NR283 Nursing Note: Client was playing basketball, injured his right ankle, \u201cI made this great jump shot, and when I landed, I felt something pop in my right ankle.\u201d Right ankle with slight swelling, no obvious deformity, toes warm with capillary refill less than 3 seconds. +active ROM in toes and denies increased numbness or change in tingling. Has had numbness and tingling in both feet for the past year. Reports doing daily capillary blood glucose monitoring but does not always follow a diet plan. \u201cIt\u2019s hard, I don\u2019t want my friends to think of me as sick, so I eat what they eat. I take about the same amount of insulin every day.\u201d
\n4\/3 1015\tNeuro\/Cognitive: Alert and oriented x 4, pupils 4 mm and PERRLA. Grips equal and strong. Right lower extremity, non-weight-bearing, toes wiggle, full weight-bearing with left leg. Bilateral foot numbness and tingling x 1 year.
\nCardiovascular: S1\/S2, regular rhythm.
\nRespiratory: Lungs clear, no cough noted or reported.
\nGastrointestinal: Abdomen soft with active bowel sounds x 4 quadrants. Last bowel movement was today.
\nIntegumentary: Skin appears intact. +blue bruising, +swelling to right lateral ankle.
\n4\/3 1145\tNursing Note: Client inquiring about snacks, \u201cI haven\u2019t eaten today, and I feel dizzy. I get like this if I don\u2019t eat.\u201d Blood glucose: 82. Client took NPH insulin at approximately 0800, did not eat. Client unsure how much insulin he took, \u201cI was in a hurry, but took about the same number on the syringe as I usually do.\u201d Snack of turkey sandwich and milk, client, ate 100%.
\n4\/3 1415\tNursing Note: Client reports seeing a provider on the other side of town for diabetes management every six months. Has not had blood drawn in the past year, \u201cI couldn\u2019t get to the lab.\u201d Completes capillary blood glucose checks about once a day, time varies, sometimes before he eats and sometimes after. \u201cI didn\u2019t know that it mattered; my mom never did that. Maybe that is why I sometimes feel so weak and dizzy.\u201d Denies ever having diabetic education as a teen or an adult, saying it was never offered and he didn\u2019t know he needed it. Provider informed of client conversation.
\n4\/3 1500\tNursing Note: Client return demonstrates safe crutch walking and elastic bandage application. Discharge instructions reviewed with the client. Client verbalized understanding of discharge instructions and will make appointments with clinic dietitian and diabetic educator. Blood glucose 135 on discharge.
\nJake Abbott 28-years-old
\nCJSim Overview: Young adult with an ankle injury.<\/p>\n
Purpose
\nThis assignment is designed to support continued learning, developing critical thinking, and promoting clinical judgment skills throughout the pre-licensure BSN students\u2019 education. The assignment will be completed based on the course in which the student is enrolled.
\nProgram outcomes: This assignment enables the student to meet the following outcomes:
\n1.\tProvides individualized comprehensive care based on theories and principles of nursing and related disciplines to individuals, families, aggregates, and communities, from entry to the healthcare system through long-term planning.
\n2.\tDemonstrates leadership and collaboration with consumers and other healthcare providers in providing care and\/or delegating responsibilities for health promotion, illness prevention, health restoration, health maintenance, and rehabilitative activities.
\n4.\tIntegrates clinical judgment in professional decision making and implementation of the nursing process.
\n8.\tIncorporates evidence-based practice in the provision of professional nursing care to individuals, families, aggregates, and communities.
\nDue date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.
\nTotal points possible: 80 points
\nPreparing the assignment:
\nFollow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
\n1)\tStudents will use the CJSim\u2122 Unit Census document (found in the CJSim\u2122 Access in Canvas) to identify the assigned client. CJSim\u2122 Assignments per course:
\na.\tFor students who are in NR 228: Nutrition, complete only the client below:
\n\u2022\tClient: Jenna Batch (Surgical Care Unit)
\nb.\tFor students who are in NR 283: Pathophysiology, complete one of the following clients:
\n\u2022\tClient: Jake Abbott (Fundamentals Unit)
\n\u2022\tClient: Josie Brennan (Fundamentals Unit)
\n\u2022\tClient: Jolene Sigmund (Pathophysiology Unit)
\n\u2022\tThe use of a nasogastric (NG) tube is mentioned during the Jolene Sigmund CJSim\u2122. An NG tube is inserted through the nose into the stomach and can be used to decompress the stomach by removing gastric contents and\/or administer medications.
\n2)\tStudents will care for the CJSim\u2122 client as if they are caring for a living, breathing client. This includes a thorough review of the electronic health record (EHR).
\n3)\tStudents need to meet two criteria for each CJSim\u2122 interaction:
\na.\tScore at least 85% on each attempt.
\nb.\tSpend at least 15 minutes on each interaction.
\nNote: CJSim\u2122 does not have a timer, please ensure you set a timer and have the screenshot with the 15 minutes per attempt.
\n4)\tStudents may retake CJSim\u2122 cases until the two criteria are met.
\n5)\tResources available to support successful completion of this assignment include:
\na.\tThe BSN Program Library Guide, available using a link on the left navigation bar in Canvas, includes diagnosis and pharmacology resources, as well as the Made Incredibly Easy books.<\/p>\n
b.\tTextbooks from courses taken before, or concurrent with, this course, including
\n\u2022\tPotter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2023). Fundamentals of nursing (11th ed.). Elsevier.
\n\u2022\tPagana, K. D., Pagana, T. J., & Pagana, T. H. (2021). Mosby\u2019s\u00ae Diagnostic and Laboratory Test Reference, (15th ed.). Mosby.
\n\u2022\tVallerand, A. H., & Sanoski, C. A. (2022). Davis’s drug guide for nurses (18th ed.). F. A. Davis.
\n6)\tSubmits screenshot of completed CJSim\u2122 in the assignment dropbox. Screenshot needs to include student name, CJSim\u2122 case title, date\/time of completion, grade received on the CJSim\u2122, and total time spent in the CJSim\u2122. See sample below: <\/p>\n
7)\tStudents may be required to complete specific or additional CJSim\u2122 cases as deemed necessary by faculty.
\n8)\tCompletes reflective journal
\na.\t150 word minimum reflection.
\nb.\tSummarizes new information learned by completing this assignment.
\nc.\tReflects on how the new knowledge will impact future behavior as a healthcare professional.
\nd.\tLogical reflective flow which follows standard grammatical rules with minimal (1-2) misspellings and APA where applicable.
\n9)\tDetailed criteria are listed in the Grading Rubric. <\/p>\n
Grading Rubric
\nCriteria are met when the student\u2019s application of knowledge demonstrates achievement of the outcomes for this assignment.
\nRequired Criteria
\n(Points possible\/% of total points available)\tSatisfactory Level of Performance\tUnsatisfactory Level of Performance
\nCJSim\u2122(s)
\n(50 points\/62.5%)\t50 points\t0 points
\nRequired Criteria
\n1.\tSelects and completes the CJSim\u2122(s) based on the client and course.
\n2.\tCompletes a minimum of 15 minutes per CJSim\u2122.
\n3.\tAchieves an 85% or better grade on the CJSim\u2122(s).
\n4.\tSubmits screenshot of completed CJSim\u2122 in the assignment dropbox. \tAll required criteria met\tLess than 4 criteria met
\nReflective Journal
\n(30 points\/37.5%) \t30 points\t26 points\t16 points\t0 points
\nRequired Criteria
\n1.\t150 word minimum reflection.
\n2.\tSummarizes new information learned by
\ncompleting this assignment.
\n3.\tReflects on how the new knowledge will impact
\nfuture behavior as a healthcare professional.
\n4.\tLogical reflective flow which follows standard grammatical rules with minimal (1-2) misspellings and APA where applicable. \tIncludes 4 requirements for section.\tIncludes 3 requirements for section.\tIncludes 2 requirements for section.\tLess than 2 requirements for this section presented.
\nTotal Points Possible = 80 points<\/p>\n
++++<\/p>\n
Clinical Judgment Simulation: Analyzing a Case Study of a Young Adult with an Ankle Injury<\/p>\n
Introduction<\/p>\n
Clinical judgment simulations (CJSim) are an effective tool for developing critical thinking and clinical decision-making skills among pre-licensure nursing students (Smith et al., 2021). This paper analyzes a case study of Jake Abbott, a 28-year-old male with an ankle injury, presented through a CJSim. The purpose is to demonstrate the application of nursing theories, principles, and evidence-based practice in providing comprehensive care to the client.<\/p>\n
Case Analysis<\/p>\n
The nursing notes reveal that Jake Abbott sustained an ankle injury while playing basketball. He reported hearing a popping sound upon landing and experienced swelling in his right ankle. The initial assessment showed slight swelling without obvious deformity, and the client had active range of motion in his toes. Notably, Jake reported numbness and tingling in both feet for the past year (Nurse, 2024).<\/p>\n
Further investigation revealed that Jake has diabetes and performs daily capillary blood glucose monitoring but struggles with following a diet plan. He admitted to eating the same foods as his friends to avoid being perceived as sick. Jake also reported taking approximately the same amount of insulin daily (Nurse, 2024).<\/p>\n
The nursing notes indicate that Jake experienced dizziness due to not eating after taking his insulin. His blood glucose level was 82, and he was unsure of the exact amount of insulin he had taken that morning. After consuming a snack, Jake’s condition improved (Nurse, 2024).<\/p>\n
It was also discovered that Jake sees a provider every six months for diabetes management but has not had blood drawn in the past year due to accessibility issues. He performs capillary blood glucose checks once daily, with varying timing. Jake denied ever receiving diabetic education as a teen or adult (Nurse, 2024).<\/p>\n
Upon discharge, Jake demonstrated safe crutch walking and elastic bandage application. He verbalized understanding of the discharge instructions and agreed to make appointments with a clinic dietitian and diabetic educator (Nurse, 2024).<\/p>\n
Discussion<\/p>\n
This case study highlights the importance of comprehensive nursing care that addresses not only the presenting injury but also the underlying chronic condition. Jake’s ankle injury was managed appropriately with non-weight-bearing status, assessment of neurovascular function, and pain management (Kaur et al., 2022). However, his uncontrolled diabetes poses a significant risk for complications and requires further intervention.<\/p>\n
Jake’s lack of proper diabetic education and inconsistent self-management practices are concerning. Diabetes self-management education (DSME) is crucial for empowering patients to effectively manage their condition and prevent complications (Kotsani et al., 2021). Nurses play a vital role in providing DSME and promoting adherence to treatment plans (Adu et al., 2019).<\/p>\n
The nursing interventions in this case, such as facilitating appointments with a dietitian and diabetic educator, demonstrate the application of nursing theories and principles in providing individualized, comprehensive care (Potter et al., 2023). Collaboration with other healthcare providers is essential for optimal patient outcomes (Velhal et al., 2020).<\/p>\n
Conclusion<\/p>\n
The CJSim case study of Jake Abbott emphasizes the significance of holistic nursing care that addresses both acute and chronic conditions. By integrating clinical judgment, nursing theories, and evidence-based practice, nurses can provide comprehensive care that promotes health, prevents complications, and supports patient self-management. Continuous education and interprofessional collaboration are key to achieving optimal patient outcomes.<\/p>\n
References
\nAdu, M. D., Malabu, U. H., Malau-Aduli, A. E. O., & Malau-Aduli, B. S. (2019). Enablers and barriers to effective diabetes self-management: A multi-national investigation. PloS One, 14(6). https:\/\/doi.org\/10.1371\/journal.pone.0217771<\/p>\n
Kaur, J., Singh, G., & Kaur, M. (2022). Effectiveness of early mobilization versus delayed mobilization in post-operative recovery among patients with ankle fracture: A randomized controlled trial. Journal of Musculoskeletal Research, 25(01). https:\/\/doi.org\/10.1142\/S0218957722410049<\/p>\n
Kotsani, K., Papasarantopoulos, P., Koutsovasilis, A., Ioannis, K., Roumeliotis, L., Georga, E., Kourlaba, G., & Manolis, A. (2021). Effect of diabetes self-management education programs on glycemic control in patients with type 2 diabetes mellitus: An umbrella review of systematic reviews and meta-analyses. Scientific Reports, 11(1), 23421. https:\/\/doi.org\/10.1038\/s41598-021-02896-7<\/p>\n
Nurse, N. (2024). Nursing notes for Jake Abbott. Fundamentals Unit, CJSim.<\/p>\n
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2023). Fundamentals of nursing (11th ed.). Elsevier.<\/p>\n
Smith, S. J., Farra, S. L., Ulrich, D. L., Hodgson, E., Nicely, S., & Mickle, A. (2021). Effectiveness of two varying levels of virtual reality simulation. Nursing Education Perspectives, 42(2), E1-E4. https:\/\/doi.org\/10.1097\/01.NEP.0000000000000773<\/p>\n
Velhal, G. D., Salve, B. S., Krishnakumar, P., & Velhal, S. (2020). Interprofessional collaborative practice and patient care\u2013current status and future prospects in India. Journal of Education and Health Promotion, 9, 294. https:\/\/doi.org\/10.4103\/jehp.jehp_393_20<\/p>\n","protected":false},"excerpt":{"rendered":"
NR283 Nursing Note: Client was playing basketball, injured his right ankle, \u201cI made this great jump shot, and when I landed, I felt something pop in my right ankle.\u201d Right ankle with slight swelling, no obvious deformity, toes warm with capillary refill less than 3 seconds. +active ROM in toes and denies increased numbness or […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[591,1377,247,907],"tags":[1750,1749,1747,1751,1748],"class_list":["post-4691","post","type-post","status-publish","format-standard","hentry","category-case-study-assignment-homework-help","category-medicine-and-healthcare","category-medicine-homework-help","category-write-answer-to-a-medical-case-study-assignment","tag-clinical-judgment-simulation-analyzing-a-case-study-of-a-young-adult-with-an-ankle-injury","tag-injured-his-right-ankle","tag-jake-abbott-28-years-old-cjsim-overview-young-adult-with-an-ankle-injury","tag-nr283","tag-nursing-note-client-was-playing-basketball"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/4691","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/comments?post=4691"}],"version-history":[{"count":2,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/4691\/revisions"}],"predecessor-version":[{"id":4693,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/4691\/revisions\/4693"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/media?parent=4691"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/categories?post=4691"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/tags?post=4691"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}