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Napa Valley College

Associate Degree Program in Nursing Nursing in Health Alterations II – NURS 143

NURSING CARE PLAN GUIDELINES

1. Gather your data.

Review the patient’s chart. Read the medical history and physical, nursing admission notes, progress notes, laboratory and diagnostic tests. You may also visit (interview) the patient.

2. Fill in the patient database and lab analysis sheet. Review all lab values, normal &

abnormal, as they apply to your client’s plan of care. Indicate relationships between medical diagnosis, lab test results, medications, and treatments. (Do not use patient’s name on your papers).

3. Under the plan for each assessment section, include your plan based on the information

including teaching. 4. Complete medication sheet for all prescribed meds on assigned patients. 5. Gather information from your texts and resources about the patient’s diagnosis, signs and

symptoms, and medications. 6. Write a minimum of three nursing diagnoses; one psychosocial and two physiological per

patient.

A three part nursing diagnosis has three components: a. The diagnosis according to NANDA b. Related to the etiology c. The signs and symptoms that manifest the diagnosis

7. Set your priorities. Decide on the urgency for intervening. Use textbook as a guide. 8. Identify the desirable goals/outcomes. They should be realistic for both the patient and you.

They should also be stated clearly, concisely and be understood and measurable by any member of the health care team. Write short term goals appropriate for each nursing diagnosis. Write a minimum of one long term goal per patient. (Must include discharge planning).

9. Nursing interventions are the actions you believe will resolve the problem. These activities

are required to restore, maintain or promote health. 10. The scientific rationale (evidence) explains and justifies the use of your nursing actions. It

states how the action achieves the outcome.

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11. The evaluation is an assessment of whether the patient achieves the outcome/goal, and if the nursing interventions were effective in reaching the goal.

Other Instructions Related to Nursing Care Plan (NCP) 1. Keep all your Nursing Care Plans together in a folder and turn in the folder each week. 2. You must submit a complete NCP for one assigned patient per week throughout the

semester focusing on Respiratory, Cardiovascular-Hematological, Reproductive, Renal-Urinary.

3. A complete NCP consists of:

a. Patient data base b. Lab analysis/Diagnostic Related Studies work sheet c. Definition of medical diagnosis and surgery, description of pathophysiology d. Health alterations assessment e. Medication sheet f. NCP with at least 3 nursing diagnoses, prioritized and with goals/outcomes, nursing

interventions, rationales and evaluation g. The NCP is due to your clinical instructor at the end of the last clinical day of the

week. 4. When you have more than one assigned patient, you will be expected to complete only a

mini-prep on your second patient. A mini-prep consists of:

a. Patient data base b. Health alterations assessment c. Three prioritized nursing diagnoses d. Medication sheet (include only those meds you will administer) e. The mini-prep is also due on the last clinical day of the week

5. Complete any one of the body systems assessments, (cardiovascular and respiratory)

when it is appropriate to your patient’s major diagnosis.

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NAPA VALLEY COLLEGE ASSOCIATE DEGREE PROGRAM

NURS 143

MEDICATION ASSIGNMENT GUIDELINES

A. General Instructions

1. Use prep packets available in bookstore.

2. List all drugs ordered: trade (add generic) name, dose, frequency, route, times to be given, and safe range.

3. Giving meds includes giving all meds except IV meds.

4. Preparation prior to clinical includes reviewing carefully:

a. The medication procedure for that hospital (see nursing procedure books in

skills lab and on each hospital unit).

b. Drug information: classification, action, side effects, why ordered for given patient, actual M.D. order, nursing implications, expected outcome and evaluation.

B. Med Sheet Format:

1. Action

State simple action (i.e. what it does), not the mechanism (how it does it). For some drugs, class and action are the same (i.e., diuretic). Example: the action of digitalis is to decrease heart rate, increase cardiac output and increase force of contraction.

2. Why ordered

This is the key to being able to evaluate the effectiveness of a drug. Avoid repeating the action, use or overall goal. State what medical diagnosis or problem you found documented for this patient that supports why the drug was ordered.

3. Side Effects

Two or three, which seem most likely are adequate for this worksheet. It is often useful to group side effects rather than spell them out (i.e., GI distress – N & V, diarrhea, cramps).

4. Nursing Implications

Again, choose one or two pertinent items for this patient. Omit repeating to check for side effects, since this is always the case.

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The implications should pertain only to this patient. They should pertain to the route used. For example: is the medication being given to your patient to lower blood pressure or cause diuresis?

5. Expected Outcome

These are always measurable. First, look at “why ordered,” which is the key for this area. State those data or facts you will look at to determine if the medication is solving the problem. Digoxin, ordered to treat congestive heart failure, could have these expected outcomes: lungs clear, no edema, JVD, or pulse deficit, etc. These parameters could vary with each patient. If you are having difficulty with outcomes, ask your instructor for assistance. Outcomes are to be filled out prior to clinical. Remember, they directly relate to “why ordered.” If this is unknown, outcomes are not possible to determine.

6. Evaluation

Ideally, should be completed at the end of each clinical day. At least fill these in by the second day. Evaluations are done by simply listing the actual findings/data/facts listed as listed under expected outcomes. If outcomes are stated properly, then anyone could collect the data. State facts only, no judgments or conclusions. Example: if the expected outcome is decreased H.R., you will simply state what the heart rate is (HR 70).

Outcome: regular rhythm Eval: Irregular pulse (or regular) Outcome: afebrile Eval: Temp. 100 Outcomes (for prn): “relief” (quotes mean indicated patient statement).

Eval: used x 1 for c/o H/A without relief OR used x 2 for incisional pain with relief

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Napa Valley College Associate Degree Program in Nursing

N143 Patient Data Base Student Name_____________________________ Clinical date(s)______________

Pt. Initials ________ Age______ Sex______ Rm #_________Dr._________________ Adm. Date_____________ Allergies____________________________________________________________________________________ Current Medical Diagnosis______________________________________________________________________ Surgical Procedure/ Date ______________________________________________________________________ Admission Height__________ Weight______lbs. _____kg ____ BMI

Socioeconomic/Health history: Religion___________________ Ethnic identity_________________ Primary language__________________ Cultural practices_________________________________________________________________________________ Educational level___________________ Occupation__________________________________ FT__ PT__ Retired__ Living arrangements: Alone___Spouse___ Parent____ Other:_____________________________________________ Institution (name & describe)________________________________________________________________ Insurance: Yes____ No____ Health patterns at home: ADL’s: Independent___ Needs help with:_____________________________________________________ Diet: ________________ # of Meals a day____ Snacks (describe)_______________________________ Sleep pattern ________________________________ Aids to sleep_________________________________ Elimination pattern: Voiding_______________________________________________________________ BM__________________________________ Use of laxatives/enemas: Yes__ No__ Alcohol use: No__ Yes ___ Type______________ Daily amount____________________________ Smoking: No__ Yes __ Quit/ When? ________________ Type& Amount____________________________ Recreational drugs: No__ Yes ___ Type & Amount______________________________________________ List community resources used_____________________________________________________________________ ______________________________________________________________________________________________ Relevant family history: Hypertension ___ Diabetes___ Heart disease____ Stroke____ Cancer___ Other__________________ Advanced Directive: Living Will: Yes ___ No___ DPOA: Yes __ No__ Developmental Stage (Erickson): ___________________________________________________________________ Justify with examples of stage:___________________________________________________________________ ______________________________________________________________________________________________ Nursing considerations:_________________________________________________________________________ ______________________________________________________________________________________________ Pertinent illness/surgical or OB/GYN history: ____________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Medication Reconciliation including herbs & OTCs used at home:

Medication & Dose Frequency Reason for taking

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Napa Valley College - Associate Degree Program in Nursing Patient Data Base

Pathophysiology of current medical diagnosis include reference (describe how normal physiological processes are altered by medical diagnosis) include internet source :___________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Symptoms on admission: ________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Admission Vital Signs:T.____ P.____ R. ____ B.P. _____SPO2 ______Pain: location_________________ Scale0-10__ Patient’s statement of reason for admission: _________________________________________________________ ________________________________________________________________________________________________

Current functional health status:___________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Most recent V.S.: T____ P_____ R____ BP____ SPO2 ______ Pain: Location_____________________ Scale0/10____ Last 24hr. Intake_________ Output ___________ Most recent weight______kg Date of last BM___________ Current Medical Treatment Orders: Activity: Fall risk: low__ med__ high__Assist devices:

Vital signs: I&O: CSBG: Telemetry: I.V. site: _______________________ Saline (peripheral) lock: No __ Yes__ Flush frequency__________ Intravenous solution(s):_____________________________ rate: ________ml/hr _______gtts/min rate:________ ml/hr _______gtts/min Diet: Tube feedings: method_____________ formula____________________ rate______ Oxygen:___________L/min method____________________ TCDB: __________ IS__________ Respiratory treatments/procedures: Tubes, Drainage devices, Catheters: __________________________________________________________________ Dressings:

Restraints: Other: Scheduled diagnostic tests: Code Status: Full______ DNR_______ Other____________ Living Will________ DPA_____

Possible discharge needs: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

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Napa Valley College Associate Degree Program in Nursing

NUR 143 Assessment & Plan Flowsheet

Describe assessments that are not within normal limits

Neuro/Sensory LOC

Speech/Pupils

Motor Response

Communication

Vision/Hearing Restraints

Pain

Alert Oriented Disoriented Lethargic Unresponsive Clear Slurred Aphasia Nonverbal PERRL Other (L) (R) Follows instruction/spontaneous movement Other ______________________________________________ Movement/Strength of U.E. Rt Lt L.E. Rt L ______________ Grasps ideas and questions Other_________________________________________________ WNL Wears glasses Blind WNL Hearing aid R L Deaf NA Type _____________ None Yes Location:________________ Intensity (0-10)________ Radiates_______________ Relieved by:____________________________________________________________________________ Other observations:__________________________________________________________________________________ Plan: _____________________________________________________________________________________________

Cardiovascular Pulses Heart sounds Edema Telemetry

R Radial R Pedal Rhythm: Regular Irregular Present Absent Present Absent Strength________________ L Radial L Pedal B.P._____________ Pulse Rate_________ Apical rate_______________ S1 S2 S3 S4 none Pitting Non-pitting Location ___________________________________________________ Telemetry Rhythm (if applicable) _________________________________________________________________ Other observations:__________________________________________________________________________________ Plan: _____________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Respiratory Effort Breath sounds Cough/Sputum

Rate____ Respirations even, regular, & unlabored SPO2 ___ room air SPO2 ___ via _____@__L/min Clear Diminished Crackles Rhonchi Wheezes Absent Location of adventitious sounds:_________________________________________________________________ None Nonproductive Productive Sputum (describe)________________________________________ Other observations:__________________________________________________________________________________ Plan: _____________________________________________________________________________________________ ___________________________________________________________________________________________________

Gastrointestinal Diet/swallowing Comfort Abdomen Bowel sounds Tubes Elimination

Diet type ________________ _____%taken NPO Dysphagia ____________Enteral feeding____ml/hr Tolerates diet well Nausea Emesis (describe) Soft Hard Firm Distended Tender Active in all quads Hypoactive Hyperactive Absent State location:___________________________ None N/G Salem Other: _________ Ostomy (type)_________ Describe drainage: ___________ BM this shift (describe) _______________________ Constipation Diarrhea Other observations:__________________________________________________________________________________ Plan: _____________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________

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Renal/Urinary Voiding/pattern Urine Diversion

Without complaints Dysuria Incontinent Condom Indwelling urinary catheter Suprapubic Amount:_____________ Color: ______________ Clarity:______________ Sediment:__________________ Other observations:__________________________________________________________________________________ Plan: _____________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________

Musculoskeletal Movement ROM Assist devices Activity Feed/Bath Turn/Oral

Strength/movement equal Flaccid/weak: Rt___ Lt____ Tolerates activity well Other_____________ Full active Passive Restricted___________________ Immobile_____________________________ Contractures _____________________ Hip precautions None Cane Crutches Walker W/C CPM Venodyne/SCD/Pneumonatic boots Ambulates by self Ambulates with assist Up in chair Other:______________________________ No assistance required Fed with assistance Fed by staff Partial bath Complete bath Turn with partial assist Turn with max. assist Oral care with assist Oral care by staff Other observations:__________________________________________________________________________________ Plan: _____________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________

Integumentary Appearance Incision Dressing

Warm Dry Skin color appropriate Cool Diaphoretic Pale Flushed Cyanotic Jaundiced Intact Redness/Rash Lesion/Wound (describe)_____________________________________________ _________________________________________________________________________ None Approximated Clean Dry Staples in place Reddened Open Swollen None Yes/Location____________________________________ Dry Drainage(describe)_________________________________________ Other observations:__________________________________________________________________________ Plan: _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________

Reproductive (complete on all patients)

Birth control method______________ Last menses___________ Last PAP smear _____________ None Itching Bleeding Discharge (describe)_____________________ Pain Breast lumps Pregnant SBE STE Last mammogram__________ Last testicular exam_________ Rectal______ Other observations:__________________________________________________________________________________ Plan: _____________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________

Endocrine/

Metabolic

Temperature ______________ Height__________ Weight_______________ Blood glucose________________ Polyuria Polydipsia Polyphagia Heat intolerance Cold intolerance Nervousness Other observations:__________________________________________________________________________________ Plan: _____________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________

Psychosocial Emotional status Support/Coping Care participation Code status

Calm Anxious Depressed Irritable Frightened Aggressive Other:_________________ Coping/support systems adequate Family/friends visit Visit by chaplain Sacraments of the sick Support system:______________________________________________________________________________ Active Passive Non-compliant Non-responsive Full Code No Code Limited Code_________________________ Concerns related to hospitalization:_______________________________________________________________ Other observations:__________________________________________________________________________________ Plan: _____________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________

Risk I.D. Precautions

Siderails/Safety

Skin breakdown Falls Patient checked q1hr Restraints Type ________________ Respiratory Contact Neutropenic All down Top rails up Top & bottom up Bed in low position Call bell within reach brake on Other observations:___________________________________________________________________________ Plan: _____________________________________________________________________________________

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Lab Values Patient Values Date Date Date

Name of Test

Normal Range (include units of measure)

What is the Significance/Trend of Lab Test?

Nursing Actions

Review all lab values, normal & abnormal, as they apply to your client’s plan of care. Indicate relationships between medical diagnosis, lab test results, medications, and treatments.

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Name: ___________________________Date of Care: __________________Patient’s Initials_____________ Room Number _________

Allergy Reaction Allergy Reaction

Medication Teaching

Which medication? What did you teach and how did you adapt your teaching style to meet individual need or special considerations? Evidence of understanding, effectiveness of teaching, action plan: Dat

e Ordered

Medication Trade Name Generic Name Dose Route Frequency Safe Range Age Related Considerations

Times given 1) Class 2) Action 3) Side Effects 4) Why administered

Nursing Implications Expected Outcome Evaluation

Date Ordered

Medication Trade Name Generic Name Dose Route Frequency Safe Range Age Related Considerations

Times given 1) Class 2) Action 3) Side Effects 4) Why administered

Nursing Implications Expected Outcome Evaluation

Date Ordered

Medication Trade Name Generic Name Dose Route Frequency Safe Range Age Related Considerations

Times given 1) Class 2) Action 3) Side Effects 4) Why administered

Nursing Implications Expected Outcome Evaluation

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Name: ____________________________________________Date of Care: __________________Patient’s Initials_____________ Room Number _________

Date Ordered

Medication Trade Name Generic Name Dose Route Frequency Safe Range Age Related Considerations

Times given 1) Class 2) Action 3) Side Effects 4) Why administered

Nursing Implications Expected Outcome Evaluation

Date Ordered

Medication Trade Name Generic Name Dose Route Frequency Safe Range Age Related Considerations

Times given 1) Class 2) Action 3) Side Effects 4) Why administered

Nursing Implications Expected Outcome Evaluation

Date Ordered

Medication Trade Name Generic Name Dose Route Frequency Safe Range Age Related Considerations

Times given 1) Class 2) Action 3) Side Effects 4) Why administered

Nursing Implications Expected Outcome Evaluation

Date Ordered

Medication Trade Name Generic Name Dose Route Frequency Safe Range Age Related Considerations

Times given 1) Class 2) Action 3) Side Effects 4) Why administered

Nursing Implications Expected Outcome Evaluation

Date Ordered

Medication Trade Name Generic Name Dose Route Frequency Safe Range Age Related Considerations

Times given 1) Class 2) Action 3) Side Effects 4) Why administered

Nursing Implications Expected Outcome Evaluation

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Student’s Name: ____________________________________________________________Date: _______________________ Client’s initials: ____________

Prioritize your nursing diagnoses based on Maslow’s Hierarchy of Needs and give your rationale. (Potter & Perry)

1. __________________________________________________________________________________________________________________________

2. __________________________________________________________________________________________________________________________

3. __________________________________________________________________________________________________________________________

What does your client identify as their long-term goal? ______________________________________________________________________________________

Nursing Diagnosis Relate to: (causes) Evidenced by: (S & S)

Expected Outcomes (Goals) (Singular, measurable and

realistic, dated)

Evaluation (Actual Outcomes)

(Did nursing interventions lead to expected outcomes?)

Implementation (Nursing interventions,

actions, teaching, medical treatments)

Rationale (Scientific principles - include source and page numbers)

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Nursing Care Plan

Nursing Diagnosis Relate to: (causes) Evidenced by: (S & S)

Expected Outcomes (Goals) (Singular, measurable and

realistic, dated)

Evaluation (Actual Outcomes)

(Did nursing interventions lead to expected outcomes?)

Implementation (Nursing interventions,

actions, teaching, medical treatments)

Rationale (Scientific principles - include source and page numbers)

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Student’s name: _______________________ Date: _______ Patient’s initials: ______ S ____ U ____ RESPIRATORY ASSESSMENT: 1. Signs and Symptoms (circle if present): cough, sputum, hoarseness, SOB, PND,

orthopnea, tachypnea, Kussmaul’s respirations, use of accessory muscles, nasal flaring, retractions, intercostal bulging, increased AP diameter, kyphosis, scoliosis, splinting, labored breathing, pursed lips breathing, pallor, cyanosis, crackles, rhonchi, wheezes, pleural friction rub, absence of breath sounds.

2. Assess for risk factors: Smoking, substance abuse, occupation, environment, nutrition,

activity level, stress, family history, allergies. 3. Inspect chest and observe for:

Respiratory rate Respiratory rhythm, depth, effort Use of accessory muscles Retraction, nasal flaring Work of breathing AP diameter __________________ Splinting __________________ Kyphoses, scoliosis __________________ Skin color, color of mucous membranes __________________ Factors which precipitate SOB __________________ Correlation of cough with activity __________________

4. Abnormal Labs: _____________________ __________________________ _____________________ __________________________ _____________________ __________________________ 5. Auscultate chest to identify:

a. Normal breath sounds: vesicular, broncho-vesicular, bronchial b. Abnormal breath sounds: rhonchi, crackles, wheezes, pleural friction rub,

decrease or absence of breath sounds Anterior Chest RUL LUL RML LLL RLL Posterior Chest RUL LUL RLL LLL Respiratory NANDA Dx.:___________________________________________________

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Student’s name: _______________________ Date: _______ Patient’s initials: ______ S ____ U ____

Cardiovascular Assessment

Signs & Symptoms: (circle if present) chest pain, radiating pain, angina palpitations, tachycardia, bradycardia, irregular heart rate, diaphoresis, pallor, hypertension, hypotension, orthostatic hypotension, JVD, edema, fatigue, weakness, syncope, dyspnea, DOE, PND, hemoptysis, bruits, thrills, murmurs, rubs, cough, cyanosis, blanching, mottled skin, ascites, intermittent claudication, phlebitis, arterial skin color or temperature, ulcerations, leg pain, redness, fullness, swelling, numbness, bruising, cold extremity, muscle cramps, bleeding Risk factors: (circle if present) smoking, age, gender, hypertension, DM, sedentary lifestyle, Type A personality with aggression, obesity, oral contraceptives, recreational drugs Assessment: Extremities: Skin: color _____temperature ______capillary refill (2-3 seconds) ____ Edema: location: _______________pitting ____ non-pitting _____ Hair distribution: ___________________________________________________ Homan’s sign (do not perform if thrombophlebitis) present ____ absent _____ Antiemboli stockings: thigh high ___knee high __measurements: _____size ____ Ulcers: location/gangrene ___________________________________________ Peripheral pulses: radial R___ L ___ Scale Femoral R___ L ___ 0 not palpable Dorsalispedis R___ L ___ 1 weak, diminished Post-tibial R___ L ___ 2 easily palpated 3 bounding Heart Rate: AP ______ rate _____ reg _____ irreg Radial _____rate reg ____ irreg ____ Yes No Pulse deficit (difference between Apical and radial pulse such as in atrial fibrillation)): Location PMI: _______________________________ Pacemaker: Yes No Telemetry rhythm: ____NSR other: ___________________ (obtain a strip) Heart sounds & heart valves: S1S2 ____ S3S4 _____ Murmurs______

Tricuspid - location ________________ Pulmonic valve - location ___________ Mitral - location ___________________ Aortic valve- location _______________

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http://www.instantanatomy.net/diagrams/thorax042b.jpg Activity _____tolerance ______intolerance AEB: ______________________________ Orthostatic BP Supine R ___/___ L ___/___ Pulse pressure: SBP-DBP ____ ↑- exercise, effects sustained ↑ SBP, ↓ HF, hypovolemia Sitting R ___/___ L ___/___ MAP SBP+ (DBPx2) ÷ 3 ____ Standing R ___/___ L ___/___ 1/3 PP plus DBP ____ MAP perfusion pressure > 60 for adequate tissue perfusion Chest Pain Assessment of Chest ___ indigestion Precipitating

events

___burning Quality of pain ___numbness Radiation of pain ___tightness or mid-chest pressure

Severity of pain__/10

___epigastric or midsternal pain radiating to shoulder, neck, arms, jaw, back

Timing

Medications: ASA Anticoagulants

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ACEI Beta blockers ARBS Calcium channel Blockers Diuretics Oxygen Nitrates Anemia: type __________________________ Hgb _____ Hct _____ RBC ______ Labs & Diagnostic Studies: Echocardiogram: ejection fraction _____%

Labs: (CK-MB, myoglobin, tryponins, C-reactive protein, WBC, cholesterol, homocysteine)

EKG: _____________________________________________________ Chest x-ray: ________________________________________________ Abnormal labs:______________________________________________ Other diagnostic studies: ______________________________________ Other Cardiovascular relevant assessment/history: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Nursing Diagnosis:

1. _____________________________________________________________ 2. _____________________________________________________________ 3. _____________________________________________________________

Lewis, S. M., Hertkemper, M., & Dirksen, S. R., O’Brien, P. G.,& Bucher, L. (2010). Medical-surgical nursing assessment & management of clinical problems. (8th ed.) St. Louis: Mosby.

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Nursing Care Plan for a Patient with a Chronic Illness

Each student will be expected to complete a Nursing Care plan with the primary nursing focus of chronic illness.

1. After studying your Medical-Surgical textbook, select the “Expected patient outcome”

which would be specific to chronic diseases. 2. Choose two physiological nursing interventions which addresses:

a. The limiting disability b. Promoting self-care

3. Select either one of the two for developing the psychosocial interventions:

a. Promoting self-esteem b. Supporting coping skills

4. Evaluate the effectiveness of your identified nursing interventions and compare patient

behaviors with those stated in the expected patient outcome. 5. Verify across the top of your data sheet this is the specific:

“Nursing Care for the Patient with Chronic Illness” 6. This assignment is due no later than week 6. 7. Submit your teaching assignment with the care plan.

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Guidelines for Patient and Family Teaching Assignment / Chronicity 1. Keep this teaching plan simple. 2. Select an appropriate patient or family in need of teaching and get approval from your

clinical instructor. (You need to do this on first clinical day or early on second day in order to be able to plan and implement your teach).

3. Use the form provided in N143 syllabus to:

a. Assess the patient/family’s learning needs (use only the area/areas appropriate to your teach)

b. Write the nursing diagnoses

c. Note any barriers to learning

d. Identify two community resources involving the chronic illness/disability.*

4. Complete column on outcomes

a. Use appropriate terms for learning objectives.

5. Complete column on plan

a. Teaching method to be used (e.g., discussion, video, pamphlets, demonstration) b. Describe the content to be taught.

6. Implement your teaching activity. 7. Evaluate

(Ask patient/family to do return demonstration, to verbalize or even to read back to you the content taught. Be honest in your evaluation. This is a learning process for you, as well as your patient!)

8. Turn in your form with care plan by week 6. * One resource must be Internet based. Turn in the printed page from this resource with your

paper.

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Patient and Family Teaching and Discharge Planning – Worksheet Student: Date: Patient Initials: Diagnosis: Room: Surgery: Assessment of Learning Needs: Health Alteration: Medication, purpose, schedule: Ways to minimize pain: Diet: Activity: Home care/treatments: When to notify doctor (Sx): Nursing Diagnosis: Lack of knowledge R/T______________________________________________________________ M/B_____________________________________________________________________________ Barriers to Learning: Resources available:

Teaching Plan Outcomes

(knowledge and skills to achieve)

Plan

Evaluation Information given to:_________ patient____________ family_____ Other: ______________

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Specialty Assignments

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Student Name: _______________________________Date: ___________________ Specialty Rotation: Child development OR/PACU SDS/ACU (other) ____________ Reviewer: __________________________ Grade: satisfactory needs improvement unsatisfactory

Unsatisfactory Needs Improvement Satisfactory 1 2 3

Critical thinking

Critical thinking

Critical thinking

The paper … does not respond to the

assignment

The paper … responds adequately to the

assignment but the response is somewhat weak and ineffective

The paper … addresses the assignment

adequately provides evidence

Support & Development Support & Development Support & Development The paper … uses irrelevant details or lacks

supporting evidence entirely brief

The paper … uses generalizations to support the

points. provides some detail and

supporting evidence

The paper … uses evidence appropriately and

effectively providing sufficient examples, details, and explanation to develop ideas fully

Organizational Organizational Organizational The paper …

lacks logical organization lacks transition and logical

ordering has no headings, appropriate

tables.

The paper … does not have clear

expectations and goals. lacks in depth discussion of

learning objectives . Uses inadequate illustrations or tables to present medication or teaching given.

uses sentences within the paragraph which lack coherence.

summary does not include reflective analysis of experience.

The paper … has an introduction that

describes expectations and goals of assignment

uses headings describing learning objectives that were met or not met.

Uses tables/graphs to delineate medication action/side effects/teaching

Reflective summary describes learning/expectations met or not met.

At least 4 pages, typed double spaced in a folder.

Grammar/Clarity/Style/Mechanics Grammar/Clarity/Style/Mechanics Grammar/Clarity/Style/Mechanics The paper …

contains many awkward sentences and misused words

contains many grammatical errors - hard to follow.

includes misspelled words lacks subject and verb

agreement includes jargon and clichés does not include citations does not follow NVC

academic honesty policy

The paper … uses sentences which are

wordy, unfocused, repetitive or confusing

contains several mechanical and grammatical errors making it impossible to follow the thinking from sentence to sentence

uses formatting which is clear and mostly correct

The paper … is concise free of misspellings is free of mechanical and

grammatical mistakes lacks incomplete sentences uses correct punctuation includes subject & verb

agreement uses pronouns correctly is free of jargon & clichés cites references correctly

Comments: Recommendations: unsatisfactory grade requires rewriting assignment for resubmission.

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NURS 143– Nursing in Health Alterations II

Management of the Surgical Patient

Preoperative, Intraoperative and Postoperative

Upon completion of the O.R. experience, the student will be able to: 1. Discuss the role of the nurse in the operative unit. 2. Describe the preoperative, intraoperative and postoperative assessment and the rationale for

collecting the various types of data. 3. Describe the goals for the patient undergoing surgery. 4. Discuss the usual patient teaching regarding surgery. 5. Relate the nursing responsibilities with anesthesia. 6. Discuss the legal/ethical issues in relationship to the surgery. 7. Participate in the nursing interventions for the preoperative, intraoperative, and postoperative

patient.

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Management of the Surgical Patient Preoperative, Intraoperative and Postoperative It is planned that each student will have the opportunity to observe a patient during the perioperative, intraoperative, and the postoperative period. Assignment: The student should check the operative schedule the day before the experience. The student is to review the OR schedule and complete pathophysiology research for scheduled surgeries. Prior to surgery, meet with the patient in the holding area. What is the nurse’s role in the holding area? While in the operating room, observe the activities being performed by the circulating nurse and the scrub nurse. What interventions are used related to patient safety? The OR lead nurse will direct the student to another case as time permits. When you are assigned to a specialty unit, such as the O.R., PACU, or Same Day Care/Ambulatory Care Unit, you are first to report to your instructor on your assigned unit, before going to the specialty area. Your Intraoperative and Post-operative experience paper will consist of the following areas, in order to meet the criteria and obtain a satisfactory evaluation for the experience (see next page).

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THE IMMEDIATE POST-ANESTHESIA EXPERIENCE

NURS 143– Nursing in Health Alterations II

After the student completes the experience assigned to the postanesthesia care unit (PACU), known as the Recovery Room, the student will be able to: 1. Describe the postoperative phase as a component of the surgical experience. 2. Identify postoperative complications that may compromise a client’s safety and stability

after anesthesia and surgical intervention.

3. Discuss the client’s risk factors for potential postoperative complication.

4. Describe the nursing interventions to prevent and/or treat postoperative complications.

5. Include a reflective summary

RECOVERY ROOM GUIDELINES

1. Review the post anesthesia nursing care studied in NURS 141.

2. Be prepared to provide nursing interventions to prevent and/or treat postoperative complications.

3. Be prepared to identify clients at risk for postoperative complications and provide the

needed nursing care.

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Intraoperative & Post-operative Paper

Pathophysiology 1. Describe the pathophysiology of the patient that requires surgical intervention. This is to be

turned into your instructor before you go to the operating room on Thursday or Friday morning.

Anxiety Aspects 2. Talk with the surgical patient, including the preoperative and postoperative phase, and find out

what their greatest source of anxiety is about the surgical experience. Also find out what they do or what another health worker did that was most helpful to them in resolving their preoperative anxiety. Describe this in your paper.

Pharmacology 3. List the preoperative medications given, the dosage, effects and the nursing implications for

giving these medications. Include the type of anesthesia your patient experienced; include the pharmacological action, method of administration and the post operative complications. List the postoperative medications given to your patient; include the pharmacological action, method of administration and the nursing interventions with these medications.

*** use the medication form from the NCP Nursing Care Intervention 4. List the nursing assessments and interventions completed in the postanesthesia care unit and

give the rationale for each. If your patient returns directly to assigned clinical unit, describe the common nursing interventions for the postoperative patient.

Postoperative Teaching 5. Prepare a discharge-teaching program for the patient. Include factors that predispose the

patient to postoperative complications and what you would teach to prevent the potential complications.

Reflective summary 6. Write an analysis of your experience include your reaction, impression and conclusion about

the experience. All papers must be typed or printed from the computer. A paper that is hand written will not be accepted. The paper will be due the first Monday after your assignment, at the end of your class day. If the paper is late or not turned in, an “unsatisfactory” will be given for the assignment. You are responsible to turn the paper in to your clinical instructor. Students who have the experience at the last week of the semester must turn in the paper by 4:00 pm on Monday of final exam week.

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NURS 143– Nursing in Health Alterations II Same Day Care / Ambulatory Care Experience

Upon completion of the SAME DAY CARE experience, the student will be able to: 1. Describe the usual purposes of the Same Day Care unit.

2. Compare and contrast the admission procedure for the Same Day Care in relationship to the patient admitted on a unit in the hospital.

3. Give evidence of the baseline nursing data to be recovered preoperatively, or pre-procedure, as a basis for post management.

4. Provide the nursing role in the psychological and education preparation of the preoperative or pre-

procedure patient.

5. Describe the special considerations and needs for the older adult patient, preoperatively or preprocedure and post management.

6. Verify the etiological factors and nursing assessment and management of potential problems during

the post period.

7. Provide the information needed by the postoperative or post-procedure patient in preparation for discharge.

Instructions for Same-Day Care (SDC) / Ambulatory Care Unit

1. Your first priority is learning a different approach to delivery of nursing care. This means that it is not

all observation, but actual assisting in admissions, preparing the patients for surgery or a diagnostic procedures, monitoring patients, providing comfort and alleviating pain, preparing for discharge, assist with discharge planning and teaching.

2. Go to the SDS the day before the experience to note scheduled procedures, such as bronchoscopy,

colonoscopy, nerve blocks, including preoperative medications.

3. Introduce yourself at the time to the nursing supervisor or charge nurse. 4. Study the procedures and be prepared for the nursing interventions related to those procedures for

your clinical experience. 5. Report for pre and post conference. 6. You may administer any care or medications that you have been approved to do (i.e.: ophthalmic

drops, oral medications). There are incidents when you may not have administered a medication in the route or method that is ordered. You may administer it under the supervision of your instructor who will come to the unit and supervise you or with an RN if he/she is willing to take that responsibility. At no time may you administer I.V. medications in the unit.

7. Submit a typed paper, summarizing what you learned regarding the care of the patient in the Same

Day Care such as procedures, pre and postoperative care. Your paper will address objectives 2, 4, and 7 and is to include a reflective summary. This paper is due at the Nursing 143 class on Monday following the rotation. Late papers constitute unsatisfactory performance.

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COMMUNITY CLINICAL

Napa Valley College Child Development Center

OBJECTIVES: 1. Observe the physical and psychosocial characteristics of the specific age group with whom you

are working.

2. Using the attached “Daily Health Check”, identify any signs and symptoms of illness in the children in the classroom. Report any “problems that you observe to the teacher.

3. Assist the classroom teachers as a community volunteer would i.e. assist with feeding; playing

with children in the classroom and playground; read stories etc. 4. If the teacher requests you might offer to do heights and weights, or other assessment

activities. 5. If possible, perform one very short health/safety related activity for a group of the children –

such as hand washing; basic first aid for abrasions and lacerations; good eating practices, roles of nurses with children.

EVALUATIUON: The typed, double-spaced paper will be due the first Monday after your assignment. If the paper is late or not turned in, an “unsatisfactory” will be given for the assignment. You are responsible to turn the paper in to your clinical instructor.

Write a summary of your day at the Center, include the following:

a. Describe your observations about the psychosocial, developmental and physical status of the children. b. Describe any findings that you observed during the Daily Health Check assessments. c. Discuss the quality of the classroom environment. d. Describe any concerns that you noted regarding safety or health issues at the Center. e. Describe the various cultural backgrounds of the children and staff.

f. List 2 or 3 NEW things that you learned from the experience that broadens your understanding of Pediatric health.

g. List any ideas you have of how Associate Degree Nursing students could be of assistance at the center on future occasions.

h. Identify one safety and one health concern commonly related to children in the age group you studied.

i. Identify the topic you performed or shared as described in objective 5 above. j. Reflect on your experience at the end of the day.

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DAILY HEALTH CHECK

Do the daily health check when you greet the child and parents as they arrive. It usually takes less than a minute. Also observe the child throughout the day. LISTEN: Greet the child and parent. Ask the child, “How are you today?” Ask the parent, “How are you doing? How’s (name of child)?” “Was there anything different last night?” “How did he/she sleep?” “How was his/her appetite this morning?”

Listen to what the child and parent tell you about how the child is feeling. If the child can talk, is he complaining of anything? Is he hoarse or wheezing?

LOOK: Get down to the child’s level so you can see him/her clearly. Observe signs of health or illness:

General appearance (e.g., comfort, mood, behavior, and activity level) Is the child’s behavior unusual for this time of day? Is the child clinging to the parent, acting cranky, crying, or fussing? Does he/she appear listless, in pain, or have difficulty moving?

Breathing: Is the child coughing, breathing fast, or having difficulty breathing? Skin: Does the child look pale or flushed?

Do you see a rash, sores, swelling, or bruising? Is he/she child scratching his/her skin or scalp?

Eyes, Nose, Ears, Mouth Do the child’s eyes lock red, crusty, goopy, or watery? Is there a runny nose? Is he/she pulling at his/her ears? Are there mouth sores, excessive drooling, or difficulty swallowing?

FEEL: Does the child feel unusually warm, or cold and clammy? Does the skin feel bumpy?

SMELL: Be aware of unusual odors Does the child’s breath smell foul or fruity? Is there an unusual or foul smell to the child’s stools? Try to figure out what’s wrong by encouraging the child to be as specific as possible about

his/her complaints. Ask them to show or tell you where it hurts. For older children, ask them to try to explain how it feels, when the discomfort began, and what they think might have caused it. Ask what makes it feel worse and what makes it feel better.

“I DON’T FEEL GOOD” This is the most common complaint of illness among young children. It can be difficult for young children to identify the specific cause of their discomfort and describe it to you, especially when they are not feeling well. They might have a headache, stomachache, fatigue, stress, sadness, or hunger.

Ask the child, “What’s the matter?” or “Tell me what’s bothering you.” She/he might tell you that the other children would not let him/her play the game. Or he/she might tell you, “It hurts.” Ask, “Where on your body does it hurt?”, “Show me where it hurts” or “Point to where it hurts.”

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If the child can’t be more specific about where it hurts, or “It hurts all over,” He/she might have a viral illness which can cause general achiness and discomfort.

HEADACHE Headache can be caused by an illness, but is also commonly caused by stress, anxiety, allergies, vision problems, or head injury.

Ask the child if he/she can tell you why it hurts, and to show you where it hurts. He/she might explain that it hurts because he/she got hit on the head, and he/she might show you a bruise. Or he/she might tell you that he/she feels too hot and needs to lie down.

SORE THROAT Children might also complain, “It hurts when I swallow” or “My neck hurts,” pointing to the throat area at the front of their neck. Sore throat can be caused by a throat infection, a cold, allergies, dry indoor air, or persistent coughing.

Ask the child if he/she would like something cool to drink to try and make his/her throat feel better

EARACHE Ear pain is usually caused by an ear infection, often associated with a cold. Earache can also be caused by cutting new teeth, a blow to the head, or an object placed in the ear.

Ask the child if she can tell you why it hurts. She might explain that she stuck a pencil in his/her ear.

STOMACHACHE Stomachache can be caused by an illness, but is also commonly caused by stress, anxiety, hunger, overeating, or constipation.

Ask the child if he/she has to go to the bathroom or feels like throwing up. Stomachache caused by a communicable disease is often accompanied by vomiting and diarrhea. Ask the child if he/she feels like eating a snack. When a child with a stomachache has a good appetite, the cause is usually not a serious illness.

SKIN RASH Skin rashes are the most varied – and most difficult to interpret – symptom of childhood illness. Skin rashes may be all over the body or in just one spot; constant or changing; pink, red, purple, brown, white, or yellow; flat, raised, blistery, flaky, or crusty; itchy or not; and accompanied by fever and other symptoms of illness or not. Skin rashes can appear very different on different colored skin. For example, the rash of scarlet fever that looks bright red on light-colored skin might just cause a subtle reddish tint or glistening on dark-colored skin, and may be more easily identified by the sandpapery texture of the rash. Another example is the rash of ringworm which usually appears pinkish on light-colored skin, but can appear either pinkish or whitish on dark-colored skin.

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Many skin rashes are caused by viruses that do not require treatment. However, rashes may also be caused by bacteria, parasites, fungus, allergy, or other medical conditions that do require medical evaluation and treatment. And some rashes are signs of a medical emergency. Therefore a child with an undiagnosed rash should always be referred to a health care provider. Observe and document the following characteristics of the rash to report to the parent and/or health provider:

Where on the body did the rash start? How has it changed since then? What color is the rash (e.g., red, pink, purple, brown, white, or yellow)? What does the rash look and feel like (e.g., flat or raised; pin prick size or blotchy; dry or

blistery/crusty)? Is the rash itchy to the child? What other symptoms accompany the rash? Does the child look or act sick? Is there a fever?

Additional information that you could provide might also help the health provider in the diagnosis of the rash:

Has the child had this rash before? Has the child been in contact with someone else who has this rash? Has the child had recent exposure to medications, chemicals, or skin products?

Keep an eye out for:

A rash of tiny blood-red/purplish spots or bruising, not associated with an injury – this might be a sign of an emergency bleeding condition and/or serious infectious disease.

Any rash accompanied by the child looking or acting very ill, fever, difficulty breathing, or vomiting – this could be a sign of various serious illnesses.

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Child Development Center

Dear Visitor, Welcome to our program! We strive to create a quality early care and education program that serves the needs of the children and families enrolled. As a guest in the children’s environment, we would like you to keep in mind key points that honor the work of the children and their needs. The following list is based on research and what we know best meets the needs of children. You are asked to remember / follow these key points. If you have concerns or questions please contact the program Director. Things to remember: You are a visitor in the children’s environment. You should wear clothing that is free of alcohol logos, sexual overtones, or other inappropriate

subject matter. Please try to stay low. Sit down on the ground, floor or chair. Cell phones are not allowed in the classrooms or on the playground. Please do not use any form of discipline. If you see a situation that needs attention, alert the teaching staff. You may interact with the children. Refrain from using inappropriate language, asking children to say ‘sorry’, or asking them to share. You may ask children to tell you about their creations or their play. You may use the materials with the children but we ask that you not use the swings, bikes, climbers, or other child-sized gross motor equipment. When exploring art or building materials with children, please refrain from making models that the

children might want to copy. Children will often discuss relevant issues in their lives, events they have seen on TV, imagined

stories, and ideas they have overheard. Sometimes the tellings are graphic and/or seem unusual. Please refrain from criticizing or stopping them. If you are concerned, please talk to the teacher.

If you have questions about what you observe, please contact the teacher in the classroom or the Director. You may know a staff member, a child, or a family that is enrolled. You are allowed to visit on the

condition of confidentiality. You may not share information about children, families, or staff that you may gain from your visit.

Adult conversation should be kept to a minimum and focus on the program. Please do not bring food or drinks into the environment with the children. Ask a teacher where you may put your coat, backpack, or things. Please refrain from wearing perfume or scents. Many children are allergic to, or are bothered by,

the strong smell of perfumes. Please remember you are not here to entertain the children and should not be the focus of the play. We hope that you enjoy your visit. Allow yourself to experience the world of the children. Children have so much to offer us if we pay attention and clearly observe them and their work and play. Sincerely, CDC Staff