Level 2 Direct Patient Care Documentation (6).pdf - C H AMB...

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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 2 CLINICAL COURSES PAGE 1 OF 8 Student Name: Course: Samantha Maxey D#: 41064092 Session and Year: NR226 Date: 1/11/21 January 2021 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: 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 significance are to be completed after patient report has been received. 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: – 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 have not previously completed a template. Time Due Drug/Classification 0800 Calcium Carbonate 600mg PO qAM 0800/ 2000 Docusate sodium 100mg PO BID 0800 Enoxaparin 40 mg SubQ qAM 0800/2000 0000/1200 0000 Clinical Significance Lactated rings @ 75 ml/hr (0900) Oxycodone IR 5mg PO q4 pm (0000) Senna 8/6 mg PO daily bedtime (0000) Normal Saline Flush 5ml IV q8h Oxycodone ER 10mg Ondansetron 4 mg IV q4h PRN • 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. 1. Risk for impaired tissue perfusion related to surgical procedure on right knee r/t osteoarthritis 3. 3/5 strength in right lower extremity related to decreased ROM r/t osteoarthritis 2. Pain related to osteoarthritis related r/t wearing down of cartilage • 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 one page and no more than three pages. 12-180404 ©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 2 CLINICAL COURSES PAGE 2 OF 8 I-SBAR I Introduce Yourself S Situation Samantha Maxey Your Name: D#: 41064092 Your Title: Student Nurse Reason for being there: R.J. Patient: 52 Age: Male Gender: Height/Weight: 175 cm/ 83.6 kg Race/Ethnicity: Caucasion Allergies: Shellfish- rash Code Status: full code Advance Directive (Durable Power of Attorney, Living Will, Other) & Clinical Significance: Attending Physician: Dr. Smiley Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance: Elective total right knee arthroplasty Pathophysiology of Primary Medical Diagnosis: N/A Removal of damaged cartilage and bone from a surface of the knee joint, replaced with metal or plastic. Privacy Code: N/A Date of Care/Time: 0800 **Include clinical significance with each** B Background Past Medical History: Past Surgical History: Chronic osteoarthritis N/A Social History/Socioeconomic Factors: History of smoking 1/2 pack/day stoped a week ago, warehouse worker, married for 30 yrs, alcohol use Vital Signs: A B/P HR RR TEMP SP02 PAIN N/A N/A N/A N/A N/A N/A Assessment No risk N/A Falls risk:_________ Accu check:_________ IV Site: _____________________________ IV Fluids:____________________________ N/A Isolation Isolation Precautions RESPIRATORY WNL CARDIOVASCULAR WNL NEUROLOGICAL WNL GI/GU I&O WNL INTEGUMENTARY PSYCHOLOGICAL FAMILY - SUPPORT SAFETY N X Y Contact Droplet Slightly limited ROM RL extremity. 3/5 strength. 4/10 pain. otherwise WNL. Married, has son Teaching needed: N/A Quality in Safety Education Nurses (QSEN) Risk(s) Identified: R REQUEST/ RECOMMENDATION 12-180404 Air Hand off report to: N/A From: Monitor/ control pain. Keep NPO till surgery. ©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 Text LEVEL 2 CLINICAL COURSES PAGE 3 OF 8 Initial Assessment Findings and Time: Ongoing Assessment Findings and Time: Vital signs: N/A T: P: Resp: BP: Height: Weight: 4/10 R knee Pain scale used with rationale: P (Palliative, Provocative) What makes the pain better/worse? Q (Quality) How is the pain described? Sp02: Apical HR: Vital signs: T: P: Resp: 98.6 72 26 BP: 122/82 Height: 175 cm Weight: 83.6 kg 5/10 R knee, 8/10 R calf Pain scale used with rationale: P (Palliative, Provocative) What makes the pain better/worse? Pain medication and sitting in recliner. Pain meds make it better, movement makes it worse Cramping calf, dull sharp knee pain Q (Quality) How is the pain described? dull ache with some sharpness R (Radiation) Does the pain travel or spread anywhere else? If so, where? S (Severity) What is the intensity of the pain? N/A R (Radiation) Does the pain travel or spread anywhere else? If so, where? S (Severity) What is the intensity of the pain? 4/10 T (Temporal) Is the pain constant, or does it come and go? WNL Respiratory (lung sounds, breathing effort, accessory muscles): Respiratory (lung sounds, breathing effort, accessory muscles): WNL WNL Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): WNL Abdomen (inspection, bowel sounds, palpation, contour): WNL Bowel incontinence: WNL 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): WNL WNL Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities): Slightly limited ROM RL extremity. 3/5 strength, 4/10 pain, otherwise WNL Genitourinary (burning with urination, frequency, color of urine): Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities): RL extremities limited 3/5, slightly limited ROM RL extremity. Red, warm R calf with 1+ pitting edema, R calf measured 30 cm, L calf 27 cm Genitourinary (burning with urination, frequency, color of urine): WNL WNL Toileting plan: Urinary incontinence: N/A Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): N/A Warm, dry Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.): Toileting plan: N/A Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): N/A Integumentary (rashes, lesions, wounds, etc.): Redness, warmth to RL calf, otherwise WNL Specialty assessment (mental health exam, fetal heart rate, etc.): N/A N/A Abuse screen (physical, elderly, child, sexual, etc.): Abuse screen (physical, elderly, child, sexual, etc.): N/A N/A 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): 12-180404 Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): 1+ pitting edema otherwise WNL Abdomen (inspection, bowel sounds, palpation, contour): N/A Constant Head and Neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea): WNL Urinary incontinence: No 5/10 R Knee, 8/10 R Calf T (Temporal) Is the pain constant, or does it come and go? Constant Head and Neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea): Bowel plan: Sp02: 98% Apical HR: N/A 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): N/A ©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 2 CLINICAL COURSES PAGE 4 OF 8 Labs Test Result/ Date WBC 5660 RBC 5.2 Hgb 16 Hct Plt 47 Norm 4-10 4.5-5.9 12-16 37-47 Reason out of norm/reason for drawing if normal or N/A if not drawn Glu Iinfection Hemorrhage, anemia, perfusion General health, diroders (anemia) Measure RBC levels N/A Test Result/ Date 108 Na 135 135-145 K 4.5 3.5-5.1 Cl 99 95-102 Check chloride levels/electrolytes 0.7 0.5-1.1 See if kidneys are working properly Creat Trig N/A CO2 LDH N/A Ca 9.7 PT 15 Phos N/A APTT N/A AST N/A Check blood sugar levels 18 N/A Blood clotting 70-130 Reason out of norm/reason for drawing if normal or N/A if not drawn BUN Chol 11-15 Norm Mag T.Pro ALT N/A Alb Tdl* N/A Tdl* 22 8-21 22-29 8.7-11.9 Check kidney function Sodium levels (dehydration, kidney problems) Electrolyte imbalance effective breathing bone disease N/A N/A N/A N/A *Therapeutic drug level 12-180404 ©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 2 CLINICAL COURSES PAGE 5 OF 8 Healthcare Provider Orders Items Order/Frequency Diet NPO I/O N/A VS q4 x 24hrs Activity Out of bed with assistance Accu-check N/A Foley N/A NG tube N/A PEG tube N/A PEJ tube N/A Chest tube N/A Trach N/A Suctioning N/A Drains N/A Ostomy N/A Dressing change and/or wound care N/A Treatments N/A Special equipment Other 12-180404 SCDS Pt/OT eval Reason (explain specifically why ordered for this patient) Risk for apiration Make sure pt remains stable Pt is in pain and on pain meds Decrease risk of DVT/PE See patient needs for discharge ©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 2 CLINICAL COURSES Concept Map PAGE 6 OF 8 Signs and Symptoms Interventions for Nursing Diagnosis Lab Values Related to Nursing Diagnosis Nursing Diagnosis Rationales for Interventions Medication(s) r/t Diagnosis Medication Side Effects Patient Outcome(s) 12-180404 ©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 2 CLINICAL COURSES MY ALT’S ARE HANDWRITTEN! 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. 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 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. 0119pflcpeADA ...
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