Concept Map This assignment is designed to extend the learner’s use of concept mapping as a tool for clinical care planning. The nursing process continues to provide the foundation for organizing info

CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 1 OF 8 Student Name: D#: Date: Course: Session and Year:

Directions This Direct Patient Care Documentation must be completed for one patient\ whom you are providing direct care in a clinical learning setting. All informa\ tion within this packet must be handwritten, (with the exception of the reflectio\ n journal) reviewed with your faculty on your assigned clinical day and submitted with\ in 24 hours (or as directed by course coordinator). If additional space is needed,\ please use the back of each page.

• Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the Clinical Learning Evaluatio\ n. Satisfactory rating meets the following: with the following.

– Clinical 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 significan\ ce are to be completed after patient report has been received. Students should deliver a hand-off report at the end of their shift to t\ he bedside nurse.

• Assessment Findings, Labs and Healthcare Provider Orders: Document your initial and ongoing assessment findings, lab results wit\ h why they were drawn specifically for your patient and healthcare provi\ der orders with why they were specifically ordered for your patient.

• AT I ® Active Learning Templates Required: – Nursing 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.

– Medications: List medications below and complete one Active Learning Template: Medication for each medication classification in which you ha\ ve not previously completed a template.

Time Due Drug/Classification Clinical Significance • Nursing Diagnosis:

Identify three nursing diagnoses for your patient and list them by prior\ ity below. Complete one concept map for your top nursing diagnosis listed below.

1. 2.

• Reflection Journal Complete a reflection journal and submit to your faculty within 24 hou\ rs of completing your clinical learning experience. Reflective journaling provid\ es a format to share your knowledge, skills, experiences and personal reflection r\ elated to concepts and strategies learned throughout your program. The reflection \ journal is required to be typed, Word document, Times New Roman 12-point font. Minimum of one page and no more than three\ pages.

12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Offlce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 2 OF 8 I-SBAR I Introduce Yourself Your Name:D#:Your Title:Reason for being there: S Situation Patient: Age:Gender:Height/Weight:Race/Ethnicity:Allergies:Code Status:Advance Directive (Durable Power of Attorney, Living Will, Other) & Clinical Significance:

Privacy Code:Date of Care/Time: Attending Physician: Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance:

Pathophysiology of Primary Medical Diagnosis: B Background **Include clinical significance with each** Past Medical History: Past Surgical History:

Social History/Socioeconomic Factors: A Assessment Vital Signs: B/P HR RR TEMP SP02 PAIN Falls risk:_________ Accu check:_________ IV Site: _____________________________ IV Fluids:____________________________ Isolation Isolation Precautions N Y Contact Air Droplet RESPIRATORY CARDIOVASCULAR NEUROLOGICAL GI/GU I & O INTEGUMENTARY PSYCHOLOGICAL FAMILY - SUPPORT SAFETY Teaching needed:

Quality in Safety Education Nurses (QSEN) Risk(s) Identified: R REQUEST/ RECOMMENDATION Hand off report to: From:

Vital signs:

T: P: Resp: Sp0 2: BP: Height: Weight: Apical HR: Pain scale used with rationale:

P (Palliative, Provocative) What makes the pain better/worse?

Q (Quality) How is the pain described?

R (Radiation) Does the pain travel or spread anywhere else? If so, whe\ re?

S (Severity) What is the intensity of the pain?

T (Temporal) Is the pain constant, or does it come and go?

Head and Neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea):

Respiratory (lung sounds, breathing effort, accessory muscles): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Abdomen (inspection, bowel sounds, palpation, contour): Bowel incontinence:

Bowel plan: Last BM:

Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities):

Genitourinary (burning with urination, frequency, color of urine): Urinary incontinence: Toileting plan:

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.): IV access (type/size, site, reason for IV access, type of fluid/rate, reason f\ or type of IV fluid, assessment of IV site, last dressing change): Ongoing Assessment Findings and Time:

Vital signs:

T: P: Resp: Sp0 2: BP: Height: Weight: Apical HR: Pain scale used with rationale:

P (Palliative, Provocative) What makes the pain better/worse?

Q (Quality) How is the pain described?

R (Radiation) Does the pain travel or spread anywhere else? If so, whe\ re?

S (Severity) What is the intensity of the pain?

T (Temporal) Is the pain constant, or does it come and go?

Head and Neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea):

Bowel plan: Last BM:

Genitourinary (burning with urination, frequency, color of urine): Urinary incontinence: Toileting plan:

12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 4 OF 8 Labs Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn WBC RBC Hgb Hct Plt Chol Trig LDH PT APTT AST A LT Tdl* *Therapeutic drug level Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn Glu BUN Na K Cl Creat CO2 Ca Phos Mag T.Pro Alb Tdl* 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Ofce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 5 OF 8 Healthcare Provider Orders Items Order/Frequency Reason (explain specifically why ordered for this patient) Diet I/O VS Activity Accu-check Foley NG tube PEG tube PEJ tube Chest tube Trach Suctioning Drains Ostomy Dressing change and/or wound care Treatments Special equipment Other 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Ofce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 6 OF 8 Concept Map Interventions for Nursing Diagnosis Rationales for Interventions Nursing Diagnosis Medication(s) r/t Diagnosis Signs and Symptoms Lab Values Related to Nursing Diagnosis Medication Side Effects Patient Outcome(s) 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Ofce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information. CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSES PAGE 7 OF 8 Active Learning Template:

Medication 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 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Offlce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic 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: Skill Name: Review Module Chapter: Description of skill CONSIDERATIONS Indications Nursing Interventions (pre, intra, post) Outcomes/Evaluation Client Education Potential Complications Nursing Interventions 12-180404 2019 Chamberlain University LLC. All rights reserved. 0119pcpeADA CHAMBERLAIN UNIVERSITY National Management Offlce | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specic address, phone and fax information.