Create Clinical Judgment Plan (CJP).

Patient Information:

• Begin with the patient’s demographics, medical history, and chief complaint.
• If available, provide information about the patient’s background and relevant medical history.
• Mention the patient’s vital signs, if applicable.

Assessment:

• Describe the patient’s condition and what you have observed or assessed.
• Reference any diagnostic tests or findings that inform your assessment.
• Cite relevant clinical guidelines or medical literature for your diagnosis.

Nursing Diagnosis:

• Identify the nursing diagnosis based on the patient’s condition and needs.
• Utilize NANDA-I (North American Nursing Diagnosis Association International) terminology for nursing diagnoses.
• Provide a rationale for your nursing diagnosis.

Goals and Expected Outcomes:

• Outline specific, measurable, and time-bound goals for the patient.
• Ensure that these goals are realistic and relevant to the patient’s condition.
• Refer to evidence-based practice or clinical guidelines to support your choice of goals.

Interventions:

• Detail the nursing interventions you plan to implement to address the nursing diagnosis and achieve the goals.
• Justify your choice of interventions with evidence from relevant sources.
• Include potential complications or risks and how you plan to mitigate them.

Evaluation:

• Describe how you will evaluate the effectiveness of your interventions and whether the goals were met.
• State when and how you will reassess the patient’s condition.
• Use data and objective measures to assess outcomes.

Rationale:

• Explain the rationale for your choice of nursing interventions, goals, and evaluation methods.
• Cite reputable sources and clinical guidelines that support your plan.

If you could provide more specific information about the fake patient, their medical condition, and the template you’re using, I would be happy to help you create a detailed Clinical Judgment Plan.