Patient Care Document Wk2.pdf - C H AMB ER LAIN U N I V E...

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Unformatted text preview: C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 1 OF 10 Student Name: Kasey Clemente  D#: Course: NR-224: Fundamentals – Skills Other 40742520 7/16/20  Date:   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 information within this packet must be handwritten, (with the exception of the reflection journal) reviewed with your faculty on your assigned clinical day and submitted within 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 Evaluation. Satisfactory rating meets the following: –C  linical 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. •P  atient Report: Utilized for receiving report. Students should deliver a hand-off report at the end of their shift to the bedside nurse. • Assessment Findings, Labs and Healthcare Provider Orders: Document your initial and ongoing assessment findings, lab results with why they were drawn specifically for your patient and healthcare provider orders with why they were specifically ordered for your patient. • ATI® Active Learning Templates Required: – Diagnostic Procedure: Select one diagnostic procedure from the healthcare orders table and complete one Active Learning Template: Diagnostic Procedure. The selected diagnostic procedure should be one in which you have not previously completed a template for this session. – Therapeutic Procedure: Select one therapeutic procedure from the healthcare orders table and complete one Active Learning Template: Therapeutic Procedure. The selected therapeutic procedure should be one in which you have not previously completed a template for this session. –N  ursing 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: Complete one Active Learning Template: Medication for each medication classification in which you have not previously completed a template. • Nursing Diagnosis: Identify three nursing diagnoses for your patient and list them by priority below. Complete one concept map for your top nursing diagnosis listed below. Acute pain related to arthroplast of the left knee as evidenced by reports of pain. Risk for infection related to athroplasty of the left knee. 1.  2. impaired physical mobility related to surgery as evidenced by limited ROM of the LLE. 3. • Reflection Journal: Complete a reflection journal and submit to your faculty within 24 hours of completing your clinical learning experience. Reflective journaling provides a format to share your knowledge, skills, experiences and personal reflection related 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 1 page and no more than 3 pages. 12-180406 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 2 OF 10 Patient Report and Information Patient MB Allergies Age/ Gender 52 Male Height/ Weight 6’3” 200 lb Chief Complaint PMH/PSH Neuro GI/GU Patient Report and Information Penicillin Primary Diagnosis Code Status/ Advance Directive Provider Dr Kahr Patient Allergies Deep joint infection Age/ Gender Primary Diagnosis full code Height/ Weight Code Status/ Advance Directive left knee pain HTN CAD RA L Knee AO x4 bowel sounds in all 4 VS Cardio Skin Chief Complaint BP 122/74 38.6C 99% O2 RA HR 92 redness, warm, swelling IV Resp Psych Right Forearm Left Forearm 20 single, social drinker, office PMH/PSH VS IV Neuro Cardio Resp GI/GU Skin Psych Risks/ Safety Infection of his Left Knee Risks/ Safety Tests/ Labs WBC BMP Blood Cultures Culture & Sensitivity of Knee Tests/ Labs Meds Transfer/ Discharge Provider Atenolol 25 mg chlorthalidone 25 mg Vancomycin Meds Transfer/ Discharge After meds are finished and pain level is down Patient Report and Information Patient Allergies Age/ Gender Height/ Weight Patient Report and Information Provider Patient Allergies Primary Diagnosis Age/ Gender Primary Diagnosis Code Status/ Advance Directive Height/ Weight Code Status/ Advance Directive Chief Complaint Provider Chief Complaint PMH/PSH VS IV PMH/PSH VS IV Neuro Cardio Resp Neuro Cardio Resp GI/GU Skin Psych GI/GU Skin Psych Risks/ Safety Risks/ Safety Tests/ Labs Tests/ Labs Meds Meds Transfer/ Discharge Transfer/ Discharge 12-180406 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 3 OF 10 Initial Assessment Findings and Time: Ongoing Assessment Findings and Time: Vital signs: T: 38.6 P: 92 Resp: 20 122/74 6’3 BP: Height: Weight: 200 Pain scale used with rationale: P (Palliative, Provocative) What makes the pain better/worse? Sp02: 99 Apical HR: 86 constant Vital signs: T: P: Resp: BP: Height: Weight: Pain scale used with rationale: P (Palliative, Provocative) What makes the pain better/worse? Sp02: Apical HR: Q (Quality) How is the pain described? Q (Quality) How is the pain described? R (Radiation) Does the pain travel or spread anywhere else? If so, where? R (Radiation) Does the pain travel or spread anywhere else? If so, where? S (Severity) What is the intensity of the pain? S (Severity) What is the intensity of the pain? T (Temporal) Is the pain constant, or does it come and go? 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): Head and Neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea): Respiratory (lung sounds, breathing effort, accessory muscles): Respiratory (lung sounds, breathing effort, accessory muscles): always there no 6/10 constant symmetrical on both sides, no lesions, facial expressions appropriate lung sounds clear bilaterally, no crackles, no rales. Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): no jvd, hear sounds S1 and S2 noted, no murmurs, tachycardia Abdomen (inspection, bowel sounds, palpation, contour): equal, sounds in all 4 quadrants Bowel incontinence: Bowel plan: Abdomen (inspection, bowel sounds, palpation, contour): Bowel incontinence: Last BM: Bowel plan: Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Last BM: Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): alert and oriented x4 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): Genitourinary (burning with urination, frequency, color of urine): Genitourinary (burning with urination, frequency, color of urine): Urinary incontinence: Urinary incontinence: NA Toileting plan: Pelvic (female: LMP): NA Rectal (bleeding, hemorrhoids): NA Integumentary (rashes, lesions, wounds, etc.): redness, warmth, swelling Specialty assessment (mental health exam, fetal heart rate, etc.): Toileting plan: Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.): NA Abuse screen (physical, elderly, child, sexual, etc.): Abuse screen (physical, elderly, child, sexual, etc.): NA IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change): IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change): 18 gauge of right antecubical 18 gauge of left antecubical 12-180406 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 4 OF 10 Telemetry Rhythm Strip: Attach your patient’s rhythm strip below and determine the following information: PRI: QRS: QT: Rate: Rhythm: NA Labs Result/ Date 13,500 4k-10k RBC 4.7 normal BUN Hgb 15 normal Hct 42 Plt 260 Test WBC Result/ Date 152 70-110 8 normal Na 135 normal normal K 3.5 3.5-5 normal Cl 0.9 normal Norm Reason out of norm/reason for drawing if normal or N/A if not drawn infection Test Glu Chol Creat Trig CO2 LDH Ca PT Phos APTT Mag AST T.Pro ALT Alb Tdl* Tdl* Norm Reason out of norm/reason for drawing if normal or N/A if not drawn high blood glucose low potassium * Therapeutic drug level 12-180406 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 5 OF 10 Healthcare Provider Orders Item Diet I/O VS Order/Frequency Regular Diet NA Q4H Activity NA Accu-check Check BG Foley NA NG tube NA PEG tube NA PEJ tube NA Chest tube NA Trach NA Suctioning NA Drains NA Ostomy Dressing change and/or wound care Treatments Every 4 hours to check on the vital signs as apart of a routine Glucose elevated. Monitor checks for increase or decrease of BG. NA NA NA Special equipment NA Other NA 12-180406 Reason (explain specifically why ordered for this patient) ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 6 OF 10 Concept Map Student Name: Intervention for Nursing Diagnosis Inspect skin, observe for reddened areas. Keep linens dry and wrinklefree. Perform and assist with the range of motion exercises to unaffected joints. Medicate before procedures and activities.   Date: Signs and Symptoms Guarding redness warm swelling pain level 6/10 Lab Values Related to Nursing Diagnosis WBC Nursing Diagnosis Rationales for Interventions impaired physical mobility related to surgery as evidenced by limited ROM of the LLE. Muscle relaxants, analgesics decrease pain, reduce muscle tension and/or spasm, and facilitate participation in therapy. Prevents skin breakdown and eases irritation. Patient with joint disease can quickly lose joint function during periods of restricted activity. Medication(s) r/t Diagnosis Analgesics Medication Side Effecgts Patient Outcomes(s) nausea vomiting stomach cramp heartburn Client will display increased strength and function of affected joint and limb. 12-180406 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 7 OF 10 Active Learning Template: Diagnostic Procedure Student Name: Procedure Name: Synovial Joint Aspiration   Review Module Chapter: Description of Procedure s a procedure to remove fluid from the space around a joint using a needle and syringe. This is usually done under a local anesthetic to relieve swelling and/or to obtain fluid for analysis to diagnose a joint disorder or problem CONSIDERATIONS Indications Nursing Interventions (pre, intra, post) joint effusion bacteremia inaccessible joints infection of soft tissue educate the patient on the procedure and what is about to happen. Watch for infections after the procedure. Interpretation of Findings Client Education presence of an infection tell hcp of any symptoms after procedure let hcp know if you feel anything painful furing procedure have a good understanding of what this procedure entails. Potential Complications Nursing Interventions reaction bruising bleeding into the joint loss of pigment Make sure the bleeding stops if patient has a clotting problem tell the client they will feel pressure when needle is inserted. 12-180406 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 8 OF 10 Active Learning Template: Therapeutic Procedure Student Name: Procedure Name: Treat a fever   Review Module Chapter: Description of Procedure Give medication to decrease the fever of a patient CONSIDERATIONS Indications Nursing Interventions (pre, intra, post) Give acetaminophen to decrease the fever in a patient explain you are taking a temperature for their benefit give medication based off result monitor patient after Outcomes/Evaluation: Client Education fever has reduced or gone back to a normal temperature let a hcp know if you aren’t feeling well let hcp know if you have increased temp or feel unwell. Potential Complications Nursing Interventions fever continues to increase check temperature at a timely manner cold compress on body keep cool ask patient subjective questiosn 12-180406 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 9 OF 10 Active Learning Template: Nursing Skill Student Name: Skill Name: Accu Check   Review Module Chapter: Description of skill Testing a patient’s Blood Glucose. CONSIDERATIONS Indications Nursing Interventions (pre, intra, post) checking a patient blood glucose by pricking their finger explain procedure to client sanitize area, wear gloves prick finger catch reading with blood on the strip determine if they need insulin based off result Outcomes/Evaluation Client Education shows if their glucose reading is high, low, or within normal range. ask questions if you are uncertain about the task. let hcp know if you have any side effects Potential Complications Nursing Interventions shows a reading that is unreadible batteries are dead explain procedure to client 12-180406 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 4 CLINICAL COURSES PAGE 10 OF 10 Active Learning Template: Medication Student Name:  Medication: Review Module Chapter:   Category Class: PURPOSE OF MEDICATION Expected Pharmacological Action Therapeutic Use decrease blood pressure Complications Medication Administration Contraindications/Precautions Nursing Interventions Interactions Client Education Evaluation of Medication Effectiveness 12-180406 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA ...
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