NURSING 354
Nursing & Healthcare II: Adult Health and Illness
CLINICAL PACKET
Fall 2012
Course Coordinator:
Janet Tompkins McMahon RN, MSN
Clinical Associate Professor of Nursing
Nursing Consultant
Towson University
janetmcmahon2@gmail.com
DEPARTMENT OF NURSING
COURSE:
NURS: 354 – Nursing Practice II: Adult Health
TOPIC: Concept Map/Clinical Prep
NURS 354 Clinical Worksheet/Prep – Complete this and provide report to clinical faculty by 0730.
Student Name:
Date:
Dates of Care for the Assigned Patient:
Past medical history or previous medical diagnoses:
Patient Age:
Gender:
SAFETY categories
S-Identify specific focused assessment
data to be collected:
Religion:
A-Accuracy of
F- What to do first?
orders/assignments
What should you focus your
assessment on and why?
Occupation:
E-expected
Allergies?
concerns?
Oxygen Therapy
delegate?
Ordered how often?
ordered?
What should you
What is your
Any abnormal?
monitor?
Labs due or
Why the patient is
ordered O2?
with the patient?
patient:
time, & why:
What considerations
What should you
ordered for today?
should be considered?
evaluate?
1.
before and after:
2.
3.
Any safety issues:
Isolation precautions? Why is the
patient ordered?
Miscellaneous
Vitals
Diet ordered for the
Special measures
Y-Ethics, family
What should you
expected outcome
Safety precautions?
T-Trending data
outcomes
Special measures:
Procedures ordered,
Code Status:
IV therapy? What is
the purpose for it?
What might you
anticipate?
NURS 354 Concept Map
Information due morning of clinical by 0730 to clinical faculty. Remainder of map by 1200 to clinical faculty
The entire map is due one clinical week later at 0630 with a hard copy to the clinical faculty. (If revision requested.)
What lab work is anticipated for the
client and why?
List and explain the abnormals.
What complications can occur? Be
prepared to discuss.
What medications will you give
with the main condition?
What measures should the nurse
consider before administering?
Identify 1 priority NANDA dx related to
admission dx. What is the most “critical
problem?
Use
Problem
Etiology
Sign/Symptom
(actual or potential problem)
List 1 projected
outcome
List 3 interventions for
NANDA admission dx
Admission Diagnosis of the Client
Describe the major reason of the client’s admission
and include pathophysiology of the disease. (Use a
med-surg textbook to find your reference)
Describe the cultural, social and
religious needs of the client-
List dietary
considerations
today with the care
of the client?
What nursing interventions
can be delegated to the UAP or
nursing staff related to the
priority NANDA Dx?
List 1-2
“I don’t know”
What is any area of the client
care or assessment don’t you
understand?
Safety concerns?
List any past medical history of the client. Be prepared to
describe these to clinical faculty
Example:
1. Ovarian cancer- Ovarian cancer is a disease that
affects the ovaries of the female (Smith, 2010)
2. Pancreatitis3. Diabetes Mellitus
Identify a NANDA
Dx related to either
of these two areas.
This can be an
actual or potential
problem for the
client. Be specific.
Explain why
List any previous surgeries and dates of
surgeries for the client. How is this
relevant to your clients condition
today?
Example:
Hysterectomy- 1985
Varicose Veins Stripped- 1993
Due morning of clinical
Current Medications: (by 0730 with report to clinical faculty) List ALL regularly scheduled and PRN medications scheduled on your patient.
Cite reference and include page number from required Towson University DON Drug reference or textbook (due with final submission one week later, no internet web sites accepted).
Generic /Trade Name
Dosage/Route
Classification
Intended Action
/therapeutic use.
WHY is the patient
taking med?
Adverse Action /
1 major Side
Effects
(May be
verbalized)
Nursing Implications – 1 appropriate for your
patient taking the ordered medication. (May be
verbalized)
Please clarify with your clinical faculty the PRN medications. Know the ones that your patient is currently receiving.
List any PRN’s given within the last 24 hours only.
Documentation from the clinical day
After performing a head to toe assessment, document your data collection of objective and subjective findings.
Be specific to detail regarding your patient’s main admission diagnosis as well as all other systems. Be inclusive
and identify all relative data on the assigned patient. (Submit to clinical faculty by 1200) This will also be resubmitted with final copy one week later. (after discussion and added details with clinical faculty)
Neurological:
Respiratory:
Cardiac:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary:
Psychiatric / Mental health:
Reproductive:
Clinical Laboratory and Diagnostic Findings as assigned by faculty. List ONLY abnormal for your patient. This is final submission as
assigned.
Lab Test
Date
Normal
Most
H / L Why is this result abnormal for this patient? What are possible evidenced based
reasons?
done
range
Recent
***Cite reference and page number.
Serum
Hgb
HCT
RBC
Platelets
WBC
PTT
PT/INR
Blood Glucose
Na+
K+
ClMg+
Phos+
Ca+
BUN
Creatinine
Albumin
Liver Profile
BNP level
Triponin level
Cholesterol (Total)
LDL
HDL
U/A
Date done
Normal
range
Most
Recent
Interpretation as related to Pathophysiology- cite reference and page #
Date
completed
Most
Recent
Results
Date/time
Interpretation as related to Pathophysiology- cite reference and page #
Identify
Patients
rhythm
Normal
range
Date/Time
What does this mean for this patient? Is this expected with the history or admission dx?
Most
Recent
Interpretation as related to Pathophysiology- cite reference and page #
Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Radiology/Other
X-Rays
Scans:
EKG-12 Lead
Telemetry
Other
NURS 354 Daily Clinical Evaluation
Name:
Faculty:
Date/Week:
Students are responsible for each behavior listed on these outcome statements. A student who receives a “U” or in any area below must satisfactorily
remediate any area listed before the last day of clinical. This means a scheduled appointment with your clinical instructor or success specialist or lab
faculty. If the student does not have a successful remediation, the student will not be permitted to go to the clinical institution for the remainder of
clinical and may fail the course. Any student who receives a “U” for two clinical days may fail the course.
I. ROLE: PROVIDER OF CARE
1. Is prepared for clinical assignment as assigned by clinical faculty
a. Submits appropriate data for patient assignment to clinical faculty on time
b. Prepared for clinical skills necessary to safely perform assigned skills
2. Verbalizes scientific rationale supporting nursing interventions for assigned skills
3. Demonstrates therapeutic communication skills at an beginning level
4. Demonstrates beginning skill in the application of nursing interventions
5. Provides safe care with assigned skills and patient interactions
6. Begins to provide individualized patient teaching during clinical as assigned
7. Begins to evaluate effectiveness of nursing interventions in the achievement of patient outcomes
II. ROLE: MANAGEMENT OF CARE
1. Begins to prioritizes nursing care appropriately
RATING*
S U N/O N/I
N/A
2. Is organized. Care is complete at the end of the daily experience.
3. Demonstrates legal and ethical behaviors that reflect accountability and standards of nursing practice according to the
ANA CODE OF ETHICS
III. ROLE: MEMBER WITHIN PROFESSION OF NURSING
1. Demonstrates professional behavior when interacting with patients, families, and/or health care team members.
2. Functions within the boundaries of the student nurse (including dress code).
3. Identifies own strengths and weaknesses in the clinical setting and seeks
appropriate assistance from faculty, staff and peers as appropriate.
4. Begins to recognize the importance of utilizing evidenced-based literature to support clinical decision making.
5. Prepares and participates in planning and discussion of assigned topics for post-conference.
Faculty Signature:
Student Signature:
Comments
S N/I U
NURS 354-Daily Journal
Name:
Unit Assignment
Objective for the day:
Objective met: yes no (Why or Why not)
Summary of experience (Please include what you learned from today’s clinical experience.)
Most challenging patient situation:
Biggest challenge overall:
Your impressions & reactions:
New skills learned (list):
Skills reinforced (list):
Date/Week:
Rank the day:
(worst)
1
2
3
4
5
6
7
8
9
10
(best) please discuss with faculty if below 7 after clinical
NURS 354 Student Learning Contract Form- Remediation Plan for “At Risk Behavior”
Name ____________________________________ Course _________________________________
Date_____________________________________ Class or Clinical (circle area involved)
Has this occurred before? Yes_____ No______ if yes, what course and semester? ______________
Description of behavior(s) placing student at risk:
Classroom-did not meet NURS 354 Course requirements for Unit ____ exam. The student must attain ______% in order to maintain a passing average
in course on next unit exam.
Clinical Behavior violation:
Remediation action plan (to be written by student in collaboration with the faculty member)
Identify actions that are intended to fix the behavior. Include date and resources required to be successful with action remediation plan.
Actions must be specific and list specific outcomes for success.
1. ____________________________________________________________Date to be completed:_____________________________________
2. ____________________________________________________________Date to be completed:_____________________________________
3. ____________________________________________________________Date to be completed:_____________________________________
4. ____________________________________________________________Date to be completed:_____________________________________
Faculty feedback/comments: (optional)
____________________________________________________________________________________________________
Failure of the student to correct and meet remediation action plan may or will result in failure of the course.
Student Signature____________________________ Date___________________ Advisor’s Name_____________________
Faculty signature_____________________ Date___________________ (A copy will be submitted to the student’s advisor and/or success specialist)
Final Evaluation of remediation plan:
Satisfactory ______ Unsatisfactory________
Faculty signature____________________ Date______________ Student signature_______________________________ Date_____________