NR226 WK2 Direct Patient Care Documentation_Virtual NR226 Level2 Sept 2020 Session.docx

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1 Clinical Learning Direct Patient Care Documentation Sept/2020
2 Table of Contents NR 226 DIRECT PATIENT CARE DOCUMENTATION Submit in the Weekly CLA drop box each virtual clinical day May be hand written or typed I-SBAR on iHuman patient for the virtual clinical day ..................................................................................... 3 Nursing Skill ALT (Use ALT template to complete) .......................................................................................... 4 Healthcare Provider Orders ....................................................................................................................... 5 &6 Concept Map ................................................................................................................................................. 7 Reflection paper (1 paragraph only) ……………………………………………………………………………………………………………8 Nurses Note (already completed in the iHuman) ……………..…………………………………………………………………………8 Sept/2020
3 Sept/2020 B/P HR RR TEMP SP02 PAIN 128/70 68 18 98.8 F 99% 4/10 I Introduce yourself Your Name: Your Title: Reason for being there: Jostna Khanam Student Nurse Clinical S Situation Patient: David Douglas Age: 74 Gender: Male Height/Weight: 6’0” (183 cm), 165 lb(75 kg) Allergies: no known allergies Code status: Full Privacy Code: N/A Time: 8 am Attending Physician: Dr. Sandhu Patient Chief Complaint: Chronic osteoarthritis Admitting Diagnosis: Day 1 rehab for left total hip arthroplasty, post op day 5 Admission Date: 9/10/2020 B Background Past Medical History : Osteoarthritis, high blood pressure, high cholesterol Social History: wife in nursing home, has no help at home Current Medications : Amlodipine 5mg po daily oxycodone 5/325 mg 1 tab every 4 hours prn pain 4/10 Atorvastatin 10 mg PO at bedtime Oxycodone/acetaminophen 5/325 mg every 4 hours prn A Assessment Vital Signs: BP:128/70, Pulse:68, RR:18, Spo2: 99%, TEMP:98.8 oral Falls risk: low Accu check: N/A IV Site: N/A IV Fluids : N/A Isolation Isolation Precautions N Y Contact Air Droplet RESPIRATORY Lung sounds are clear anteriorly and posteriorly in all lung fields. No accessory muscle is using CARDIOVASCULAR S1, s2 heard in all cardiac points, no murmur, no edema present.

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