Direct Patient Care Documentation JMRP.docx - 1 Clinical Learning Direct Patient Care Documentation Sept\/2020 2 Table of Contents NR 226 DIRECT PATIENT

Direct Patient Care Documentation JMRP.docx - 1 Clinical...

This preview shows page 1 - 4 out of 7 pages.

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 142/88 105 28 99.3 F 98% 4/10 140/82 102 28 100.8 F 98% 8/10 I Introduce yourself Your Name: Jimmy Yip Your Title: Student Nurse Reason for being there: Assessment of patient S Situation Patient: Juan Manuel Rodrigu ez Pizano Age: 55 Gender: M Height/Weight: 5’5” 250lbs Allergies: No known Code status: Full Privacy Code: Apple Time: 1600 Attending Physician: Dr. Hubbard Patient Chief Complaint: Severe GI issues for the last 24 hours Admitting Diagnosis: Rule our bowel obstruction Admission Date: 9/27/20 B Background Past Medical History : History of colorectal cancer Total colectomy with colostomy 2 years ago Social History: None Current Medications : Allopurinol 200mg PO daily Atorvastatin 20mg PO daily Colchicine 1.2mg PO PRN Fenofibrate 145mg PO daily Losartan 50mg PO daily Meformin ER 2000mg PO daily Tamsulosin 0.4mg PO daily A Assessment Vital Signs: Pulse: 105 BP: 142/88 RR: 28 Temp: 99.3 F SpO2: 98 Falls risk: Low Accu check: 188 IV Site: Right AC IV Fluids : NS 0.9% and LR

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture