Juan Manuel Rodriguez ihuman - C H AMB ER LAIN U N I V E RS I T Y National Management Office | 3005 Highland Parkway Downers Grove IL 60515 |

Juan Manuel Rodriguez ihuman - C H AMB ER LAIN U N I V...

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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 Date: 6/15/20 Student Name: D#: Course: 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: 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 Q 4 hr Drug/Classification Clinical Significance Nalaxone/ Opioid Antagonist OpIoid Reversal Hydromorphone IV 0.5-1.5 mg/ opioid (narcotic) analgesics Treats moderate to severe pain Ondansetron/ Serotonin 5-HT3 Normal Saline lactated ringers Q 6 hr • Nursing Diagnosis: Ketorolac To treat nausea and vomiting Ketorolac 30 mg IV Q 6hr for mild to moderate pain (1-4/10) used as a flush -- to clean out an intravenous (IV) catheter. Allopurinol PO daily Atorvastin PO daily Replacing fluids and electrolytes in those who have low blood Colchicine PO PRN volume or low blood pressure. Fenofibrate PO daily for mild to moderate pain (1-4/10) Losartan PO daily Metformin PO daily Tamsulosin Identify three nursing diagnoses for your patient and list them by priority below. Complete one concept map for your top nursing diagnosis listed below. Imbalanced nutrition :less than body requirements related to Inability to digest foods as evidence by vomiting and ab pain. 1. Acute Pain related to Small Bowel Obstruction as evidence by patient stating ‘8/10 pain’. 3. Risk for Deficient fluid volume related to Increased metabolic rate as evidence by temperature of 100.8 F. 2. • 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 Your Name: D#: Your Title: Reason for being there: Clinicals Patient: Juan Manuel Rodriguez Age: 55 Gender: M Height/Weight: 165 cm/ 113.6 kg Race/Ethnicity: Hispanic Allergies: No Known Code Status: Full Advance Directive (Durable Power of Attorney, Living Will, Other) & Clinical Significance: Attending Physician: Dr. Hubbard Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance: Rule out Small bowel obstruction-pt has not had BM in more than 24 hrs. Patient has had a colectomy with colostomy which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon. Pathophysiology of Primary Medical Diagnosis: There is urgency since the has no bowel movements within 24 hrs and has had surgery for a total colectomy w colostomy as there's a risk the colon could burst. Privacy Code: Date of Care/Time: 6/15/20 15:00 **Include clinical significance with each** B Background Past Medical History: History of colorectal cancer (cancer that affects the colon and the rectum). Type 2 diabetes, hyperlipidermia, hypertension, hypertrigluceridemia Social History/Socioeconomic Factors: Past Surgical History: Total colectomy w colostomy 2 yrs ago. he has insurence tht can pay for bills. Vital Signs: B/P A 140/82 HR 102 RR TEMP SP02 100.8 F 98% 28 PAIN 8/10 in abdomen Assessment Low Falls risk:_________ Accu check:_________ 18-gauge, patient with fluids running. IV Site: _____________________________ IV Fluids:____________________________ Isolation Isolation Precautions RESPIRATORY N✓ Y Contact Air Droplet RR 28. No adventitious breath sounds, non-labored breathing CARDIOVASCULAR 102 BPM. No adventitious heart sounds, cap refill is 2 sec. to all extremitites NEUROLOGICAL Cranial Nerves 2-12 are intact. Stoma is pink, dry, edematous, protruding 2 cm, round, and intact. Hypoactive bowel sounds. Stoma noted to LLQ. Hypoactive bowel soundfs GI/GU I&O INTEGUMENTARY Cap refill is 2 seconds bilaterally. Skin is warm and diaphoretic with no lesions seen. Skin is turgor. Patient scored a 18 (mild risk) on Braden Skin assessment PSYCHOLOGICAL FAMILY - SUPPORT Pt. smokes, uses marijuana, and consumes alcohol SAFETY Teaching needed: Ostomy patient teaching, healthy lifestyle changes for hypertension, hyperlipidermia, diabetes and hypertrigluceridemia Quality in Safety Education Nurses (QSEN) Risk(s) Identified: R REQUEST/ RECOMMENDATION 12-180404 Hand off report to: Next Shift Nurse From: Katherine Driscoll, Student Nurse Monitor rising temperature, Teach patient about healthy lifestyle changes for hypertension, hyperlipidermia, diabetes and hypertrigluceridemia ©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 3 OF 8 Initial Assessment Findings and Time: Ongoing Assessment Findings and Time: Vital signs: Day 1 15:30 T: 99.3 F P: 105 Resp: 28 Sp02: 98 BP: Height: 5.5 ft/in Weight: 113.6 kg Apical HR: 105 142/88 Pain scale used with rationale: 4/10 with 0 being no pain, 10 being a lot of pain P (Palliative, Provocative) What makes the pain better/worse? Vital signs: Day 1 16:00 T: 100.8 F P: 102 Resp: 28 Sp02: 98% BP: 140/82 Height: 5.5 ft/in Weight: 113.6 kg Apical HR: 102 Pain scale used with rationale: 8/10 with 0 being no pain, 10 being a lot of pain P (Palliative, Provocative) What makes the pain better/worse? 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? Pain feels like cramping Pain is in abdomen 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? Constant 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): No visible scaliness, edema, masses, conjuctiva is pink, sclelera is white. Trachea is midline and freely mobile. Respiratory (lung sounds, breathing effort, accessory muscles): Respiratory (lung sounds, breathing effort, accessory muscles): No adventitious breath sounds, non-labored breathing Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): No adventitious heart sounds, cap refill is 2 sec. to all extremitites Abdomen (inspection, bowel sounds, palpation, contour): Bowel incontinence: Abdomen (inspection, bowel sounds, palpation, contour): patient states bloating and cramping pain Bowel plan: Last BM: Bowel incontinence: 24 hrs without BM Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Bowel plan: patient states bloating and cramping pain Last BM: Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): A/O X 4 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): Strength 5/5 bilaterally, full ROM Genitourinary (burning with urination, frequency, color of urine): Genitourinary (burning with urination, frequency, color of urine): Urinary incontinence: Urinary incontinence: Toileting plan: Toileting plan: Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.): Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.): Abuse screen (physical, elderly, child, sexual, etc.): Abuse screen (physical, elderly, child, sexual, etc.): 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, patient with fluids running. NG patent, on low intermittent suction. 250 mL of dark green fluid in canister 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 4 OF 8 Labs Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn Test Result/ Date Norm WBC 14,250 4,00011,000 / mcL To Check for infection (WBC count elevated = infection) Glu 188 70-130 non fasting RBC 5.7 mil/mcL 4.7-6.1 million/ mcL 13.5-1 7.5 g/dl To check if anemic (Pt’s who are anemic may breath abnormally fast) To check if anemic (Pt’s who are anemic may breath abnormally fast) BUN 8-21 15 Na 144 K 3.5 Cl 100 Chol Creat 0.6 Trig CO2 LDH Ca PT Phos APTT Mag AST T.Pro ALT Alb Tdl* Tdl* Hgb 18 g/dL Hct Plt 38.3% 48.6% 332 150,000450,000/ mcL To check if anemic (Pt’s who are anemic may breath abnormally fast) 135-145 Reason out of norm/reason for drawing if normal or N/A if not drawn To check blood sugar levels (key source for body’s energies Check for control of diabetes sees how well kidneys are working. Plays a role in making cells have enough H20 plays key role in cell health 3.5-5.1 To check for clotting 91-118 one of the most important electrolytes in the blood. provide your doctor with information about how 23 9.2 0.5-1.1 well your kidneys are working. 22-29 can help diagnose kidney and respiratory problems. used to monitor certain cancers during and after 8.7-11.9 treatment. bnormal levels of magnesium are most frequently seen fasting: 70 A high glucose level in a person with diabetes to 130 mg/ means that the diabetes isn’t being managed dL correctly. Serum Glucose MCV MCH MCHC 90 29 22% 82-103 26-34 30-37% measures size of RBC may indicate blood disorder if too big checks the average amount of hemoglobin in a group of red blood cells. 1.4 Blood Culture Lactic acid Blood Type 1.3-2.1 in conditions or diseases that cause impaired or excessive excretion of magnesium by the kidneys or that cause impaired absorption in the intestines. negative checks for foreign invaders like bacteria, yeast, and other microorganisms in your blood. 4.5 to 19.8 mg/dL used to diagnose lactic acidosis. safe blood transfusions depend on careful blood typing and cross-matching. MCHC value is used to evaluate the severity and cause of anemia. *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 Diet Order/Frequency NPO Reason (explain specifically why ordered for this patient) Prescribed as a safety precaution prevents nauseous which can lead to aspiration meaning you might uptake your stomach contents into your lungs. I/O VS Activity Q 4 hr Bed rest Vital signs assessment serves as an early warning of a change in patient condition, playing an important role in assisting the healthcare professional to prevent adverse events. Patients with abnormal vital signs should be reassessed no less frequently than every 2 hours for the first 4 hours, then every 4 hours if clinically stable. The NG tube should be continuous suction. Pt is also at risk for lightheadedness. Helps keep close eye on I&O Accu-check Foley NG tube PEG tube PEJ tube Chest tube Trach Suctioning Drains Ostomy Dressing change and/or wound care Treatments Special equipment Other CT Scan 12-180404 CT of abdomen/pelvis with IV contrast diagnosing bowel obstructions. ©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 assess patients pain level 15-30 minutes after IV and 1 hr after oral distraction techniques Repositioning as needed relaxation exercises Pain higher than 0 on a 0-10 rating scale Agitation Grimacing Appetite changes poor sleeping teeth grinding Fidgeting Nursing Diagnosis Rationales for Interventions Lab Values Related to Nursing Diagnosis Hypertension Tachycardia Increased cortisol level Increased WBC Electrolyte abnormalities Acute Pain related to Small Bowel Obstruction as evidence by patient stating ‘8/10 pain’. One’s perception of time may become distorted during painful experiences. The aid of an imagined event or a mental picture involves use of the five senses to divert oneself from painful stimuli.Increasing one’s concentration, these techniques help an individual decrease the pain experience. The aim of these techniques is to lessen the stress, tension, subsequently decreasing the pain. Medication(s) r/t Diagnosis Hydromorphone IV 0.5-1.5 mg/ opioid (narcotic) analgesics To treat moderate to severe pain Ketorolac to treat mild to moderate pain (1-4/10) Patient Outcome(s) sufficient pain management 12-180404 Medication Side Effects Headache Insomnia Dry mouth Lightheadedness Drowsiness Diaphoresis Diarrhea Nausea Abdominal Cramping ©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 7 OF 8 Active Learning Template: Medication Student Name: katherine Driscoll Medication: Review Module Chapter: Hydromorphone IV 0.5-1.5 mg q4 hr Category Class: opioid (narcotic) analgesics PURPOSE OF MEDICATION Expected Pharmacological Action Therapeutic Use Mimic the actions of naturally occuring opioids. They do this by binding with the mu receptors at the opioid receptor site. Stimulation of theses receptors cause analgesia, sedation, euphoria and Resp depression Complications To treat moderate to severe pain. Medication Administration Respiratory depression, sedation, dizziness, lightheadedness, drowsiness Contraindications/Precautions Obtain pts baseline v/s before admin. Have naloxone and resuscitation equip readily avaliable. Nursing Interventions Contraindicated in pregnant women, pts w renal failure, increased intracranial pressure, biliary colic, and preterm labor. Precautions: older adults, head injury, inflammatory bowel disease. Interactions Closely monitor v/s and 02 Sat and ausculate the lungs for congestion. Observe for a decrease in RR from baseline. Client Education Interact w CNS depressants and alcohol by increasing their CNS depressant effects. Emphasize to pt they should only take drug when they need it and on short term basis. Do not use this drug prior to driving, when feeling lightheaded, make sure to sit down. Evaluation of Medication Effectiveness Relief of moderate to severe pain. 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 7 OF 8 Active Learning Template: Medication Student Name: Katherine Driscoll Medication: Review Module Chapter: Category Class: Naloxone Opioid Antagonist PURPOSE OF MEDICATION Expected Pharmacological Action Therapeutic Use This drug produce their effects by blocking opioid receptors, effectively reversing or antagonizing the effects of opioids Complications To reverse effects of opioids such as respiratory depression or opioid OD Medication Administration ventricular arruthmias. Increased HR and RR but remain alert for abnormal rates. Abstience syndrome Contraindications/Precautions Can be administered IM, IV or SubQ. Titrate the dose very carefully. Monitor V/ S Q 5-15 min. Prepare to admin naloxone Q 2-3 min until reversal of undesirable effect occurs Nursing Interventions Pts who are opioid dependent or have R depression due to nonopioid drugs shouldnt take this drug. Use cautiously w pts who have cardiac irritability, head injury and brain tumors Interactions Closley monitor for dangerous elevations of pts BP. Monitor heart rhythms for s/ of pts who are opioid depend Client Education Opi...
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