Relearning: Clinical Judgment Plan of Care Template
Student Name: Date of Admission:
CJSim™ Client Initials: GROUP Date of Care:
Age/DOB: Schol-aged Admitting Diagnosis:
Allergies: Comorbidities:
BSA/BMI: Code Status: 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: Health Promotion/Development:
Be prepared to accommodate diverse cultural and spiritual needs Be aware of the developmental stages of potential pediatric
of accident victims and their families. victims and adapt care strategies accordingly.
Neurological/Cognition/Coping/Adaptation/Function: Infection/Immunity/Inflammation:
Stock up on antibiotics and sterile dressings for wound
Anticipate potential neurological injuries and psychological management and infection control.
trauma among the victims. Plan for immediate assessment and
interventions. Mobility:
Nutrition/Elimination:
Prepare for potential urgent nutritional and elimination needs, Prepare for immobilization equipment and procedures for
especially for severely injured patients. potential musculoskeletal injuries.
Pain/Comfort/Tissue Integrity:
Fluid/Electrolytes/Acid-Base: Arrange for a sufficient supply of pain medications and wound
care materials.
Ready IV fluids and equipment for managing possible fluid
imbalances and shock. Safety:
Gas Exchange/Perfusion: Prioritize safety protocols, including triage procedures and
emergency response plans.
Ensure availability of oxygen tanks, ventilators, and monitoring
equipment for managing respiratory issues and perfusion Other:
problems.
Glucose Regulation: Ensure psychological support services are available for victims
Have glucose testing kits ready for any victims with diabetes or and families.
those at risk of glucose dysregulation due to stress.
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. Multiple trauma cases with 1. Multiple trauma cases with 1. Multiple trauma cases with
1. Triage incoming patients
varying degrees of injury varying degrees of injury varying degrees of injury
to assess the severity of
severity. severity. severity.
injuries.
2. Potential for life-threatening 2. Potential for life-threatening 2. Potential for life-threatening
2. Monitor for signs of shock,
conditions like head injuries, conditions like head conditions like head
head injuries, or internal
internal bleeding, or injuries, internal bleeding, injuries, internal bleeding,
bleeding.
fractures. or fractures. or fractures.
3. Look for emotional distress
3. Psychological impact, 3. Psychological impact, 3. Psychological impact,
or trauma in victims,
especially in children, due to especially in children, due especially in children, due
especially children.
the traumatic event. to the traumatic event. to the traumatic event.
Priority Laboratory Tests/ Priority Actual & Potential Priority Collaborative
Priority Medications
Diagnostic Cues Complications/Cues Actions
, Relearning: Clinical Judgment Plan of Care Template
START of Shift (CJSim™) Priorities
1. Imaging studies (e.g., X-
rays, CT scans) for 1. Multiple trauma cases with 1. Multiple trauma cases with 1. Multiple trauma cases with
suspected fractures or varying degrees of injury varying degrees of injury varying degrees of injury
internal injuries. severity. severity. severity.
2. Complete Blood Count 2. Potential for life-threatening 2. Potential for life-threatening 2. Potential for life-threatening
(CBC) and coagulation conditions like head injuries, conditions like head conditions like head
profiles for suspected internal bleeding, or injuries, internal bleeding, injuries, internal bleeding,
internal bleeding. fractures. or fractures. or fractures.
3. Blood typing and 3. Psychological impact, 3. Psychological impact, 3. Psychological impact,
crossmatching in especially in children, due to especially in children, due especially in children, due
preparation for possible the traumatic event. to the traumatic event. to the traumatic event.
transfusions.
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