David Erickson
Student Name: Date of Admission: N/A
Client Initials: D.E. Date of Care: 17/03/2024
Age/DOB: 13 years Admitting Diagnosis: Urticaria/Asthma exacerbation
Allergies: N/A Comorbidities: Asthma
BSA/BMI: 19.6 Code Status: Planned Treatments/Procedures: Allergy testing
Full Code
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing
actions, and provider orders
Cultural/Spiritual: Assess cultural beliefs regarding illness Health Promotion/Development: Educate on
and treatment asthma triggers and management.
Neurological/Cognition/Coping/Adaptation/Function: Infection/Immunity/Inflammation: Assess for signs
Assess client and family coping mechanisms. of infection in scratch wounds
Nutrition/Elimination: Assess dietary habits and fluid Mobility: Encourage physical activity within limits
intake of asthma symptoms.
Fluid/Electrolytes/Acid-Base: Monitor hydration status. Pain/Comfort/Tissue Integrity: Assess and manage
discomfort from scratch wounds.
Gas Exchange/Perfusion: Monitor respiratory rate and
auscultate lung sounds. Safety: Educate on safe use of medications and
avoidance of triggers.
Glucose Regulation: Monitor blood glucose levels if
indicated. Other: Consider skin prick testing after 96 hours
of discontinuing diphenhydramine.
Prescribe loratadine for urticaria management.
START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to
phase 1/Question 1 section)
Recognize & Analyze Generate Solutions &
Prioritize Hypotheses Evaluate Outcomes
Cues Take Actions
Priority
Priority Priority Hypotheses for Priority
Teaching/Discharge
Assessments/Cues Nursing Care Interventions/Actions
Needs
, • Administer
loratadine as prescribed
for urticaria • Educate David
management. and his mother on the
• Urticaria • Provide wound importance of
• Evaluate the exacerbation: Due to recent care for scratch wounds, compliance with
status of David's increase in scratching and including cleansing, prescribed medications
urticaria and asthma purulent drainage from applying topical antibiotic and follow-up
symptoms. scratch wounds. ointment, and dressing appointments.
• Assess the • Asthma application. • Provide
severity and extent of exacerbation: Based on • Educate David instructions on proper
scratch wounds on reported increased use of and his mother on wound care at home to
bilateral forearms and rescue inhaler and asthma management promote healing and
inner elbow area. nocturnal awakening due to strategies, including prevent infection.
• Review the congestion. proper use of rescue • Review asthma
frequency and • Diphenhydramine inhaler and identifying action plan with David
effectiveness of adverse effects: Possible triggers. and his mother,
diphenhydramine use. side effects contributing to • Instruct David emphasizing the steps
inadequate relief of urticaria and his mother on the to take during asthma
and exacerbation of asthma importance of exacerbations
symptoms. discontinuing
diphenhydramine before
allergy testing.
Priority Laboratory Priority Actual &
Tests/ Diagnostic Priority Collaborative
Potential Priority Medications
Actions
Cues Complications/Cues
• Collaborate
with the healthcare
• Administer provider to adjust
• Consider skin prick • Potential complications loratadine for urticaria treatment plan based on
include worsening of management. assessment findings and
testing after
urticaria symptoms, • Provide laboratory test results.
discontinuation of
exacerbation of asthma, albuterol inhaler for • Coordinate with
diphenhydramine to
and risk of infection from asthma exacerbation if the allergy specialist for
identify specific
scratch wounds. indicated. scheduling skin prick
allergens triggering
testing after
urticaria.
discontinuation of
diphenhydramine.
Vital Signs & Pertinent Lab Trends
START of the Shift (CJSim™) Analysis (phase END of the Shift (CJSim™) Analysis (phase
1/Question 1 section) 3/Question 3 section)
Vital Signs: Vital Signs:
Blood pressure: Normal Blood pressure: Stable
Heart rate: Elevated due to reported asthma Heart rate: Improved with resolution of asthma
symptoms symptoms
Respiratory rate: Increased due to asthma Respiratory rate: Improved with resolution of
symptoms asthma symptoms
Temperature: Normal Temperature: Normal
Lab Trends: Lab Trends:
No specific lab trends mentioned in the provided No specific lab trends mentioned in the
information provided information.
, Clinical Debriefing (Complete these questions after
(CJSim™) Mid-Shift Purposeful Clinical Judgment
completely caring for the client and answering the
(Complete after reviewing EHR/Question 2 section)
questions for the client)
Answer these questions about today's client: Answer these questions about today's client:
• Recognize Cues: Comparison:
• Assessment changes since the start of the shift Comparing this client with previous clinical
include: experiences, similarities include the
• Improved respiratory rate and heart rate. importance of effective medication
• Reduced reported symptoms of asthma. administration, wound care, and patient
• Decreased scratch wounds with purulent education in achieving positive outcomes.
drainage. Differences may lie in the specific conditions
• Enhanced overall comfort level of the client. treated, the severity of symptoms, and the
• Analyze Cues: complexity of care required.
• These changes are important as they indicate a
positive response to interventions and Comparison with Textbook:
treatments provided during the shift. Similarities with the textbook may include
• The improvement in respiratory and heart the general principles of asthma
rates suggests better gas exchange and management, wound care protocols, and the
perfusion, possibly indicating alleviation of importance of patient education.
asthma exacerbation. Differences may exist in the individualized
• Reduced wound drainage suggests effective aspects of care tailored to the client's unique
wound care management, reducing the risk of needs and circumstances, which may not
infection. always align precisely with textbook
• Enhanced comfort level indicates successful scenarios
pain management and overall improvement in
the client's condition.
• Prioritize Hypothesis:
• The improvement in the client's condition
could be due to the administration of
prescribed medications, effective wound care,
and education provided on asthma
management.
• Compliance with medication regimens and
wound care instructions may have contributed
to the positive outcomes observed.
• Generate Solutions:
• Continue to monitor vital signs and symptoms
closely.
• Ensure ongoing adherence to prescribed
medications and wound care regimen.
• Provide reinforcement of education regarding
asthma triggers and management to promote
long-term control.
• Address any emerging concerns promptly to
prevent deterioration in the client's condition.
• Take Action:
• Throughout the shift, appropriate medications
were administered as prescribed.
Student Name: Date of Admission: N/A
Client Initials: D.E. Date of Care: 17/03/2024
Age/DOB: 13 years Admitting Diagnosis: Urticaria/Asthma exacerbation
Allergies: N/A Comorbidities: Asthma
BSA/BMI: 19.6 Code Status: Planned Treatments/Procedures: Allergy testing
Full Code
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing
actions, and provider orders
Cultural/Spiritual: Assess cultural beliefs regarding illness Health Promotion/Development: Educate on
and treatment asthma triggers and management.
Neurological/Cognition/Coping/Adaptation/Function: Infection/Immunity/Inflammation: Assess for signs
Assess client and family coping mechanisms. of infection in scratch wounds
Nutrition/Elimination: Assess dietary habits and fluid Mobility: Encourage physical activity within limits
intake of asthma symptoms.
Fluid/Electrolytes/Acid-Base: Monitor hydration status. Pain/Comfort/Tissue Integrity: Assess and manage
discomfort from scratch wounds.
Gas Exchange/Perfusion: Monitor respiratory rate and
auscultate lung sounds. Safety: Educate on safe use of medications and
avoidance of triggers.
Glucose Regulation: Monitor blood glucose levels if
indicated. Other: Consider skin prick testing after 96 hours
of discontinuing diphenhydramine.
Prescribe loratadine for urticaria management.
START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to
phase 1/Question 1 section)
Recognize & Analyze Generate Solutions &
Prioritize Hypotheses Evaluate Outcomes
Cues Take Actions
Priority
Priority Priority Hypotheses for Priority
Teaching/Discharge
Assessments/Cues Nursing Care Interventions/Actions
Needs
, • Administer
loratadine as prescribed
for urticaria • Educate David
management. and his mother on the
• Urticaria • Provide wound importance of
• Evaluate the exacerbation: Due to recent care for scratch wounds, compliance with
status of David's increase in scratching and including cleansing, prescribed medications
urticaria and asthma purulent drainage from applying topical antibiotic and follow-up
symptoms. scratch wounds. ointment, and dressing appointments.
• Assess the • Asthma application. • Provide
severity and extent of exacerbation: Based on • Educate David instructions on proper
scratch wounds on reported increased use of and his mother on wound care at home to
bilateral forearms and rescue inhaler and asthma management promote healing and
inner elbow area. nocturnal awakening due to strategies, including prevent infection.
• Review the congestion. proper use of rescue • Review asthma
frequency and • Diphenhydramine inhaler and identifying action plan with David
effectiveness of adverse effects: Possible triggers. and his mother,
diphenhydramine use. side effects contributing to • Instruct David emphasizing the steps
inadequate relief of urticaria and his mother on the to take during asthma
and exacerbation of asthma importance of exacerbations
symptoms. discontinuing
diphenhydramine before
allergy testing.
Priority Laboratory Priority Actual &
Tests/ Diagnostic Priority Collaborative
Potential Priority Medications
Actions
Cues Complications/Cues
• Collaborate
with the healthcare
• Administer provider to adjust
• Consider skin prick • Potential complications loratadine for urticaria treatment plan based on
include worsening of management. assessment findings and
testing after
urticaria symptoms, • Provide laboratory test results.
discontinuation of
exacerbation of asthma, albuterol inhaler for • Coordinate with
diphenhydramine to
and risk of infection from asthma exacerbation if the allergy specialist for
identify specific
scratch wounds. indicated. scheduling skin prick
allergens triggering
testing after
urticaria.
discontinuation of
diphenhydramine.
Vital Signs & Pertinent Lab Trends
START of the Shift (CJSim™) Analysis (phase END of the Shift (CJSim™) Analysis (phase
1/Question 1 section) 3/Question 3 section)
Vital Signs: Vital Signs:
Blood pressure: Normal Blood pressure: Stable
Heart rate: Elevated due to reported asthma Heart rate: Improved with resolution of asthma
symptoms symptoms
Respiratory rate: Increased due to asthma Respiratory rate: Improved with resolution of
symptoms asthma symptoms
Temperature: Normal Temperature: Normal
Lab Trends: Lab Trends:
No specific lab trends mentioned in the provided No specific lab trends mentioned in the
information provided information.
, Clinical Debriefing (Complete these questions after
(CJSim™) Mid-Shift Purposeful Clinical Judgment
completely caring for the client and answering the
(Complete after reviewing EHR/Question 2 section)
questions for the client)
Answer these questions about today's client: Answer these questions about today's client:
• Recognize Cues: Comparison:
• Assessment changes since the start of the shift Comparing this client with previous clinical
include: experiences, similarities include the
• Improved respiratory rate and heart rate. importance of effective medication
• Reduced reported symptoms of asthma. administration, wound care, and patient
• Decreased scratch wounds with purulent education in achieving positive outcomes.
drainage. Differences may lie in the specific conditions
• Enhanced overall comfort level of the client. treated, the severity of symptoms, and the
• Analyze Cues: complexity of care required.
• These changes are important as they indicate a
positive response to interventions and Comparison with Textbook:
treatments provided during the shift. Similarities with the textbook may include
• The improvement in respiratory and heart the general principles of asthma
rates suggests better gas exchange and management, wound care protocols, and the
perfusion, possibly indicating alleviation of importance of patient education.
asthma exacerbation. Differences may exist in the individualized
• Reduced wound drainage suggests effective aspects of care tailored to the client's unique
wound care management, reducing the risk of needs and circumstances, which may not
infection. always align precisely with textbook
• Enhanced comfort level indicates successful scenarios
pain management and overall improvement in
the client's condition.
• Prioritize Hypothesis:
• The improvement in the client's condition
could be due to the administration of
prescribed medications, effective wound care,
and education provided on asthma
management.
• Compliance with medication regimens and
wound care instructions may have contributed
to the positive outcomes observed.
• Generate Solutions:
• Continue to monitor vital signs and symptoms
closely.
• Ensure ongoing adherence to prescribed
medications and wound care regimen.
• Provide reinforcement of education regarding
asthma triggers and management to promote
long-term control.
• Address any emerging concerns promptly to
prevent deterioration in the client's condition.
• Take Action:
• Throughout the shift, appropriate medications
were administered as prescribed.
