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CLINICAL LEARNING – DIRECT
PATIENT CARE DOCUMENTATION
LEVEL 2 CLINICAL COURSES
PAGE 1 OF 8
Corina Biscos-Vinesar
D41030037
06/14/19
Student Name: D#: Date:
Other
Course: Session and Year: May
2019
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
0900
Amiodarone (PACERONE) tab 100 mg oral daily
Antiarrhythmic
0900
Atorvastatin (LIPITOR) tab 10 mg oral nightly
Cholestrol and Triglyceride
0800
Carvedilol (COREG) tab 3-125 mg oral twice with meals
HTN
0800
Spironolactone (ALDACTONE) tab 25 mg oral every other day
Heart Failure/HTN
0900
Enoxaparin (LOVENOX) injection 40 mg sub q every 24 hrs Constipation
0600
Polyethylene glycol (GLYCOMAX) packet 17g daily oral
Laxative
• 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. 2.
3.
• 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
required
to be
typed,
Word document,
Times New Roman
12-point font. Minimum
of one page
and GMT
no more
than three pages.
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C H AMB ER LAIN U N I V E RS I T Y
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CLINICAL LEARNING – DIRECT
PATIENT CARE DOCUMENTATION
LEVEL 2 CLINICAL COURSES
PAGE 2 OF 8
I-SBAR
I
Introduce Yourself
S
Situation
Your Name: Corina Biscos-Vinesar
D#: D41030037
Your Title:Student Nurse
Reason for being there:Clinicals
Patient: Lisuzzo, Salvatore L
84 y/old
Age:
Gender: Male
Height/Weight: 1.778 m/72.6 kg
Race/Ethnicity:
Allergies: NKA
Code Status: FULL CODE
Advance Directive (Durable Power of Attorney, Living Will, Other) &
Clinical Significance:
Attending Physician: Sanjolee M. Ansari
Patient Chief Complaint/Primary Medical Diagnosis and Clinical
Significance:
Reverse shoulder total arthopplasty left for OA
Pathophysiology of Primary Medical Diagnosis:
Privacy Code:
Date of Care/Time:06/14/19, 0700
**Include clinical significance with each**
B
Background
Past Medical History: Past Surgical History:
GERD, HTN, CHF s/p AICD for EP 24%, CAD s/p 4 vessel CABG stent, b/l
TKA,
left hip replacement
Social History/Socioeconomic Factors: lives alone
Vital Signs:
B/P
HR
RR
TEMP
SP02
PAIN
A
82/38
61
18
96,4 F
96% on RA
9/10
Assessment
84/49
59
18
98.0 F
96% on RA
6/10
high fall risk
Falls risk:_________
yes
Accu check:_________
PIV
IV Site: right
_____________________________
0.9% Sodium Chloride 250 mL bolus
IV Fluids:____________________________
Isolation
Isolation Precautions
RESPIRATORY
lungs clear to ausculation with no crackles, wheezes, or ronchi
CARDIOVASCULAR
RRR, s1 and s2 noted, no s3 or s4 noted, no JVD
NEUROLOGICAL
concious, not in any acute distress, A X O x4
GI/GU
I&O
hypoactive bowel sounds, soft and nondistended, no tenderness to palpation
INTEGUMENTARY
skin breakdown and sloughing on right and left legs
PSYCHOLOGICAL
FAMILY - SUPPORT
lives alone in bulding with elevator, uses walker
SAFETY
Teaching needed:
N Y Contact Air Droplet
Quality in Safety Education Nurses (QSEN) Risk(s) Identified:
R
Hand off report to: From:
REQUEST/
RECOMMENDATION
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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:
T: 98.o F
P: 59
Resp:
BP: 84/49
Height: 1.778 m
Weight: 72.6 kg
Pain scale used with rationale: 6/10 pain in left arm
P (Palliative, Provocative) What makes the pain better/worse?
Sp02: 96
Apical HR: 59
pain medication makes it better
Q (Quality) How is the pain described?
Vital signs:
T:
P:
Resp:
BP:
Height:
Weight:
Pain scale used with rationale:
P (Palliative, Provocative) What makes the pain better/worse?
Sp02:
Apical HR:
Q (Quality) How is the pain described?
sore
R (Radiation) Does the pain travel or spread anywhere else? If so, where?
stays in left shoulder/elbow
R (Radiation) Does the pain travel or spread anywhere else? If so, where?
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 pain
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):
normocephalic, neck midleine to body, PERRLA intact
Respiratory (lung sounds, breathing effort, accessory muscles):
Respiratory (lung sounds, breathing effort, accessory muscles):
lungs clear to ausculation with no crackles, wheezes, or ronchi
Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm):
Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm):
RRR, no JVD, no s3/s4 noted
Abdomen (inspection, bowel sounds, palpation, contour):
soft, non-distended, hypoacttive bowel sounds
Abdomen (inspection, bowel sounds, palpation, contour):
Bowel incontinence:
Bowel plan: increase fluids/fiber
Bowel incontinence:
Last BM: befiore surgery
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):
concious, not in any acute distress, A X O x4
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):
1+ pulse on both legs, 3+ edma on left leg, 2+ edma on right leg
Genitourinary (burning with urination, frequency, color of urine):
Genitourinary (burning with urination, frequency, color of urine):
Urinary incontinence:
Toileting plan:
Urinary incontinence:
yes
straight cath
Toileting plan:
Pelvic (female: LMP):
Rectal (bleeding, hemorrhoids):
Integumentary (rashes, lesions, wounds, etc.): dry, falaky skin
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):
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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
WBC
RBC
Hgb
Hct
Plt
Chol
Trig
LDH
PT
APTT
AST
ALT
Tdl*
Result/
Date
7.9
3.54
11.2
32.9
121
104
NA
NA
NA
Norm
Reason out of norm/reason for drawing
if normal or N/A if not drawn
4.0-11.
0k/mm
u
4.34-5. low
60m/m
m cu
13.0-1 low
7.0
g/dL
38.6-4 low
9.2%
150-45 low
0
k/mm
98-107
cu
mmol/
L
Test
Glu
BUN
Na
K
Cl
Creat
CO2
Ca
Phos
NA
Mag
NA
T.Pro
NA
NA
Alb
Tdl*
Result/
Date
Norm
Reason out of norm/reason for drawing
if normal or N/A if not drawn
101
70-99 high
mg/dL
27.6
7-25
high
mg/dL
135
133-14
4
mmol/
3.5-5.1
L
4.4
104
mmol/
98-107
L
0.98
mmol/
06.-1.3
L
mg/dL
26
8.7
NA
21-31
mmol/
L
8.6-10.
3
mg/dL
NA
NA
NA
NA
*Therapeutic drug level
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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
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CLINICAL LEARNING – DIRECT
PATIENT CARE DOCUMENTATION
LEVEL 2 CLINICAL COURSES
PAGE 5 OF 8
Healthcare Provider Orders
Items
Order/Frequency
Diet
Hearth Healthy
I/O
VS
intake - 600,
output - 480
q4h
Activity
tolerated
Accu-check
yes - 101 mg/dL
Reason (explain specifically why ordered for this patient)
Foley
NG tube
PEG tube
PEJ tube
Chest tube
Trach
Suctioning
Drains
Ostomy
Dressing change
and/or wound care
Treatments
Staight cather
PRN for uniary
Special equipment retention
Other
Troponin
elevated, 0.06 3x, stable
EKG
old q waves
Stress test
4 weeks ago - normal
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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
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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)
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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
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CLINICAL LEARNING – DIRECT
PATIENT CARE DOCUMENTATION
LEVEL 2 CLINICAL COURSES
PAGE 7 OF 8
Active Learning Template:
Medication
Corina Biscos-Vinesar
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
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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: Corina Biscos-Vinesar
Skill Name:
Review Module Chapter:
Description of skill
CONSIDERATIONS
Indications
Nursing Interventions (pre, intra, post)
Outcomes/Evaluation
Client Education
Potential Complications
Nursing Interventions
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