Instructions to student: 1) Bring one copy of this packet with you to clinical each week. 2) Your instructor will inform you of the number of packets and the dates

Instructions to student: 1) Bring one copy of this packet with you to clinical each week. 2) Your instructor will inform you of the number of packets and the dates each packet is due. They may have you complete only portions of or all of the packet. 3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect. 4) If your instructor asks you to submit the packet electronically, then record your answers in bold or in a colored or lower case font. This s us identify your answers more quickly. CLIENT INITIALS: ROOM # DOB: AGE GENDER: ADMISSION DATE: CODE STATUS: ALLERGIES: MARITAL STATUS: OCCUPATION   (FORMER): MEDICAL DX: CHIEF   COMPLAINT: PAST HISTORY   (SURGERY/PROCEDURES) WITH DATES DIET 2 g Sodium diet with nectar thick liquids only Sodium is restricted due to edema in the bilateral   lower extremities and nectar thick liquids due to dysphagia from a past   stroke. DIET ACTIVITY I/O VS BGM FOLEY NG PEG/PEJ TUBE WOUND CARE RESPIRATORY TREATMENT TRACHEOSTOMY SUCTIONING CHEST TUBE SPECIAL EQUIPMENT LAB ORDERS OTHER PHYSICAL THERAPY SPEECH THERAPY OCCUPATIONAL THERAPY IV   FLUID AND RATE: SITE   LOCATION AND CONDITION: LAST   DRESSING CHANGE: LAST   TUBING CHANGE: GAUGE: REASON   FOR IV ACCESS: see pages 378-379 Taylor, Lillis and White) or (Erikson’s Stages of Development) CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO   HAVIGHUSRT TASKS OF THIS STAGE: ASSESSMENT OF CLIENT’S SUCESSFUL   ACHIEVEMENT OF TASKS If your client has more than 12 medications, select the 12 medications that are most important, most frequently given or those that pertain to the client’s most significant medical problems. See the example below. Brand Name and Generic Name Normal Dosage Ranges Contraindications Coreg (carvedilol) 3.125 mg – 50 mg BID Asthma, heart block Pharmacotherapeutic Class Dosage, Route & Frequency Adverse Reactions β-adrenergic blocker 6.25 mg p.o. BID Bradycardia, CHF, thrombocytopenia, hyperglycemia, bronchospasm Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching He has a history of hypertension but has been taking   Coreg for 2 years to control his hypertension BP’s   for past 3 days have been 128/78, 132/72, 138/80 Do   not discontinue abruptly or before surgery Caution   with Upper airway dysfunction Rise   slowly to minimize orthostatic hypotension, check B/P and heart rate prior to   administration Take   before meals #1 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route & Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching #2 Brand Name and Generic Name Normal Dosage Ranges Contraindications #3 Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching #4 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching #5 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching # 6 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching #7 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching #8 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching #9 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching #10 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching #11 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching #12 Brand Name and Generic Name Normal Dosage Ranges Contraindications Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching For this clinical, we are having you write out your assessment findings in the form of a narrative nurse’s note. We have provided some samples of assessments.We have also provided a worksheet that you may use to take into a patient’s room to take notes during your assessment. Record your vital signs and type your physical assessment findings. This form will expand to fit your typing. A sample of charting for a long term care resident follows below. TEMP: APICAL HR: RESP: BP: HT: WT: DATE / TIME (TYPE HERE) —Head to Toe format Temp: 98.6 Apical HR: 72 Resp: 16 BP 128/62 Ht: 5’10” Wt: 145 12/22/2010 1400 Resident in semi-fowlers position in bed. Pressure reduction mattress in place. Alert   and oriented x 3. Appropriate mood and affect. Well groomed.  Recent and remote memory intact. Facial   symmetry noted. Pupils are equal, reactive to light and accommodation. Oral   mucosa moist, pink. Frequent oral care   rendered with sponge toothette and toothbrush. Dentition intact. Hearing intact. Oropharynx clear without   erythema or exudate. No chewing or swallowing difficulties. 75% of general   diet taken at breakfast. Skin pink, warm, dry, free of lesions with elastic   turgor.Hair and nails unremarkable.Carotid and radial pulses present and   equal. Motor and sensory functions grossly intact.No weakness or   paralysis. Upper extremities equal   strength bilaterally, full ROM w/ capillary refill < 3 sec. Fine resting   tremor in the left hand” No involuntary movement or abnormal posture. Lungs clear bilaterally to auscultation.Tracheostomy   dressing clean, dry, and intact. Connected to ventilator with settings:   TV-550, Fio2-40%, Rate 10, and PEEP-5cm. Sao2-92%. Suctioned for moderate   amount of white, thin secretion. Apical pulse regular (rate) and rhythm.   Double lumen picc line note to left antecubital space. Tegaderm dressing is   clean, dry, and intact. Last dressing change on 11/28/16. Chlorhexadine caps   intact to all lumens.  Bowel sounds   active x 4. Abdomen soft,   non-distended, non-tender. Last bowel movement this morning, passed a large,   soft- formed brown stool and a moderate amount of clear yellow urine.   Bilateral lower extremities,no tenderness, swelling or joint deformities   noted. Denies numbness or tingling to   extremities. Toe nails thick and yellowed w/ capillary refill < 3 sec.  No peripheral edema noted, pedal pulses   palpable and equal bilaterally. Use this sheet for jotting down your assessment findings.) COGNITION/NEUROLOGICAL Alert and oriented x3, recent and remote memory intact. Denies any   numbness or tingling to extremities” “Fine resting tremor of   left hand SKIN SENSORY BREASTS - DEFERRED. RESPIRATORY – CARDIOVASCULAR ABDOMEN – . BOWEL CONTINENCE? LAST BM? BOWEL PLAN? MUSCULOSKELETAL - GENITOURINARY - URINARY CONTINENCE? TOILETING PLAN? PELVIC - DEFERRED. RECTAL - DEFERRED. Begin your NCP by listing your clients individual problems (at least 10)and then identify an appropriate nursing diagnosis that you can think of that would apply to your client. Determine which 3problems/nursing diagnoses are of greatest priority and then add a #1, #2, and #3 to indicate which of the two have highest priority. Risks would not be priority 1, 2, or 3!!!!! # List the Client problem An appropriate Nursing Diagnosis stem (REFER TO   YOUR NURSING DIAGNOSIS LIST) Related to part of the statement (This is individual to your client) As evidenced by part of the statement (This is   individual to your client) REMEMEBR THIS IS NOT USED IN A “Risk For” diagnosis 1 Reports severe pain in the   right hip. “Acute Pain” “related to” fractured right hip “as evidenced by” verbal report of pain   rated at an 8 on a scale of 0 –to 10. 2 Complete bed rest “Risk for Impaired skin integrity” “related to “ immobility NONE it is a “Risk for” diagnosis so   there is no evidence statement From the list above your faculty member will give you direction regarding how many and which diagnoses they want you to develop for either a Nursing Care Plan and/or a Concept Map. (Data   that directly pertains to the above nursing diagnosis) (Patient   centered, realistic, specific, measurable, target time) (Individualized, specific,   frequency) Minimum   of 4-5 interventions per plan (Supporting   statement from text or other source, cite source) (Met,   partially met, unmet, unknown by target time) SUBJECTIVE DATA: “My right hip hurts me so much every time I   move. I am so afraid to start physical   therapy” SHORT TERM: Client will report pain level rated at a 3   or lower 30 minutes after pain medication taken 1. Educate the client on the   importance of pain relief to enhance her rehabilitation efforts and include   education on various types of methods to relieve pain. 2. Encourage client to   express any questions or concerns she may have regarding pain management   methods to alleviate anxiety and fears. 3. Educate the client on her responsibility to   honestly report pain when it occurs as well as reporting if the current pain   management is effective or ineffective for providing her pain relief 4. Provide for   alternative/complementary measures of pain relief, such as, reduce lighting   and noise, soothing music, pet therapy, massage, and hot/cold packs according   to client preferences. 1. “There are many ways to   manage pain. In addition to   pharmacologic and non-pharmacologic measures, simple nursing interventions   can alter patients’ pain experience and speed their recovery.” Taylor, Lillis   and White pg. 1168. 2. “Common fears include a   loss of control and embarrassment by being unable to deal with pain maturely…   The patient may view the need of for medication as a sign of weakness or may   fear addiction or loss of effectiveness at a later date.” Taylor, Lillis and   White pg. 1169. 3. “As a patient advocate,   ensure that a strong emphasis on the need for aggressive, individualized   strategies that can minimize or eliminate acute pain and improve patient   outcomes. Preventing pain is easier   then treating it once after it occurs.” Taylor, Lillis and White pg. 1178. 4. Alternative/complementary   measures will provide an added benefit of distraction from pain experience   and augment analgesic effect. Cold/hot therapy can provide constriction and   or dilation which will reduce pain inflammation in each specific circumstance   Daniels. Pg 378 Short Term Goal: Met; pain   was rated at a 2 on a scale of 0 to 10 after administration of Vicodin. Long Term Goal. In progress OBJECTIVE DATA: Alert and oriented 70 year   old widowed female. Lives in an   apartment independently. 2 daughter live nearby and visit often. story of a fall while out   shopping 1 ½ weeks ago. Right hip surgically   repaired 7 days ago. Surgical dressing   to right hip is clean, dry and intact. Circulation, motion and sensation   intact to right lower extremity. Afebrile; BP 124/80; R-18 AP   84 and regular. 5 foot 7 inches weighs 142 pounds. No hearing deficits; wears   eye glasses Medical history positive for   osteoarthritis and osteoporosis Non weight bearing to right   leg and to use a walker for ambulation To start physical therapy   for gait and strength training BID times 7 days and occupational therapy to   develop upper body strength once daily times 7 days Reports pain level is at 8   on a scale of 0 to 10. Has Vicodin 5mg/325 mg po 2   tabs every 4 hours prn for severe pain Ibuprofen 400 mg every 6   hours prn for moderate pain. LONG TERM: Client will report pain level of 2 or less   using ibuprofen with alternative pain control methods by discharge. Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Interventions: Each nursing intervention must come from a reliable nursing reference or source. Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) (Data that directly   pertains to the above nursing diagnosis) (Patient centered, realistic,   specific, measurable, target time) (Individualized,   specific, frequency) (Supporting statement   from text or other source, cite source) (Met, partially met,   unmet, unknown by target time) SUBJECTIVE DATA: SHORT TERM: OBJECTIVE DATA: LONG TERM: Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Interventions: Each nursing intervention must come from a reliable nursing reference or source. Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) (Data that directly   pertains to the above nursing diagnosis) (Patient centered, realistic,   specific, measurable, target time) (Individualized,   specific, frequency) (Supporting statement   from text or other source, cite source) (Met, partially met,   unmet, unknown by target time) SUBJECTIVE DATA: SHORT TERM: OBJECTIVE DATA: LONG TERM: Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) (Data that directly   pertains to the above nursing diagnosis) (Patient centered, realistic,   specific, measurable, target time) (Individualized,   specific, frequency) (Supporting statement   from text or other source, cite source) (Met, partially met,   unmet, unknown by target time) SUBJECTIVE DATA: SHORT TERM: OBJECTIVE DATA: LONG TERM: Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) 3 Impaired urinary elimination Intake=3800 Output=3200 Polyuria 3+ glucose in     urine Polydipsia and     polyuria Pt. will have     urine output of 1000 – 2000 ml/24 hours. Monitor I     & O q shift. Monitor BGM     a.c. and h.s. Monitor     kidney function tests Administer antihyperglycemics     as ordered. Knowledge deficit Pt verbalizes confusion about diagnosis,new     meds,diet, exercise routine Verbal     statements and questions. Pt will     verbalize understanding of ADA diet and administer insulin using     appropriate technique by discharge. Assess level     of knowledge regarding diabetes/ treatment and client’s preferred learning     style. Provide     information q shift according to teaching plan recorded in EMR and document     pt’s response. Reassess     level of knowledge daily. Provide     written information. Provide     educational resources available in the community. 4 Newly     diagnosed diabetic S/S of hyper and hypoglycemia, good     intake, I/O, glucose level, vitals Tests: FBS, hemoglobin A1C “I don’t know     how this fits” Recent widow Kids live out     of state ? support     system 1 : Acute anxiety : Restless, verbally states she     is anxious. Pt states “I don’t know what I     will do with diabetes, this is too much.” Pt. will verbalize under-standing     of resources available by discharge. Provide pt. with an opportunity each     shift to verbalize anxiety by asking open ended questions. Demonstrate progressive relaxation     exercises and have pt. return demonstrate. Provide pt. with a list of community     resources for newly diagnosed diabetics. Identify client’s perception of anxiety Utilize empathy. 2 Hypertension x 20 years; appendectomy at     age 9. Mother had Type 2 diabetes;     hypertension; Native American descent; sedentary lifestyle; 290 pounds, age     52 Imbalanced nutrition, more than BMI:35.0–39.9; Ht: 5”9; Wt: 290 lbs Anthropometric measurements. Client will verbalize a     realistic weight loss goal and three strategies to reach it prior to     discharge. Assess client’s knowledge of nutrition     and its relationship to diabetes. Arrange for dietary consultation. Reinforce teaching  by dietician. Encourage physical activity as a     weight loss strategy. Provide pt with community resources     that can assist her with weight loss goal. “I DON’T KNOW HOW THIS FITS” PAST MEDICAL HISTORY RISK FACTORS MEDICAL PROBLEMS     (PATHOPHYSIOLOGY)/SURGICAL PROCEDURES: KEY ASSESSMENTS: Key Assessments: Tests: KEY PROBLEM: DATA: AEB: OUTCOMES: INTERVENTIONS: KEY PROBLEM: DATA: AEB: OUTCOMES: INTERVENTIONS: KEY PROBLEM: DATA: AEB: OUTCOMES: INTERVENTIONS: KEY PROBLEM: DATA: AEB: OUTCOMES: INTERVENTIONS: Student   Name: Clinical   Date: Site: 10 points Patient Demographics, Diagnoses, Surgeries, Orders,   Rehab, IV, Imaging and Lab Page 1 fully and correctly completed  5   pts Page 2 fully and   correctly completed 5 pts 20   points Medications Medication Trade   Name  2   pts Medication Generic   Name 2 pts Pharmacological   Classification 2 pts Normal Dosage Range  2   pts Dose ordered 2 pts Route and Frequency 2 pts Contraindications 2 pts Adverse   Effects/Reactions 2 pts Nursing Considerations   & Teaching 2 pts (Legible or typed) 2 pts 10 points Narrative Notes Head-to-Toe Assessment Narrative note is in Head   to Toe order Head-to-toe assessment   documented Abnormal results noted10   pts 60   points (either a Concept Map or a Patient Care Plan) Concept   Map Correct Medical   Diagnosis 15 pts Pathophysiology 15 pts Key Assessments 15 pts At least 3 problems   identified 15 pts 60   points (either a Concept Map or a Patient Care Plan) Patient   Care Plan 3nursing diagnoses Related to” “As evidenced by”18 pts 2 Outcomes specific,   measurable, timed 8 pts 4-5Interventions are   logical, appropriate 15 pts 4-5Scientific Rationales   supporting each intervention15 pts2Evaluations4 pts

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