NR 324 Relearning_Clinical Judgment Plan of Care for G.A.

Clinical Debriefing (Complete these questions after completely caring for the client and answering the questions for the client) Relearning: Clinical Judgment Plan of Care Template Relearning Clinical Judgment Plan of Care Template-July24 2 Vital Signs & Pertinent Lab Trends START of the Shift (CJSim™) Analysis (phase 1/Question 1 section) END of the Shift (CJSim™) Analysis (phase 3/Question 3 section) No fever at the start of shift, there is a Dx of orthostatic hypotension, no signs of respiratory distress, significant drop of systolic BP due to OHTN. Is stable on room air O2 (CJSim™) MID-SHIFT Purposeful Clinical Judgment (Complete after reviewing EHR/Question 2 section) Answer these questions about today's client: 1. Recognize Cues — Explain any assessment changes since the start of shift. strong smelling, dark amber and cloudy urine, speech remains slow 2. Analyze Cues — How are the changes important or significant? change in urine, overflow incontinence/retention, UIT in dementia pt 3. Prioritize Hypothesis — What could be causing the changes? underlying dementia/Parkinson’s urinary stasis 4. Generate Solutions — What can/should you do about these changes? notify the provider; reinforce hydration, maintain perineal hygiene; monitor temp and mental status closely 5. Take Action — What did I do about it? What would I do about it? report any urinary changes, monitor mental status; encourage fluid intake 6. Evaluate Outcomes — Did my actions make a difference? Why are why not? What should have been done differently? early intervention and report prevent further complications END of Shift (CJSim™) 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 1. Cloudily, dark urine with strong odor 2. Attempted to stand unassisted 3. Delayed speech and difficult responding 1. Risk for UTI related to incontinence/retention 2. Risk for falls related to dizziness/orthostatic hypo 3. Acute confusion related to infection/dementia progression 1. Notify provider/monitor temp/mental status 2. Reinforce fall precautions/assist w/ambulation 3. Reorient frequently, provide calm environment, monitor LOC closely 1. Educate family on UTI signs and importance of fluid intake 2. Teach about calling for help and using assistive devices consistently 3. Involve family in strategies for cognitive support and supervision Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions 1. UA/ C&S 2. CBC w/differential 3. Renal panel 1. UIT progressing to delirium/sepsis 2. Fall-related injury 3. Confusion worsening due to infection/UTI 1. Carbidopa-levodopa/ropinirole 2. Carvedilol and Lisinopril 3. Rivastigmine and amitriptyline 1. Speech therapy 2. Physical therapy 3. Urology and wound nurse Relearning: Clinical Judgment Plan of Care Template Relearning Clinical Judgment Plan of Care Template-July24 4 CONSIDER QUESTIONS Document the Answers to Your Questions Here Consider Questions from CJSim™ Question #1 Consider Questions from CJSim™ Question #2 Consider Questions from CJSim™ Question #3 1. Ask about the dizziness, in detailed 2. Orthostatic hypotension/Parkinson’s 3. Reinforce fall precautions/assist w/ position changes/ non slip socks/bed in lowest position 1.