RN 225, Advanced Med/Surg Nursing: Care of the Adult Clinical CLINICAL FORMS 1 Carrington College LVN to RN Advanced Placement Associate Degree RN Program CRITICAL THINKING WORKSHEET CLINICAL DATA COLLECTION SHEET Students: __________________________________________________________________________ Date care given: _________________ Patient’s Initials: _____________________Age/Sex: ________Religion: ______________________ Primary Language: ________________________Occupation: _______________________________ Admitting Diagnosis: _______________________________ Date: _________Allergies: ________________ History of present illness:(precursors leading up to this hospitalization) ______________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Health Hx: _____________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Discharge Plan: __________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 2 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Physical Assessment: Systems Review Focused physical exam Neurological: LOC, GCS, etc. Findings: Nursing implications: Respiratory: Lung sounds, O2 Sats, etc. Cardiovascular: Gastrointestinal: BS, last BM, etc. Genitourinary: Voiding? Foley? etc. Immune: Isolation? Musculo/skeletal: Mobile? Strength scale? ROM? Endocrine: pertinent to this client, diabetic, thyroid? Nutrition: Diet, Wt: Integumentary: Wounds? Braden scale, etc. Psychosocial: 3 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Laboratory Values: List ALL normal lab values in column #2, the “Normal Values” column. There should be no blank boxes in this column. In column #3 list ALL lab values/diagnostics that have been done on YOUR patient, whether normal or abnormal. Column #4 demonstrates your critical thinking. In this column state your interpretation of the lab value for YOUR patient. Why is this value being measured? How is this value significant to YOUR patient? What else will you consider? What meds affect this value? DO NOT COPY FROM A TEXTBOOK AS THIS INFO IS PERTINENT ONLY TO THIS PATIENT. CBC Normal values: Patient value: Interpretation: WBC Hgb Hct RBC Platelets Differential Bands Lymphocytes Monocytes Neutrophils Electrolytes/Comp Panel Glucose Na+ K+ ClCO2 Ca++ 4 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Mg++ PO4BUN Creatinine Albumin Protein AST ALT SGPT Alk Phos Bili Amylase Lipase Coagulation: PTT PT INR Cardiac: CPK/isoenzymes Troponin Myoglobin LDH Urine: UA (dip stick and/or micro) 5 Carrington College LVN to RN Advanced Placement Associate Degree RN Program ABG’s: PH PCO2 HCO3 PO2 O2 Sat Other Lab Values Vanco/gentamycin trough (peak?) ESR Blood cultures Urine culture Sputum cultures Wound cultures PSA Other Other Other Diagnostic Tests (XRAY, CT, MRI, US, etc.) Date: Findings: Nursing Implications: 6 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Admitting Diagnosis & Relevant Medical Diagnoses: In your own words, list the diagnoses in order of importance including patient’s signs & symptoms and the pathophysiology of the diagnosis. You need to be able to clearly identify and connect the patient’s signs and symptoms with the pathophysiology. Clinical Pathophysiology: Nursing foci: 1. 1. 2. 2. 3. 3. 4. 4. 7 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Nursing Care Plan: Nursing Diagnosis: Plan: * Nursing Interventions: 1. 1. 1 Evaluation: (of client’s response) Goal met/unmet? 2. 3. 4. 2. 1. 1. 2. 3. 4. 3. 1. 1. 2. 3. 4. *Plan: SMART – Specific, Measurable, Attainable, Realistic, Time Bound 8 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Recommendations: (Look at your patient holistically and examine what else needs to be done, advocate for your patient. What did we miss as a healthcare team? i.e. consults, therapies, management, diagnostic examinations, etc.) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ________________________________ 9 Carrington College LVN to RN Advanced Placement Associate Degree RN Program MEDICATION INFORMATION SHEET Patient’s Initials: Room #: Diagnosis: Medication Allergies: Action/Indications Nursing Implications/Side Effects Pertinent Lab Values/Vital Signs In your own words list the above information pertinent to this patient. Rx: Classification: Route: Dose: Rx: Classification: Route: Dose: Rx: Classification: Route: Dose: Rx: Classification: Route: Dose: Rx: Classification: Route: Dose: Rx: Classification: Route: Dose: 10 Carrington College LVN to RN Advanced Placement Associate Degree RN Program CLIENT TEACHING PLAN Student: _________________________________________________________________________ Date: _____________ Patient Diagnosis: Course: ______________________ Age: Procedures: Potential Barriers to Learning: Language ___________________________________________________ _____________________________________________________________________ Ability to Learn ______________________ ________________________________________________________________ Motivation ___________________ ____________________________________________________________ Culture ___________________ ______________________________________________________ ______ Sensory/Perceptual _________________________________________________________________________________ _____________________________________________________________________ Support System _______ _____________ ______ ______________________________________________________ Other _______ _____________ ____________________________________________________________ Family/Caregiver present for patient teaching: Yes No Variances:_______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________ Assessment of Learning Needs: ___________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _______________________________________________________________________________________ ___________________________________________________________________________ _________________________________________________________________________________ 11 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Plan: 1. __________________ ____________ __________________ ______________________________________________________________________________ 2. _____________ _________________________ ________________________________________________________________________ 3. ____________ _________________________ ________________________________________________________________________ 4. __________________ _________________________ ________________________________________________________________________ Interventions (nursing action): 1. ___________________ _________________________ ________________________________________________________________________ 2. __________________ _________________________ ________________________________________________________________________ 3. ____________ _________________________ ________________________________________________________________________ 4. ____________ _________________________ ________________________________________________________________________ Evaluation: _________________________________________________________________________________ _________________________ ________________________________________________________________________ 12 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Report: Beginning of shift: Vital signs/Pain: Assignment Reporting Off-- Report: Vital signs/Pain: Resp/O2 sat/O2: Resp/O2 sat/O2 IV: IV: CV: CV: GI: GI: GU: GU: MS: MS: Skin: Skin: Labs: Labs: Misc: Misc: Kardex Information: Activity level: ______________________________ Diet: ________________________________ PT/OT: _______________ RT: __________________ Suction:_______Oxygen: _____________ Respirator: Trach: _______________________________________________________________ Vital Signs: ________ Frequency: __________ I& O: 24hr In _______ Out _____ 8hr in______ out ______ Fluids: IV: _____________________________________________ Saline Lock: ______________ GI: Bowel Care: ________________________________________ Enterostomy: ______________ Nutrition: Diet: ______________Tube Feeding: ___________________Residual ck: ____ Wt.: _____ Glucose check: _______________________ when: result_________________________________ GU: Urinary Care: Foley? ___________________________________________________________ 13 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Immune: Wound: Skin Care: Treatments: Client Assessment Tool (students will only be required to do a complete Client Assessment Tool once, subject to the instructor’s evaluation and recommendation for improvement/revision) Client Initials: __________ Age: ________ Diagnoses: ______________________________ Cognition/Perception/Communication/Interaction Level of Consciousness: Alert Lethargic Semicomatose Stuporous Comatose Behavior: Appropriate to Situation Combative Confused Anxious Restless Flat Affect Uncooperative Withdrawn Other Describe variance: _________________________________________ Oriented to: Person Place Time Describe variance: ______________________________ Thought Content: Appropriate to Situation Delusions Obsessions Somatic Concerns Depersonalization Compulsions Paranoia/Suspiciousness Hallucinations Describe variance: __________________________________________________________________ Thought Process: Logical Sequential Relevant Goal Directed Follows Commands Disjointed Irrelevant Tangential Circumstantial Describe variance: __________________________________________________________________ Memory: Short-term Memory Intact Long-term Memory Intact Memory Not Intact Describe variance: _____________________________________________ Speech: Clear Slurred Stutter Difficult to Understand Laryngectomy Other ___________ Aphasia: Type ___________________________________ Describe variance: __________________________________________________________________ Pupil Reaction: PERRLA Right: Left: Size (circle) 1 2 3 4 5 mm Size (circle) 1 2 3 4 5 mm Brisk Sluggish NR Other __________ Brisk Sluggish NR Other ___________ Describe variance: __________________________________________________________________ Eyesight: Normal Nearsighted (Myopia) Farsighted (Presbyopia) Wears Glasses Contacts Blurred Diplopia Glaucoma Blind: OD OS Describe variance: __________________________________________________________________ Hearing: Normal Hard of Hearing (Presbycusis): Left Ear Right Ear Uses Hearing Aid: Left Ear Right Ear Deaf: Left Ear Right Ear 14 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Neurological: MAE Motor Disturbances Seizures Tremors Headaches Numbness Tingling Other: ________________________________________________________________________ Describe variance: _________________________________________________________________ Activity/Exercise Respiratory: No Cough Cough Non-productive Productive Describe (color, characteristics, amount): __________ Dyspnea: At Rest With Exertion Orthopnea: # of pillows used: _____ Requires HOB increase _____ Tachypnea Pursed lip Breathing Pattern: Non-labored Labored Symmetrical Asymmetrical Periods of Apnea Describe variance: _________________________________________________________________ Oxygen delivery mode: Room Air NC Mask (type) ____________________ Trach collar Other _____________________________________ Pulse Oximetry on: On Room Air _____ % (result) O2 _______ type of delivery mode _____% (result) Clear/Equal Bilaterally R L Location Crackles _____________________________ Rhonchi _____________________________ Wheezes _____________________________ Diminished _____________________________ Absent _____________________________ Describe variance: _________________________________________________________________ Tracheostomy: NA Size: __________________Type: ____________________ Describe Secretions (color, characteristics, amount): _______________________________________ Frequency of Suctioning: _______________________________________________ Breath Sounds: Chest Tube: NA Location: _____________________________ Water Seal Suction (amount): ___________________________ Drainage (color, characteristics, amount): ____________________________________________ Pulse Rate: Apical _____ Radial _____ Pulse Deficit Describe variance: ____________________________________________________ Heart Rhythm: Regular Irregular Describe: ___________________________________________ Chest Pain Palpitation Heart Sounds: Audible S1S2 Murmur Extra Sounds Describe variance:_________________________________________ EKG Rhythm: ________________________ (per chart) None in chart, none performed Pacemaker Type: __________________ Describe variance: ________________________ Pulses: (A) Absent (W) Weak Carotid: Brachial: (S) Strong (D) Doppler Right _____ Right _____ Left _____ Left _____ 15 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Radial: Femoral: Right _____ Right _____ Left _____ Left _____ Pulses (continued): Popliteal: Right _____ Left _____ Post Tibial: Right _____ Left _____ Dorsal Pedis: Right _____ Left _____ JVD Describe variance: ___________________________________________________________ Capillary Refill: ___________________________ (# of seconds x 4 extremities) Activity/Exercise (continued) Extremeties: Color: WNL for client or describe UR ______________________________ UL ________________________________ LR ______________________________ LL ________________________________ Temperature H (hot) W (warm) C (cool/cold) UR _____ UL _____ LR _____ LL _____ Calf tenderness: Right Left Describe color change with positional changes: _________________________________ Edema: None Generalized (Anasarca) Ascites Dependent Non-pitting Pitting Scale: +1 (2mm) +2 (4mm) +3 (6mm) +4 (8mm) Location: ______________________________________________________________________________ Activities of Daily Living: (I) Independent (A) Assist (D) Dependent Feeding___ Bathing___ Grooming___ Toileting___ Dressing___ Other ______________ Describe variance: ________________________________________________________ Mobility: Ambulatory Ambulatory w/ assistance Transfer w/ assistance Bed to Chair Bed rest Other __________________________________________________________________________ Describe distance ambulated: _________________________________________________________ Activity Tolerance: No Problems Ambulating Weakness Fatigue Dizziness Light-headed DOE Describe variance: __________________________________________________________________ SCD's TED's Other ______________________________________________________ Nutrition/Elimination/Metabolic Height: __________ (in/cm) Weight: __________ (lbs/kg) IBW: __________ (lbs/kg) General Appearance: Well-nourished Obese Thin Cachectic Other ______________________________________________ Recent Weight: No Change Loss Gain Intentional How much? ___________ (lbs/kg) Over what amount of time? ________________________________________________________________ Describe variance: __________________________________________________________________ 16 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Mouth: Full Dentition Loose Teeth Missing some teeth Edentulous Dentures: Upper Lower Partial Lesions Sore Mouth Describe variance: ____________________________________________________ Gums: Moist Pink Dry Pale Hyperplasia Other: _____________________________ Tongue: Moist Pink Dry Coated Other Describe variance: _____________ ______________________________________________________________________________ Mucous Membranes: Moist Pink Dry Pale Other Describe variance: ______________________________________________________________________________ Nutrition/Elimination/Metabolic (continued) Type of Diet: ___________________________% Eaten: ______________________________ Fluid Restriction: __________ cc's Recent changes in: Appetite Eating Describe variance: ____________________ ______________________________________________________________________________ Indigestion Nausea Vomiting Anorexia Choking with solids Choking with liquids Difficulty chewing Difficulty swallowing Describe variance: ______________________________________________________________ NG G-tube J-tube G/J-tube Small feeding tube Tube feeding Bolus Continuous Formula (type & strength): ______Rate: ______ TPN: Central Peripheral Abdomen: Soft Non-tender Flat Round Distended Gravid Firm Rigid Cramps Pain Masses Gas Describe variance: _________________________________________________________________ NG LIS LCS Drainage (color, characteristics, amount): ___________________________________________ Bowel Sounds: X 4 Quads Normal Hyperactive Hypoactive Absent Describe variance: ______________________________________________________________ Stool: Continent Incontinent Hemorrhoids Blood in stool Ostomies: Colostomy Ileostomy Other _______ Describe stool or ask client to describe (color, characteristic, amount, frequency): _________________________________________________________________________________________ Last BM: __________________ Usual Pattern: ________________________________ Stoma: Describe (color, size): ______________________________________________ Skin: Intact Other Describe variance: ________________________________________________________ Bladder: Continent Incontinent Frequency Urgency Retention Dribbling Burning 17 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Dysuria Anuria Nocturia Distention Other Describe variance: ________________________________________________________ Urine: Clear Dark Cloudy Bloody Concentrated Odorous Other Describe urine or ask client to describe (color, characteristics): _______________________________ Condom catheter Foley catheter I/O Catheter How often? _______________ Suprapubic catheter Urostomy Nephrostomy tube CBI Describe variance: ________________________________________________________ 24 hour I & O: I __________ O __________ cc Dialysis Access ___________ Location and type: ____________________________ Comfort/Function Vital Signs: Temperature: ________ (site _________) Respirations: ________________ B/P: Left arm Right arm Other __________ Supine: ______ Sit: _______ Stand:______ _________ Pulse: Left arm Right arm Other _________ Supine: ______ Sit: ______ Stand: _______ _________ Sclera: White Jaundiced Red Other ____________ Describe variance: ______________________________________________________________ Skin: Intact Color appropriate to client Warm Dry Pale Flushed Clammy Diaphoretic Cyanotic Jaundiced Dusky Mottled Hot Cool/Cold Other _____________________________________________ Describe variance: ________________________________________________________ Turgor: Elastic Tenting Describe variance: _____________________________ Rash Scar Wound/Ulcer Lesion Petechiae Ecchymosis Hematoma Incision(s) Other Location ___________________ Description _______________ ________________________________________________________________________ ________________________________________________________________________ For incision(s): Edges well approximated Open Inflammation Redness Drainage Sutures Staples Other Describe size: ___________________________________________________________ Drain(s) Type: ________________________________________________________________________ Drainage of wounds and drains: Dressings: Site Amount Color Characteristics Location Type __________ ______________ __________ ______________ ______________ ______________ __________ ______________ __________ ______________ ______________ ______________ __________ ______________ __________ ______________ ______________ ______________ __________ ______________ __________ ______________ ______________ ______________ 18 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Parenteral Access: None #1 Site: IVF (Type) ______________ Rate ______________ Peripheral lock Location: _________________ Central (Type) ______________ PICC Line Peripheral Other Type of Access (IV Cath size & length): _______________________________________ Without redness, swelling, or pain IV patent Dressing dry and intact Red Warm Swelling Tender Bleeding Drainage Other ______________________________________________________________________________ Describe variance: ________________________________________________________ #2 Site: IVF (Type) ______________ Rate ______________ Peripheral lock Location: _________________ Central (Type) ______________ PICC Line Peripheral Other__________ Type of Access (IV Cath size & length): _______________________________________ Without redness, swelling, or pain IV patent Dressing dry and intact Red Warm Swelling Tender Bleeding Drainage Other _____ Describe variance: ________________________________________________________ Epidural Access: None Infusion Medication: _____________________________ Rate: ________________ Posture: Straight/Erect Kyphosis Scoliosis Lordosis Other _______________________________ Describe variance: ________________________________________________________ Gait: Steady Unsteady Describe variance: _____________________________________________ Assistive Devices: None Cane Crutches Prosthesis Wheelchair Other ____________________ Describe variance: _______________________________________________________ Joints: Full mobility per active ROM Full ROM per passive ROM Limited mobility Contractures Limited ROM Pain Swelling Tenderness Stiffness Other Describe variance: ________________________________________________________ Muscles: Symmetry Weakness Flaccid Cramping Spasms Other______________________ Describe variance: ________________________________________________________ Strength: (S) Strong (M) Moderate (W) Weak (A) Absent (E) Equal RUE ____LUE____ Equal Unequal RLE ____LLE____ Equal Unequal Grips: R _____ L _____ Equal Unequal Pain: None Location: ______________________________________ Rating (1 to 10): _________ Description:______________________________________________________________ Constant Intermittent Aching Burning Cramping Stabbing Dull Throbbing Heavy Crushing Sharp Other _______________________________ Describe variance: ______________________________________________________________ 19 Carrington College LVN to RN Advanced Placement Associate Degree RN Program Sleep: # of hours: _____________ Rested Does not feel rested after sleep Difficulty falling asleep Difficulty staying asleep Naps Usual Sleep Pattern: _______________________________________________________ Other ________________________________________________________________ Describe variance: ________________________________________________________ Reproduction/Sexuality Gender: Female Completes self-breast exam: Yes No Last mammogram: _____________________ LMP: _________ Post-menopausal Birth Control method: _________ Last Pap Smear: _________ G _____ P _____ A _____ Gyn Surgery: _____________________________ Gyn Problems: ____________________________________________________ Describe Variance: _________________________________________________ Male Circumcised: Yes No Completes self-testicular exam: Yes No Describe Variance: ________________________________________________ 20 Carrington College LVN to RN Advanced Placement Associate Degree RN Program RN 225: Advanced Medical Surgical Nursing Term 1 Clinical Preparation Grading Rubric Name: _________________________ Date________________ ACTIVITY EVALUATION 1. Clinical Pathophysiology. Describe the pathologic process of each diagnosis and state at least one related nursing focus. There needs to be evidence that the student’s choice of foci came from an understanding of the disorder’s pathology. 2. Pertinent Medical History & Discharge Plan. Write a paragraph explaining why patient seek medical help and explain how pertinent historical data influences his medical diagnosis. Identify appropriate discharge plan. 3. Systems Review. Perform a comprehensive physical examination of the assigned patient and provide evidence of critical-thinking skills used related to the patient’s medical diagnosis. 4. Nursing Diagnosis & Daily Nursing Care Plan. Using the information from your textbook regarding nursing diagnosis and data available from your patient, write at least three nursing diagnoses and related outcomes and 4 nursing actions. In the evaluation boxes, state how you would evaluate each specific nursing diagnosis you have identified. What were your evaluation findings for your patient? 5. Laboratory Values. Based on the information you have on your patient, make your interpretation of abnormal values/findings and explain the importance of the data in relation to your patient. Also be sure to document any labs that are relevant to your patient’s condition(s). 6. Medication. Based on your patient’s medication administration records, identify drug actions and the reasons why such medication was prescribed to your patient. 7. Client Teaching. Using the data presented on your assigned patient and your understanding of the disease process, choose one topic to teach on and formulate appropriate teaching plan. 8. Recommendation. Looking at your patient as a holistic being identify recommendations that will significantly impact the provision of effective, efficient and safe care. Legend: P = PASS, NI = NEEDS IMPROVEMENT, F = FAIL COMMENTS: 21 Carrington College LVN to RN Advanced Placement Associate Degree RN Program RN225, ADV. MED/SURG NURSING-1 CLINICAL COMPREHENSIVE PHYSICAL ASSESSMENT ASSIGNMENT Instructions: Student will be assigned a client in the clinical setting and will perform a complete physical assessment on the client while being observed by the instructor. Students will be required to write a comprehensive head to toe assessment in narrative form using the SBAR format. The comprehensive assessment should cover all systems listed in the focused assessment portion of clinical data collection sheet: neurological, respiratory, cardiovascular, gastrointestinal, genito-urinary, immune, musculoskeletal, endocrine, nutrition, integumentary and psychosocial. Use a separate page for this report. 22