NATIONAL AMERICAN BLOOMINGTON CAMPUS BSN PROGRAM

UNIVERSITY

Nursing 3361: Holistic Nursing Care in Acute Illness I - Clinical Fall 2013 Learning Plan 1 Introduction to Clinical Site specific clinical orientation Documentation Objective of the Course/Competency: 1. Examine the use of therapeutic communication skills in the development of therapeutic relationships with clients and families.
Knowledge and skills leading to mastery of this competency

a. Incorporate caring and healing techniques that promote a therapeutic nurse client relationship. b. Communicate effectively with the client and the clients support network. c. Maintain self-awareness and a reflective nursing practice. d. Complete a health history. e. Demonstrate the ability to report orally the information necessary to facilitate the continued nursing care of a client. 2. Demonstrate professional behavior by maintaining appropriate dress and demeanor, maintaining client confidentiality, and assuming accountability for own actions.
Knowledge and skills leading to mastery of this competency

Demonstrate accountability for personal and professional behaviors. Incorporate the professional standards of moral, ethical, and legal conduct. Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with clients and families as well as among caregivers d. Protect client privacy and confidentiality of client records and other privileged communications. e. Ensure that ethical standards related to data security, regulatory requirements, confidentiality, and clients right to privacy. 3. Incorporate the art and science of nursing when performing psychomotor skills, managing common symptoms and clients responses to interventions.
Knowledge and skills leading to mastery of this competency

a. b. c.

a.

Examine the Patterns of Knowing.

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Provide compassionate, client-centered, evidence-based care that respects client and family preferences. c. Demonstrate the application of psychomotor skills for the efficient, safe, and compassionate delivery of client care. d. Implement evidence-based nursing interventions as appropriate for managing the acute care of clients across the lifespan. e. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan 4. Interpret health data from a culturally and age appropriate health assessment and focus on physiologic, developmental and behavioral patterns of client response to acute conditions and processes.
Knowledge and skills leading to mastery of this competency

b.

Complete a comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters of acute care clients, using developmentally and culturally appropriate approaches. b. Assess health/illness beliefs, values, attitudes, and practices of individuals and their families. c. Discuss the critical thinking process of the professional nurse in health assessment. d. Identify a variety of measurements of growth and development across the age span. 5. Develop plans of care that are client and family centered using evidence to inform nursing actions.
Knowledge and skills leading to mastery of this competency

a.

Use behavioral change techniques to promote health and manage illness. Provide nursing care based on evidence that contributes to safe and high quality client outcomes. c. Facilitate client-centered transitions of care, including discharge planning and ensuring the caregivers knowledge of care requirements to promote safe care. d. Demonstrate the effective use the nursing process. e. Create an individualized, holistic and culturally appropriate nursing care plan and/or concept map. f. Practice client and family level nursing actions. 6. Communicate effectively the clients status and outcomes to others on the health care team.
Knowledge and skills leading to mastery of this competency

a. b.

a. Use information and communication technologies to share client information. b. Communicate effectively with all members of the healthcare team.
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c. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, client-centered care. d. Contribute the unique nursing perspective to interprofessional teams to optimize client outcomes. e. Report orally the information necessary to facilitate the continued nursing care of a client by any others involved. f. Record information necessary to maintain a record of nursing actions, client reactions to the care, and resulting client outcomes. 7. Apply ANA code of ethics to the care of clients with acute conditions/processes.
Knowledge and skills leading to mastery of this competency

a. Use an ethical framework to evaluate the impact of social policies on health care. b. Act to prevent unsafe, illegal, or unethical care practices. c. Analyze an ethical dilemma, citing ethical principles and a systematic approach or resolving the ethical dilemma. Overview: The clinical experience provides students the opportunity to put the theories learned in the classroom and lab, into practice. Nursing clinical are a critical part of nursing education, as they give you a chance to work with real patients in a supervised setting. During clinical, nurses are assigned to work with patients in a variety of settings, working side by side with nurses who have completed their training, along with instructors and other healthcare personnel. This clinical experience will build on the foundational concepts to provide holistic and culturally congruent nursing care for adult clients in a sub-acute and long-term care setting. This clinical will place emphasis on learning the nursing actions necessary to manage clients who present with acute signs and symptoms. Students practice will be guided by clinical practice guidelines and standard policy and procedures, while learning to provide direct nursing care such as performing delegated medical treatments (medication administration, IV therapy, wound care, oxygen therapy, sterile technique, and surgical care). Students will be required to collect and interpret a variety of data to provide client and family centered care. Learning Activities: Clinical expectations Guidelines for clinical General orientation to nursing units Review of clinical paperwork Review of clinical guidelines
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Review of syllabi Documentation review

Come to class prepared to discuss: Clinical Paperwork Post-class Review Clinical Paperwork Read: Being Prepared for Nursing Clinical Learning Objectives 1. Describe the importance of caring and healing techniques that promote a therapeutic nurse client relationship. 2. Demonstrate accountability for personal and professional behaviors 3. Incorporate the professional standards of moral, ethical and legal conduct based on clinical facility. 4. Demonstrate professionalism (including appearance, demeanor, respect for self and others, and attention to professional boundaries) with clients, families, and staff at the clinical setting. 5. Identify professional behaviors required to provide quality client care. 6. Discuss the importance of critical thinking in relation to the nursing process. 7. Identify behaviors necessary to maintain self-awareness and a reflective nursing practice.

Being Prepared for Nursing Clinical 1. RESEARCH YOUR PATIENT a. Be familiar with your patients diagnosis i. Look up the patients diagnosis and be familiar with interventions specific for this patient (use your Ackley textbook). ii. Be prepared to implement the main interventions as it pertains to your patient. (I am looking at your ability to care for your patient). When I ask you what your plan is for the daythe care plan should be your guide! b. Look up the history and physical i. You cannot care for your patient if you do not know the past history. ii. You will be required to teach your patient about his/her health. The better you understand the past, the more prepared you will be to teach your patient behavior modification with regards to their health. c. Look up ALL medications. Understand why your particular patient is taking the medication (remember, meds can be prescribed for a variety of reason. Know why your patient is taking the med!) i. Know both the generic and trade name ii. Know the action and normal dose of the medications iii. Know the main side effects 1. These are the ones typically bolded or highlighted 2. If your patient complains of specific symptoms, the first thing I will want to know is what medications your patient is on. If you have done your research, you should be able to tell me whether or not the medications are causing the problem d. Look us all diagnostic procedures and lab values. i. Look up any procedures your patient is scheduled for. Understand why the patient needs the procedure. ii. Look up lab values, especially the abnormal ones. Understand what negative effect the abnormal lab values can have on your patient. (This can also become a part of your nursing interventions). 2. Once you have familiarized yourself with your patient, using the above information, you can start to draw some conclusions as to what interventions you will be doing for your patient. Remember, this is why you are in clinical to CARE for your patient. 3. If you dont know somethingwrite it down. I recommend you carry a small tablet with you to write anything you think you may need to know to care for your patient. This may include (six rights of medication administration, procedures for specific treatments, etc.).

General

Baseline Assessment 0800 VS: T_____ P______ (regular or irregular) RR_____ BP________ Pain: (Description/location/intensity/onset): Color: _______________ Skin Temp: _______ Condition:___________ Surgical Incision: Skin Breakdown: Y/N Describe: _____________________ Swallowing ability:_____________ Oral Mucosa:_________________ LOC:___________________ Seizure Precautions: Y/N CMS:________________ Mental Orientation:________________________ Other: Lung sounds_________________ Dyspnea: Y/N SaO2_____________ O2 @_________ or RA: Y/N Cough:____________ Sputum:_____________________ Other: Heart Sounds: S1 S2 S3 S4 Murmur: Y/N Edema: Y/N Location: _______________ Rating: +1 +2 +3 +4 Ascites: Y/N Cap Refill__________ Pulses: Strong/Weak/Absent Describe:_________________ Other: Foley: Y/N Urine Color____________ Diet:__________ Appetite: ________________ Fluid Restrictions____________ Last BM__________ Abdomen_______________ Bowel Sounds_______________ Flatus: Y/N Other: Activity Level: _____________ Assist required____________ ROM: Full/Limited Describe:_________________________ Other:

Reassessment1200 VS: T_____ P______ (regular or irregular) RR_____ BP________ Pain: (Description/location/intensity/onset): Color: _______________ Skin Temp: _______ Condition:___________ Surgical Incision: Skin Breakdown: Y/N Describe: _____________________ Swallowing ability:_____________ Oral Mucosa:_________________ LOC:___________________ Seizure Precautions: Y/N CMS:________________ Mental Orientation:________________________ Other: Lung sounds_________________ Dyspnea: Y/N SaO2_____________ O2 @_________ or RA: Y/N Cough:____________ Sputum:_____________________ Other: Heart Sounds: S1 S2 S3 S4 Murmur: Y/N Edema: Y/N Location: _______________ Rating: +1 +2 +3 +4 Ascites: Y/N Cap Refill__________ Pulses: Strong/Weak/Absent Describe:__________________ Other: Foley: Y/N Urine Color____________ Diet:__________ Appetite: ________________ Fluid Restrictions____________ Last BM__________ Abdomen_______________ Bowel Sounds________________ Flatus: Y/N Other: Activity Level: _____________ Assist required____________ ROM: Full/Limited Describe:_________________________ Other:

Abnormal Findings

Skin

Mouth/ Throat Neurological

Respirator y

Cardiac/ Peripheral Vascular

GI/GU

Musculoskeletal

Baseline System Assessment NS3361

Date__________ Client Initials______

General Status: While greeting & meeting client assess Alertness______________Orientation_________________Communication________________________ _____ Pain_________________________________________________________________________________ _____ ABCs: Assess Vital Signs, Airway, Breathing, and Circulation Respiratory rate______O2 sats.________ O2 device/flow rate____________________________ Temp._______________ BP________________Apical pulse______________ Mini Physical Exam: Head to Toe Head (Use penlight to examine each) Eyes: PERLA Right________________________ Left___________________________ Extraocular movements__________________________________________________________________ Nose: Drainage____________________Lesions__________________Patency of nares____________________ Ears: Drainage_______________________Ability to hear spoken voice________________________________ Mouth, lips, tongue: Membrane moisture/dryness/color______________________________________________ Condition of teeth/dentures_______________________________________________________________ Oral lesions___________________________________________________________________________ Skin (while completing your exam observe skin in all areas): Turgor________________Dryness____________________ Lesions/Bruises________________________________________________________________________ ______ Wounds (Location, size, drainage, dressings) _______________________________________________________ _____________________________________________________________________________________ ______ Chest and chest muscle movements with respirtaitons________________________________________________ Lung sounds (listen to 6 anterior, 2-4 lateral & 6 posterior sites) _____________________________________________ _____________________________________________________________________________________ _____________ Heart sounds (listen at apex & 4 valve areas) ____________________________________________________________ _____________________________________________________________________________________ _____________ Radial pulses (rate and strength): Right______________________________Left________________________________ While palpating radial pulses check upper extremities for: Motion (wiggle fingers) R side_________________L side__________________ 8

Strength (squeeze your fingers) R side________________ L side__________________ Sensation (client eyes closed, nurse touches finger & asks client to name finger)R side________L side_________ Abdomen Inspect for movement, pulsations, lesions______________________________________________________ Ausculate bowel sounds (4 quadrants)_____________________________________________________________ Light palpation for masses/discomfort,etc__________________________________________________________ Elimination (bowel & urinary)___________________________________________________________________ Pedal pulses Right_____________Left__________ Pedal/leg edema Right_____________ Left______________ While palpating pedal pulses check lower extremities for: Motion (wiggle toes) R side_________________L side__________________ Strength (dorsi & plantar flex against resistance) R side______________ ___L side__________________ Sensation (client eyes closed, nurse touches toe & client to name which toes)R side__________L side__________ Drains/Tubes Drains & tubes (type, location, patency, drainage characteristics)______________________________________________ _____________________________________________________________________________________ _____________ Environment Safety (bedrails, bed position, call light, fall hazards, bed alarms)______________________________________________ Neatness & cleanliness (room, bathroom)________________________________________________________________ Comfort (lighting, temp.,client position, bedlinens, noise, privacy)_____________________________________________ Equipment ___________________________________________________________________________ _____________