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Unformatted text preview: Clinical Learning Direct Patient Care Documentation Direct Patient Care Documentation 1 Table of Contents Patient Worksheet ....................................................................................................................................... 3, 4, 5 I-SBAR ................................................................................................................................................................... 6 Labs ....................................................................................................................................................................... 7 Healthcare Provider Orders ................................................................................................................................. 8 IV Access ............................................................................................................................................................... 9 Diagnostic Tests .................................................................................................................................................... 9 Therapies .............................................................................................................................................................. 9 Nursing Skill .......................................................................................................................................................... 9 Nursing Diagnoses ................................................................................................................................................ 9 Care Plan #1 ........................................................................................................................................................ 10 Concept Map #1 ................................................................................................................................................. 11 Medication Template ......................................................................................................................................... 12 Diagnostic Procedure Template......................................................................................................................... 13 Therapeutic Procedure Template ...................................................................................................................... 14 Nursing Skill Template ....................................................................................................................................... 15 Direct Patient Care Documentation 2 Patient Care Worksheet Directions: The Patient Care Worksheet and Reflection Journal must be completed for one patient whom you are providing direct care in a clinical learning setting. All information within this packet must be handwritten and reviewed with your clinical faculty on your assigned clinical day (or as directed by course faculty). If additional space is needed, please use the back of the page. Patient Data & Assessment Findings Student:_______________________________________ Date of care:______________________ Age:_________ Gender: ________ Race/Ethnicity: _____________ Healthcare Provider(s):__________________________________________________________________________ Religion:_______________ Allergies:_______________________ Advance Directive & Clinical Significance: Code status:_______________________ Durable Power of Attorney Living Will Other ___________________________________________________________________________________________________________________________________ Socioeconomic Factors & Clinical Significance: ______________________________________________________________________________ Past Medical History & Clinical Significance:_________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ Admission Reason & Date:_____________________________________________________________________________________________________ Primary Medical Diagnosis & Clinical Significance:__________________________________________________________________________ Pathophysiology Description with APA citation: ____________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ Other Health Problems & Clinical Significance:_______________________________________________________________________________ Quality in Safety Education Nurses (QSEN) Risk: ________________________________________________________________________ ____________________________________________________________________________________________________________________________________ Medications: (List medications below and complete one Active Learning Template: Medication located on page 13 of this packet for each medications in which you have not previously completed a template. See Assignment Guidelines for further information). Drug/Classification Clinical Significance ________________________________________________ _________________________________________________________________________ ________________________________________________ _________________________________________________________________________ ________________________________________________ _________________________________________________________________________ ________________________________________________ __________________________________________________________________________ ________________________________________________ __________________________________________________________________________ ________________________________________________ __________________________________________________________________________ Direct Patient Care Documentation 3 Initial Assessment Findings & Time___________ Pain Scale Used with Rationale Vital Signs: T_______ P________ Resp______ SpO2_____ BP_________ Height ______ Weight ______ Apical HR ___ _________________________________________________ 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, where?)________________________________________ S (Severity: What is the intensity of the pain)___________________________________________ T (Temporal: Is the pain constant, or does it come and go?)_________________________________ Ongoing Assessment Findings & Time___________ Vital Signs: Pain Scale Used with Rationale T_______ P________ Resp_______ SpO2______ BP_________ Height ______ Weight ______ Apical HR ___ ___________________________________________________________ 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, where?)_________________________________________________ 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, lymph nodes, trachea): Head and Neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, lymph nodes, trachea): Breasts (discharge, lumps, pain): Breasts (discharge, lumps, pain): Respiratory (lung sounds, breathing effort, accessory muscles): Respiratory (lung sounds, breathing effort, accessory muscles): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Abdomen (inspection, bowel sounds, palpation, contour): Abdomen (inspection, bowel sounds, palpation, contour): Bowel Incontinence ______ Last BM ______________ Bowel Plan _______ Bowel Incontinence ______ Last BM ____________ Bowel Plan ___________________ Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): 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): Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities): Direct Patient Care Documentation 4 Genitourinary (burning with urination, frequency, color of urine): Urinary Incontinence _______ Toileting Plan ________________ Genitourinary (burning with urination, frequency, color of urine): Urinary Incontinence _______ Toileting Plan ________________ Pelvic (Female: LMP): Pelvic (Female: LMP): Rectal (bleeding, hemorrhoids): Rectal (bleeding, hemorrhoids): Specialty Assessment (Mental Health Exam, Fetal Heart Rate, etc.): Specialty Assessment (Mental Health Exam, Fetal Heart Rate, etc.): Telemetry Rhythm Strip: Attach your patient’s rhythm strip below and determine the following information: PRI: ________ QRS:_________ QT:_________ Rate: _________ Rhythm:____________________________________________________________ Direct Patient Care Documentation 5 I Introduce yourself S Situation B Your Name: Your Title: Reason for being there: Patient: Age: Gender: Height/Weight: Allergies: Code status: Privacy Code: Time: Past Medical History: Attending Physician: Patient Chief Complaint: Current Medications: Social History: Background A Assessment Isolation RESPIRATORY CARDIOVASCULAR Vital Signs: B/P HR RR TEMP SP02 PAIN Falls risk:_________ Accu check:_______ IV Site: _____________________________IV Fluids:____________________________ Isolation Precautions N Y Contact Air Droplet NEUROLOGICAL GI/GU I&O INTEGUMENTARY PSYCHOLOGICAL FAMILY - SUPPORT SAFETY LABS/TEST R Teaching needed: Abnormal: Pending: Hand off report to: From: REQUEST/ RECOMMENDATION Direct Patient Care Documentation 6 LABS Test Result/ Date Norm Reason out of norm/reason for drawing if normal or not drawn Test WBC Glu RBC BUN Hgb Na Hct K Plt Cl Chol Creat Trig CO2 LDH Ca PT Phos APTT Mag AST T.Pro ALT Alb Tdl* Tdl* Result/ Date Norm Reason out of norm/reason for drawing if normal or not drawn *Therapeutic Drug Level Direct Patient Care Documentation 7 Healthcare Provider Orders Item Order/Frequency Reason (explain specifically why ordered for this patient) Diet I/O __ ordered __ not ordered VS Activity Accu-check Foley NG tube PEG tube PEJ tube Chest tube Trach Suctioning Drains Ostomy Dressing change &/or wound care Treatments Special Equipment Other Direct Patient Care Documentation 8 IV ACCESS Type: Site: Assessment of IV site: Last dressing change: Last tubing change: Reason for IV access: Fluid/rate: DIAGNOSTIC TESTS Select one procedure from the healthcare orders table and complete one Active Learning Template: Diagnostic Procedure. The selected procedure should be one in which you have not previous completed a template for this session. Review the Active Learning Template: Diagnostic Procedure Rubric for more information. THERAPIES Select one procedure from the healthcare orders table and complete one Active Learning Template: Therapies Procedure. The selected procedure should be one in which you have not previous completed a template for this session. Review the Active Learning Template: Therapies Procedure Rubric for more information. NURSING SKILL Select one procedure from the healthcare orders table and complete one Active Learning Template: Nursing Skill. The selected skill should be one in which you have not previous completed a template for this session. Review the Active Learning Template: Nursing Skill Rubric for more information. NURSING DIAGNOSIS Identify three nursing diagnoses for your patient and list them by priority below. Complete one care plan and one concept map for your top nursing diagnosis for the session. Approval from your clinical faculty on your assigned clinical day (or as directed by course faculty) is required prior to completing your concept map and care plan for the session. 1.______________________________________________________________________________ ___ __________________________________________________________ 2.___________________________________________________________________________ __ _______ __________________________________________________________ 3.___________________________________________________________________________ _______ __________________________________________________________ Direct Patient Care Documentation 9 Care Plan #1 Nursing Diagnosis #1: Related To: As Evidenced By: Goals/Expected Outcome(s) (Minimum 1): Nursing Intervention(s) (Minimum 3): Rationale: Evaluation: Direct Patient Care Documentation 10 Concept Map #1 Direct Patient Care Documentation 11 Direct Patient Care Documentation 12 Direct Patient Care Documentation 13 Direct Patient Care Documentation 14 Direct Patient Care Documentation 15 ...
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