Level 2 Direct Patient Care Documentation - DM FINISHED.pdf...

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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 41078160 Amber Coffin 10/10/2020 Student Name:   D#:   Date: Other Course:   Session and Year: September 2020 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. •G  rading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the Clinical Learning Evaluation. Satisfactory rating meets the following: with 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. • 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. •A  ssessment 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: –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. –M  edications: 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 Clinical Significance Wed 0800 Hydromorphone - Opioid analgesic Aids in pain relief Wed 0800 Ondansetron hydrochloride - Antiemetic/anti-nausea This is to helo with any nausea that may happen Web 0800 Ibuprofen - Non-steroidal anti-inflammatory (NSAID) To help with infammation, fever, and pain • 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. Imbalaned nutrition Rsk for pressure ulcers 1.  2. 3. Imapired physcial mobility • 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: Amber Coffin D#: 41078160 Your Title:SN - Student nurse Reason for being there: Post-op admission - student nurse assigned Patient: D. M. 19 years old Age: Gender: Male Height/Weight: 5' 11" / 141 lbs Race/Ethnicity: Caucasian Allergies: NKA Code Status: FULL CODE Advance Directive (Durable Power of Attorney, Living Will, Other) & Clinical Significance: Attending Physician: Dr. Craig Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance: Patient chief complaint: Motorcycle accident, no lower extremity movement or sensation. Primary medical diagnosis: T4-T5 burst fracture and right scapula fracture Pathophysiology of Primary Medical Diagnosis: Fracture: stress placed on a bone that is too much for the bone to handle, resulting in injury of the bone, and disruption of muscle and blood vessles attached to the ends of the bone that causes soft tissue damage and bleeding. No movement or sensation: pressure from the fracture is pressing on a nerve or the spinal cord None reported Privacy Code: Date of Care/Time:Wednesday at 0800 **Include clinical significance with each** B Background Past Medical History:                    Past Surgical History: Standard balanced diet - indicates that he is a picky eater Social History/Socioeconomic Factors: N/A Full-time retail cashier and attends class part-time. Has an occasional drink on the weekend. No hx of drug use. Vital Signs: B/P HR RR TEMP SP02 PAIN A Mon - 110/68 96 20 97.8 95% on 2L/min O2 4 Assessment Wed - 110/72 62 16 99.2 93% on 2L/min O2 7 Yes - Low Falls risk:_________  N/A Accu check:_________ Saline lock IV Site: _____________________________  IV Fluids:____________________________ Isolation Isolation Precautions RESPIRATORY Bilateral breath sounds clear to ascultation and no problmes reported CARDIOVASCULAR No murmurs or shortness of breath. Regular rate and rhythm. NEUROLOGICAL A&O x 4. Reflexes 2+ in upper extremites. Reflexs absent in lower extemeties. No history of seizures. Circulation, sensation, and motor function above T6 intact. Bowel sounds active in all quadrants. Abdomen flat, no heartburn, diarrhea, or consipation. Nondistended bladder with urinary catheter intact. GI/GU I&O N   Y           Contact  Air  Droplet INTEGUMENTARY Upper extremities WNL. Lower extremities cool to the touch. Upper back has multiple abrasions. History of acne with Accutane use in the past. PSYCHOLOGICAL FAMILY - SUPPORT Assists parents. Has support from family. Lives with friends. SAFETY Teaching needed: The need for adequate nutrition to help promote healing Quality in Safety Education Nurses (QSEN) Risk(s) Identified: Saftey - Minimize the risk of harm to patients R REQUEST/ RECOMMENDATION 12-180404 Night ahift Hand off report to:                 From: Amber Coffin Patient needs encouragement to use incentive spirometer, along with repeat education realted to nutrition to help in his healing process, possible need of psychology consult due to increased stress, anxiety, and feeling increasily upset. ©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: Mon 1600 T: 97.8 P: 60 Resp: 20 BP: 110/68 Height: 5' 11" Weight: 141 lbs Pain scale used with rationale: Pain level 4 P (Palliative, Provocative) What makes the pain better/worse? Sp02: 96% Apical HR: Narcotic medication Vital signs: Wed 0800 T: 99.2 P: 62 Resp: 16 BP: 110/72 Height: 5'11" Weight: 141 lbs Pain scale used with rationale: Pain level 7 P (Palliative, Provocative) What makes the pain better/worse? Sp02: 93% Apical HR: gets worse with deep breaths Q (Quality) How is the pain described? Q (Quality) How is the pain described? Constant Sharp R (Radiation) Does the pain travel or spread anywhere else? If so, where? located in back and incision area R (Radiation) Does the pain travel or spread anywhere else? If so, where? Pain happens above the nipple line S (Severity) What is the intensity of the pain? S (Severity) What is the intensity of the pain? 4 out of 10 7 out of 10 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 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 problems reported with eyes, ears, nose, or throat PERRLA normal, conjuctive clear, full extraocular motions Respiratory (lung sounds, breathing effort, accessory muscles): Respiratory (lung sounds, breathing effort, accessory muscles): Bilateral breath sounds clear to ascultation and no problmes reported Lungs clear bilaterally with shallow breathing Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): No shortness of breath or palpitations S1 & S2 with no murmurs or rubs. Regular rate and rhythm. Abdomen (inspection, bowel sounds, palpation, contour): no heartburn, diarrhea or consipation Bowel incontinence: No incontinence Bowel plan: N/A Abdomen (inspection, bowel sounds, palpation, contour): Flat, normoactive, soft to palpation Bowel incontinence: None reported in chart but due to inability to feel below the nipple line it is possible Last BM: Bowel plan: Due to narcoric pain medicaiton he Last BM: Not reported N/A should maintain a healthy intake of fluids Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): A&O x 4. Reflexes 2+ in upper extremites. Reflexs absent in lower extemeties. No history of seizures. Circulation, sensation, and motor function above T6 intact. A&O 3. Lower extremity reflexes absent. Sensation to dull, sharp, and temperature are absent from the nipple line and below. 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): No bone or joint pain. No history of fractures Upper extremities with string hand grips. No swelling of the joints. lower extremities have no movement. Genitourinary (burning with urination, frequency, color of urine): Genitourinary (burning with urination, frequency, color of urine): No reported problems. Currently unable to sense bladder distention becasue of interuption in sensation below Nondistended the nipple bladder line with catheter intact Urinary incontinence: Toileting plan: Urinary incontinence: Toileting plan: Catheter in place due to inability to feel bladder Keep urinary catheter Pelvic (female: LMP): N/A Rectal (bleeding, hemorrhoids): N/A Integumentary (rashes, lesions, wounds, etc.): History of acne with Accutane use in the past Specialty assessment (mental health exam, fetal heart rate, etc.): Pelvic (female: LMP): N/A Rectal (bleeding, hemorrhoids): N/A Integumentary (rashes, lesions, wounds, etc.): Mutiple abrasion to upper back and surgical incision present Specialty assessment (mental health exam, fetal heart rate, etc.): N/A Mental health exam: Anxious no thoughts of hurting himself or anyone else. Abuse screen (physical, elderly, child, sexual, etc.): Abuse screen (physical, elderly, child, sexual, etc.): No history of abuse No history of abuse 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): Intermittent IV saline lock. Intact, patent, no irritation noted Use IV access to administer IV medication. Be sure to flush after medication and every 8 hours. 12-180404 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 discontinuted on Tuesday at 1730 ©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 Reason out of norm/reason for drawing if normal or N/A if not drawn WBC Wed 0700 Yes 9700 WBC will help indicate if there is an infection. Tuesday was 8975. Glu Wed 0700 Yes 86 It is to make sure that glucose is in a normal range if not it can affect healing RBC Wed 0700 No 4.3 This is a result of a lower hemoglobin BUN Wed 0700 Yes 14 This needs to be checked to see how the kidneys and liver are working. Hgb Wed 0700 No 12.2 Due to his accident and surgery this is a bit lower. Loss of blood during event. Na Wed 0700 Yes 138 Knowing the electrolyte balance. if skewed seizures can happen. Hct Wed 0700 No 35% This is a result of a lower RBC due to lower hemoglobin K Wed 0700 Yes 4.4 Plt Wed 0700 Yes This helps with knowing the clotting 15800 factor and if it has decreased or not. Cl Wed 0700 Yes 105 Used to help monitor kidneys and the heart. Too high can cause arrhythmias. Used to help monitor and diagnose kidney or liver disease. Electrolyte. Chol Creat Trig CO2 Wed 0700 Yes 29 pH balance. Diagnosis of respiratory/ metabolic - alkalosis/acidosis. LDH Ca Wed 0700 Yes 9.6 Calcium affects nerves, bones, heart, or kidneys. Can help determine dx. PT Phos APTT Mag AST T.Pro ALT Alb Tdl* Tdl* *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 Reason (explain specifically why ordered for this patient) Diet Regular He has no previous history that indicates a special diet needed. I/O Q shift See adequate hydration and food intake, as well as output especially from the foley catheter. VS Q 4 w/ neuro Due to surgical procedure VS need to be taken more frequently. Neuro assessment: MVA Activity Bedrest D. M. has no feeling in his lower extremitiesf and is unable to move lower extremities Accu-check N/A Foley Maintain/care 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 No order Dressing and incision site should be assess Q shift, when turning, or cleaning bed/patient Special equipment SCD Sequential device has been order to help with VTE prophylaxis due to inactivity. Other Incentive Spirometer Daily weight Q 1 hour while awake as prohlaxis of post operative pneumoina Supplemental oxygen 2L nasal cannula to aide in proper oxygen saturation levels Maintain catheter due to no sensation from nipple line and below. Care for infection prevention. Treatments 12-180404 This will help indicate if there is any fluid retention happening ©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 PAGE 7 OF 8 Active Learning Template: Medication Amber Coffin 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: Amber Coffin 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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