Concept Map This assignment is designed to extend the learner’s use of concept mapping as a tool for clinical care planning. The nursing process continues to provide the foundation for organizing info
CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 1 OF 8 Student Name: D#: Date: Course: Session and Year: Directions This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning setting. All informa tion within this packet must be handwritten, (with the exception of the reflectio n journal) reviewed with your faculty on your assigned clinical day and submitted with in 24 hours (or as directed by course coordinator). If additional space is needed, please use the back of each page. • Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the Clinical Learning Evaluatio n. Satisfactory rating meets the following: with the following. – Clinical Learning Competency: Completes all clinical learning experiences and requirements successfully (PO 5). • Performance Descriptor: Completes all assignments related to the clinical learning experience within established guidelines. • I-SBAR: Utilized for receiving report. Areas that indicate clinical significan ce are to be completed after patient report has been received. Students should deliver a hand-off report at the end of their shift to t he bedside nurse. • Assessment Findings, Labs and Healthcare Provider Orders: Document your initial and ongoing assessment findings, lab results wit h why they were drawn specifically for your patient and healthcare provi der orders with why they were specifically ordered for your patient. • AT I ® Active Learning Templates Required: – Nursing Skill: Select one nursing skill from the healthcare orders table and complete one Active Learning Template: Nursing Skill. The selected nursing skill should be one in which you have not previously completed a template for this session. – Medications: List medications below and complete one Active Learning Template: Medication for each medication classification in which you ha ve not previously completed a template. Time Due Drug/Classification Clinical Significance • Nursing Diagnosis: Identify three nursing diagnoses for your patient and list them by prior ity below. Complete one concept map for your top nursing diagnosis listed below. 1. 2. 3. • Reflection Journal Complete a reflection journal and submit to your faculty within 24 hou rs of completing your clinical learning experience. Reflective journaling provid es a format to share your knowledge, skills, experiences and personal reflection r elated to concepts and strategies learned throughout your program. The reflection journal is required to be typed, Word document, Times New Roman 12-point font. Minimum of one page and no more than three pages. 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Offlce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 2 OF 8 I-SBAR I Introduce Yourself Your Name:D#:Your Title:Reason for being there: S Situation Patient: Age:Gender:Height/Weight:Race/Ethnicity:Allergies:Code Status:Advance Directive (Durable Power of Attorney, Living Will, Other) & Clinical Significance: Privacy Code:Date of Care/Time: Attending Physician: Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance: Pathophysiology of Primary Medical Diagnosis: B Background **Include clinical significance with each** Past Medical History: Past Surgical History: Social History/Socioeconomic Factors: A Assessment Vital Signs: B/P HR RR TEMP SP02 PAIN Falls risk:_________ Accu check:_________ IV Site: _____________________________ IV Fluids:____________________________ Isolation Isolation Precautions N Y Contact Air Droplet RESPIRATORY CARDIOVASCULAR NEUROLOGICAL GI/GU I & O INTEGUMENTARY PSYCHOLOGICAL FAMILY – SUPPORT SAFETY Teaching needed: Quality in Safety Education Nurses (QSEN) Risk(s) Identified: R REQUEST/ RECOMMENDATION Hand off report to: From: 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 3 OF 8 Initial Assessment Findings and Time: Vital signs: T: P: Resp: Sp0 2: BP: Height: Weight: Apical HR: Pain scale used with rationale: P (Palliative, Provocative) What makes the pain better/worse? Q (Quality) How is the pain described? R (Radiation) Does the pain travel or spread anywhere else? If so, whe re? S (Severity) What is the intensity of the pain? T (Temporal) Is the pain constant, or does it come and go? Head and Neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea): Respiratory (lung sounds, breathing effort, accessory muscles): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Abdomen (inspection, bowel sounds, palpation, contour): Bowel incontinence: Bowel plan: Last BM: Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities): Genitourinary (burning with urination, frequency, color of urine): Urinary incontinence: Toileting plan: Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.): Abuse screen (physical, elderly, child, sexual, etc.): IV access (type/size, site, reason for IV access, type of fluid/rate, reason f or type of IV fluid, assessment of IV site, last dressing change): Ongoing Assessment Findings and Time: Vital signs: T: P: Resp: Sp0 2: BP: Height: Weight: Apical HR: Pain scale used with rationale: P (Palliative, Provocative) What makes the pain better/worse? Q (Quality) How is the pain described? R (Radiation) Does the pain travel or spread anywhere else? If so, whe re? S (Severity) What is the intensity of the pain? T (Temporal) Is the pain constant, or does it come and go? Head and Neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea): Respiratory (lung sounds, breathing effort, accessory muscles): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Abdomen (inspection, bowel sounds, palpation, contour): Bowel incontinence: Bowel plan: Last BM: Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities): Genitourinary (burning with urination, frequency, color of urine): Urinary incontinence: Toileting plan: Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.): Abuse screen (physical, elderly, child, sexual, etc.): IV access (type/size, site, reason for IV access, type of fluid/rate, reason f or type of IV fluid, assessment of IV site, last dressing change): 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 4 OF 8 Labs Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn WBC RBC Hgb Hct Plt Chol Trig LDH PT APTT AST A LT Tdl* *Therapeutic drug level Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn Glu BUN Na K Cl Creat CO2 Ca Phos Mag T.Pro Alb Tdl* 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Ofce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 5 OF 8 Healthcare Provider Orders Items Order/Frequency Reason (explain specifically why ordered for this patient) Diet I/O VS Activity Accu-check Foley NG tube PEG tube PEJ tube Chest tube Trach Suctioning Drains Ostomy Dressing change and/or wound care Treatments Special equipment Other 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Ofce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 6 OF 8 Concept Map Interventions for Nursing Diagnosis Rationales for Interventions Nursing Diagnosis Medication(s) r/t Diagnosis Signs and Symptoms Lab Values Related to Nursing Diagnosis Medication Side Effects Patient Outcome(s) 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Ofce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 7 OF 8 Active Learning Template: Medication Student Name: Medication: Review Module Chapter: Category Class: PURPOSE OF MEDICATION Expected Pharmacological Action Therapeutic Use Complications Medication Administration Contraindications/Precautions Nursing Interventions Interactions Client Education Evaluation of Medication Effectiveness 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Offlce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 8 OF 8 Active Learning Template: Nursing Skill Student Name: Skill Name: Review Module Chapter: Description of skill CONSIDERATIONS Indications Nursing Interventions (pre, intra, post) Outcomes/Evaluation Client Education Potential Complications Nursing Interventions 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Offlce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information.
Concept Map This assignment is designed to extend the learner’s use of concept mapping as a tool for clinical care planning. The nursing process continues to provide the foundation for organizing info
Adrianna F. Pierson NR 226: Fundamentals – Patient Care Professor Thomas September 16, 2020 Week 3 Clinical for Robert Jones Questions and Answers Questions: What are your primary concerns for this patient and what assessments and interventions would be associated with your concerns and why? What do you anticipate the patient’s home medications prior to admission might be and why? What medications do you anticipate the health care provider would prescribe while the patient is in the hospital and why? What medications would you anticipate the healthcare provider prescribing for the patient’s discharge and why? Answers: Concerns: Deficient knowledge, risk for infection or any adversity, pain, mobility, bone deformities, joint degeneration, muscle spasms, etc. Assessments: Complete comprehensive assessment to include pain and pain history. Interventions: Assess the client’s level of understanding, risk for injury, risk for ineffective breathing patterns, risk for altered tissue profusion and deficient fluid volume, subjection of pain, historical experiences with pain and relief, identify things that cause aggravation, be mindful to determine nonverbal cues of the client that pain is present, and determine if the client is experiencing any emotional or physical distress, develop a care plan for pain relief, apply heat or ice therapies, reposition client frequently, remove any client stressors, reassess client comfort and pain prior to any activities and medically treat if necessary, make adequate time for client rest periods, make use of any adaptive equipment or devices as needed, educate and instruct the client on medication regimen, adverse reactions, contraindications, duration, and completion, determine fall risk, safety concerns, etc. Pain medications: relieve pain NSAIDs: anti-inflammatory Muscle relaxants: relieve or relax painful muscle spasms Corticosteroids: anti-inflammatory for musculoskeletal pain disorders Pain or Anesthetics: control pain Possibly: Antibiotics: treat infection Pain: relieve pain. Other ways to manage pain: heat or ice applications Reflection for Robert Jones Nursing Diagnosis: Impaired walking r/t compromised ability to move purposefully within the environment as evidenced by pain. Impaired physical mobility r/t decreased muscle strength and endurance as evidenced by degenerative joint disease. Impaired physical mobility r/t limited strength as evidenced by limited range of motion. Priority Nursing Actions: Acknowledge and accept the client’s subjection of pain. Educate and treat the client’s pain with multimodal therapies. Reposition client frequently (every two hours). Medicate client before activities or relative procedures. Nurse Note Robert Jones is a 52-year-old male in postoperative care from an elective total right knee arthroplasty. He currently expressed having a new cramping pain in his right calf that is scored 8/10 on a scale from 0-10. He was admitted two days ago. He has a past medical history of chronic osteoarthritis. (App iHuman, 2020) His vitals are stable for the most part. However, he is experiencing tachypnea. On his right calf there is an area of redness and 1+ pitting edema. The right calf is 3 cm wider in girth than the left calf. The patient complains of pain upon palpation of this calf. There are no diminished pulses in the right calf or lower extremities. Currently, Mr. Jones is refusing to wear the prescribed SCDs. The incision site is well-approximated with no redness, swelling, or drainage present at the site. Sutures are intact and peri-wound area is clean and dry. (App iHuman, 2020) It is anticipated that the provider will visit Mr. Jones as soon as possible to evaluate and perform a thrombolytic assessment. I have made some recommendations and requested some relative items to include a doppler scan and lab tests. Patient is currently on bedrest with SCDs off despite nursing advisement and education. (App iHuman, 2020) Thoughts and Considerations The clinical taught me that consciousness is vital to the quality of care and communication provided by nurses. To first realize to be cognizant of the internal and external environment will incite the appropriate actions, connections, continuance of education, and professionalism. Having acquired this mindset, I further learned to identify that from the initial approach to accomplishing any nursing goal at hand is a process. References App iHuman. (2020). iHuman: Robert Jones. Retrieved September 16, 2020, from https://app.i-human.com/player?play_mode=PLAY&referer=https%3A%2F%2Fih2.i-human.com%2Fassignments&sessionId=251984ac-228c-412b-bee6-80def9363c48&timeZone=America%2FDenver&token=eyJhbGciOiJIUzI1NiJ9.eyJub25jZSI6ImMwMzRhODc4LTRhOTItNGJlYS04NmY1LTU5NTAyOTdmNjFjMiIsInBhcnRpYWxfcGFzc3dvcmQiOm51bGx9.LATiTNbOH2bd5WyKvQ2I2Z_EbNnrSjimdWIsxYUe5mQ&url=https%3A%2F%2Fih2.i-human.com%2Fattempts%2F1273972%2Fnine_play.xml&utcOffset=-21600 Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical Examination & Health Assessment (Eighth). Elsevier.