 8.4 L, Plt 143000 L, BUN 28 H, nausea, encourage turning at least once every 2 hours to
Creatinine 2.3 H, Sodium 135 L, INR 1.3 H. avoid pressure injuries, reassess pain level, assist SP to make
tasks more comfortable, administer prescribed medications
Gas Exchange/Perfusion: SOB when walking and sitting, elevated and offer non pharmacological interventions
RR and HR, SP has peripheral vascular disease along with the MI
and needs frequent checks for pulses and temp to determine Safety: Monitor SP’s glucose levels closely due to NPO status
adequate perfusion. and comorbidity of Diabetes type 1, bed in lowest position and
locked, side rails raised, call light within reach, keep pathways
Glucose Regulation: sliding scale insulin with meals: <150-no free of clutter, maintain a tidy environment and ensure IV are
insulin; 150-200=4 units, 201-250=6 units, 251-300=8 units, 301- not tangled
350=10 units
Other:
START of Shift (CJSim™) Priorities
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. Ineffective cardiac tissue
perfusion related to 1. Administer oxygen and
decreased oxygen as medication as prescribed
evidenced by SOB and
respirations
1. Chest tightness and arm 2. Frequently check
1. Heart healthy diet
pain peripheral temp and pulses
2. Acute pain related to chest to assess and monitor
tightness as evidenced by perfusion 2. Regular exercise
2. SOB and diaphoretic
pain rating 9/10
3. Reassess pain levels and 3. Smoking cessation
3. Pain 9/10
3. Deficit knowledge related to provide non
diagnosis as evidenced by pharmacological therapies
patient claiming it is the to promote comfort and
spicy food at lunch making relieve pain
her chest hurt
Priority Laboratory Tests/ Priority Actual & Potential Priority Collaborative
Priority Medications
Diagnostic Cues Complications/Cues Actions
© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept23
1
, Relearning: Clinical Judgment Plan of Care Template
START of Shift (CJSim™) Priorities
1. Communicating status
1. Inadequate oxygen changes to HCP
1. HR 102
1. Morphine 2. Confirm prescriber’s orders
2. Increased pain causing if there is confusion
2. RR 24 anxiety and increased 2. Nitroglycerin 3. Communicating
workload on the heart immediately for cardiology
3. Aspirin consult because time is
3. SpO2 95%
very important when
3. Arrhythmias dealing with an MI
© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept23
2
Student Name: Lindsey McCammon Date of Admission: 04/21
CJSim™ Client Initials: S.P. Date of Care: 04/21
Age/DOB: 43 years/DOB not given Admitting Diagnosis: Myocardial Infarction
Allergies: acetaminophen Comorbidities: type 1 diabetes, hyperlipidemia, GERD,
BSA/BMI:25.7 Code Status: FULL peripheral vascular disease
Planned Treatments/Procedures: ECG, CBC, CMP, Cardiac
enzymes, INR, chest x-ray, cardiac interventional radiology
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider
orders
Cultural/Spiritual: respect SP’s beliefs and remain unbiased Health Promotion/Development: smoking cessation, daily
exercise to improve cardiovascular health, adhere to a heart
Neurological/Cognition/Coping/Adaptation/Function: assess LOC healthy diet, schedule follow up visit with HCP
and cranial nerves, speak with SP about how they are feeling
about the situation and communicate therapeutically, ask SP Infection/Immunity/Inflammation: monitor peripheral for any
about their support system and if she has any concerns that she edema, redness, or warmth (especially the legs) for DVT
would like to discuss, assess ADL functionality
Mobility: up ad-lib
Nutrition/Elimination: NPO, monitor urine output
Pain/Comfort/Tissue Integrity: 9/10, chest tightness, arm pain,
Fluid/Electrolytes/Acid-Base: Hgb 8.4 L, Plt 143000 L, BUN 28 H, nausea, encourage turning at least once every 2 hours to
Creatinine 2.3 H, Sodium 135 L, INR 1.3 H. avoid pressure injuries, reassess pain level, assist SP to make
tasks more comfortable, administer prescribed medications
Gas Exchange/Perfusion: SOB when walking and sitting, elevated and offer non pharmacological interventions
RR and HR, SP has peripheral vascular disease along with the MI
and needs frequent checks for pulses and temp to determine Safety: Monitor SP’s glucose levels closely due to NPO status
adequate perfusion. and comorbidity of Diabetes type 1, bed in lowest position and
locked, side rails raised, call light within reach, keep pathways
Glucose Regulation: sliding scale insulin with meals: <150-no free of clutter, maintain a tidy environment and ensure IV are
insulin; 150-200=4 units, 201-250=6 units, 251-300=8 units, 301- not tangled
350=10 units
Other:
START of Shift (CJSim™) Priorities
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. Ineffective cardiac tissue
perfusion related to 1. Administer oxygen and
decreased oxygen as medication as prescribed
evidenced by SOB and
respirations
1. Chest tightness and arm 2. Frequently check
1. Heart healthy diet
pain peripheral temp and pulses
2. Acute pain related to chest to assess and monitor
tightness as evidenced by perfusion 2. Regular exercise
2. SOB and diaphoretic
pain rating 9/10
3. Reassess pain levels and 3. Smoking cessation
3. Pain 9/10
3. Deficit knowledge related to provide non
diagnosis as evidenced by pharmacological therapies
patient claiming it is the to promote comfort and
spicy food at lunch making relieve pain
her chest hurt
Priority Laboratory Tests/ Priority Actual & Potential Priority Collaborative
Priority Medications
Diagnostic Cues Complications/Cues Actions
© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept23
1
, Relearning: Clinical Judgment Plan of Care Template
START of Shift (CJSim™) Priorities
1. Communicating status
1. Inadequate oxygen changes to HCP
1. HR 102
1. Morphine 2. Confirm prescriber’s orders
2. Increased pain causing if there is confusion
2. RR 24 anxiety and increased 2. Nitroglycerin 3. Communicating
workload on the heart immediately for cardiology
3. Aspirin consult because time is
3. SpO2 95%
very important when
3. Arrhythmias dealing with an MI
© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept23
2
