Relearning: Clinical Judgment Plan of Care Template
Student Name: Ana Derasmo Date of Admission: 02/25/24
Client Initials: JJ Date of Care: 02/25/24
Age/DOB: 29 Admitting Diagnosis: Osteomyelitis
Allergies: Morphine Comorbidities: Reports using IV drugs x 5 years
BSA/BMI: 21 Code Status: Full Code Planned Treatments/Procedures: Pain medications for
discharge will be oral only
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and
provider orders
Cultural/Spiritual: This wasn’t part of the scenario, but it’s Health Promotion/Development: Obtain blood cultures x2,
important to ask patient if there is anything that the nurse should vital signs q8h, social service consultation for discharge
know about his culture to considerer during treatment. planning.
Neurological/Cognition/Coping/Adaptation/Function: Patient Infection/Immunity/Inflammation:
is alert oriented X4. Upon entering the room, the client is lying
calmly with eyes closed or sleeping.
Mobility: restricted range of motion in the affected area.
Nutrition/Elimination: Abdomen soft, active bowel sounds x4,
last BM 1 day ago. Regular diet Pain/Comfort/Tissue Integrity: Client verbalizes pain 10/10
Fluid/Electrolytes/Acid-Base: In this scenario, it was no Safety: Client states he. Live with a friend and cant take
mention anything about electrolytes but it’s important to always home IV antibiotic
check labs and make sure there isn’t any electrolytes imbalance
and keep monitoring.
Other: unable to maintain employment and often homeless.
Gas Exchange/Perfusion: Lungs are clear, heart rate is regular,
blood pressure is within normal ranges. S1 and S2 noted.
Glucose Regulation: 100 mg/dL
START of Shift (CJSim™) 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 Priority Priority
Nursing Care Interventions/Actions Teaching/Discharge Needs
1. Administer prescribed 1. Teach patient to notify their
antibiotics
1. Repositing patient every 2 healthcare any worsening
hours to avoid pressure injury symptoms
1. Inflammation 2. Evaluate the level of pain
reduction and whether
2. Pain 2. Stress how crucial it is to
2. Monitor for side effects of more pain management finish the entire course of
techniques.
pain medications. antibiotics as directed.
3. Chills
3. Utilize cushions and support
3. Monitor vital signs frequently surfaces to lessen friction 3. Give advice on acceptable
and pressure. and safe physical activity.
Priority Laboratory Tests/ Priority
Complications/Cues
Actual & PotentialPriority Medications Priority Collaborative
Diagnostic Cues Actions
1
© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept2023 v1.1
Student Name: Ana Derasmo Date of Admission: 02/25/24
Client Initials: JJ Date of Care: 02/25/24
Age/DOB: 29 Admitting Diagnosis: Osteomyelitis
Allergies: Morphine Comorbidities: Reports using IV drugs x 5 years
BSA/BMI: 21 Code Status: Full Code Planned Treatments/Procedures: Pain medications for
discharge will be oral only
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and
provider orders
Cultural/Spiritual: This wasn’t part of the scenario, but it’s Health Promotion/Development: Obtain blood cultures x2,
important to ask patient if there is anything that the nurse should vital signs q8h, social service consultation for discharge
know about his culture to considerer during treatment. planning.
Neurological/Cognition/Coping/Adaptation/Function: Patient Infection/Immunity/Inflammation:
is alert oriented X4. Upon entering the room, the client is lying
calmly with eyes closed or sleeping.
Mobility: restricted range of motion in the affected area.
Nutrition/Elimination: Abdomen soft, active bowel sounds x4,
last BM 1 day ago. Regular diet Pain/Comfort/Tissue Integrity: Client verbalizes pain 10/10
Fluid/Electrolytes/Acid-Base: In this scenario, it was no Safety: Client states he. Live with a friend and cant take
mention anything about electrolytes but it’s important to always home IV antibiotic
check labs and make sure there isn’t any electrolytes imbalance
and keep monitoring.
Other: unable to maintain employment and often homeless.
Gas Exchange/Perfusion: Lungs are clear, heart rate is regular,
blood pressure is within normal ranges. S1 and S2 noted.
Glucose Regulation: 100 mg/dL
START of Shift (CJSim™) 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 Priority Priority
Nursing Care Interventions/Actions Teaching/Discharge Needs
1. Administer prescribed 1. Teach patient to notify their
antibiotics
1. Repositing patient every 2 healthcare any worsening
hours to avoid pressure injury symptoms
1. Inflammation 2. Evaluate the level of pain
reduction and whether
2. Pain 2. Stress how crucial it is to
2. Monitor for side effects of more pain management finish the entire course of
techniques.
pain medications. antibiotics as directed.
3. Chills
3. Utilize cushions and support
3. Monitor vital signs frequently surfaces to lessen friction 3. Give advice on acceptable
and pressure. and safe physical activity.
Priority Laboratory Tests/ Priority
Complications/Cues
Actual & PotentialPriority Medications Priority Collaborative
Diagnostic Cues Actions
1
© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept2023 v1.1
