University of Saint Mary School of Nursing 2016 Nursing 306 Fundamentals of Nursing e Clinical Packet for Day 4 Communication 1.) Explain the techniques you utilized to communicate with: a. your resident. My reaiciot, toms gy Frerclly andl lilkecl 40 joke orb a ancl Bo r Sreieal a combortwate Mak We were fo You. b. the nurses and/or healthcare team. Me oil asSistecl mem in Folin Some) » ia onainer Vad petauseOshe WS Gln iW Ch Q oN Nall + oe Phone OF Ye 2.) Deseribe what TP, skills you performed well. LT remainecl toe + Ye Conversation ancl ae lateal Lncouayed Movirtasa in oo. ancl golang ‘eatin 4 oe 3.)What techniques/communication can you use to improve your communication skills with: a. the elderly population. a mainte pat Felsen xn Pete pe tae ae dts tru pt, hac roan He culty “realitig fo "Bat wou! Vrrem rer b. = nurses and/or healthcare team, Yu oad and pve ta us dn cee elie and Wt ws june ad YapgeCultural Diversity 1.) What personal values, attitudes, beliefs, and biases influenced or interfered with your imei th you ets? ate efi i cs. dike toin ‘hoon Jo We si}aasiun Yes Sushasin, Yuk Tam Mancha) she Wh me he id, 2.) What action(s) do you need to implement in dealing with situations or questions that may cause you to feel uncomfortable or contradict your values, attitudes, beliefs, and biases? T wed Ye silugtion Rowe Reade OF mew \2eCOunSe Shu Soicl ue welt dilleent wnursiing, aby Yadunts were Ossesotiy ur And she ww jus Ge wate, fied. ’s 5 C’s of Carin; Sr. M. Simone Roach encourages the nurse to experience and to give the “being” of caring as he/she administers to the needs of his/her patient. The “being” of caring in nursing encompasses compassion, competence, coufidente, commitment, and conscience. Choose a minimum of one of the 5 C’s to address weekly. At the end of your clinical experience, you will have addressed at least 4 of the C’s in your clinical packets. 1.) Chosen “C” for the week is, wa 2.) Summarize in your own words what this “C” means a to Sr. Roach. D possess Me on do cormplufc Ye joo and ie ay) 0 a to di Ceeat sittations qickoa 3.) Explain how you applied it or if you witnessed a fellow student, nursing instructor/staff, or a ‘member of the interdisciplinary team displaying the “being” of caring while caring for your resident or another resident for this particular week. fe pods reds, The LYN wo Jue im hae 00, espectully, win adept Jo Now each WK connec reds On negate dsiubmey ORNSCritical Thinking Reflect on your personal critical thinking indicators (CTIs), as described by Alfaro-LeFeve in your critical thinking textbook on page 9 and 10 Box 1-3. 1. State the CTIs you utilized this week. pietul ancl prrclunt Aurion and niquistve 2. List your major strengths that you displayed or felt utilizing these CTI’s. For ccf Gund Prrcend OF w0ll ov cumuns and gaisthee, Glen Las On tmedy Wir We nue Tooke thay o tok of guastrmny rebordinn, Me Computer tryin onc We Coweta! Clishiau}nn of inireied 3. List two (2) personal CTI’s that you can improve upon and your plan for improvement. (Use ‘ack side of paper if needed.) Proackve - IX clitHoulh Bc = to cpen - Conguencn of aclu loecanse do A acl ik) Ward fue me to actept Misdaher, FOr Fuluc Purposes, T will seek help be Not eT Co make & milake - cal ond Tne - ZT Rally, dons (ooaosty) Posey, onasiny intaion, Wain podsing, macy Wee Aiea? Por me 4 undyotand gular ) WH | F asked 30 T will Conte 40 ask Gs}skance wk) © Wecome combdctulale wihSkills Performed Today 1. List all the nursing skills you were able to perform today. ies lee brace ‘ Lior woulin } olher weds 2. For one skill (pick a different skill each week) - List the steps in the order that you performed them, using your own wording, LMA ki Wy win ie eens v akolel soso, dstton Vall, yen, nude - & oun eae pen = dora bool opqopaa - Choose oppropriak Suleg locaton =o alecnol on Tocadicn 2 Se aay el m shone, clocument, Whanel hapeytent Due this weel 1. Clinical packet. 2. The “Mini Nutritional Assessment (MNA)” (found in Chapter 11, p 84) from Jarvis’ Physical Examination & Health Assessment Student Laboratory Manual, 7 Edition. 3. The “Complete Inpatient Reassessment” form (found in Chapter 29, pages 277-279 of Jarvis). . Resident Demographic form. . The “Checklist for Identifying Actual and Potential Problems” (Alfaro-LeFevre Critical Thinking text, page 166). 6. Resident’s Problem List - Utilizing your assessment and your checklist, develop and prioritize a list of your resident's actual and/or potential problems. (Refer to Ackley front inside cover and section 2). Write two nursing diagnoses for your residents top 2 problems. 7. Concept Map - Complete the concept map on one of your nursing diagnoses. Must be different from Day 3 - discuss with instructor prior to leaving clinical. wails, weeny nor hed sit LPN84 UNITIL Approach to the Clinical Setting Nestle i pel Assessment GQUEEn i aig osm iRETHOTE tastnames __ & ‘roar soc Foe: WB, oe 7 wages 144 _ veers o.nnbe: eng tn eran ying nt bose wth EP PETES “Tua the numbers forthe fal eroring SOE, nar ood ake deine over te pst months dum 2 58 cepa, eigestve probes, chewing oF towing aiicutos? Oana deren # foadinh, See esrease in f003 wise ‘ie decreas foo mse a weight ose during the fost months Feet oss gretortnan 30 (56) {Sdoes nara dons eaten {and kg @2 ar SS) a ‘Sino wei os moby ed orca Dour ox bed ue beaker bt oes not 99. oa ost a oe ied oytnngealauae or ance daneein te Fat mone > Ee Onyes2=n0 = Neuropeyehotogisl problems Oct onan or cersion 22> no paychologial probiems oo a Body Mane nex (BD (eight n ka) (eta Oe bhitoes than 1 i isan 3 ay eles tan 29 Sa anizs orga 3 TU SNOT AVALASLE REPLACE QUESTION WT SYS AGN SAGA oN ete GuESTION FS ALREADY COMPETSS ‘oncGlese tan SEER St or rater ‘Sereening acore Ee (mex. 14 pois) oo “tea ports: Normal nator a of malniion ora mare rah aeeeeeet coo te Feet, a Aan Ge Ovniow te a I ery and Chatege. 9h Fo a cn, as smn saan Gren: PN ‘pomerg esters Fom seen wisn ive Ate Sirpone_ Malnoursnod Ta al tate ak wnat cm ratte restarts MOE OESCHAPTER29 Bedside Assessment and Electronic Health Recording 277 COMPLETE INPATIENT REASSESSMENT Date W/15o tsennns Pluss Hlaaclae, Patient SE Age 13 Gender Occupation canons Sur. Letaal cneason for amision cyatusion Introduction 1. Check for flags or markers at doorway. 2. Introduce yourself 3. Perform hand hygiene. 4, Make eye contact. 5. Offer water. 6. Check name band. 7. Ask appropriate interview questions, including current pain. ; 8, Elevate the bed to appropriate height, General Appearance 2 1. Facial expression __Camnfgrkalole J we 2, Body position A 3. Level of consciousness Xi 4, Skin color 5: Nutritional satus —@paanate Be lect obd asec AEvaL Ar aduabitin foun 6. Speech: articulation, pattern, content appropriate Clb ypeg@hy wins vuhriti diel 7, Hearing SU@AE i AsseSSRay, 8, Personal hygiene Wan, o ‘Measurement 1. Temperature 2, Pulse 3. Respiration 4, Blood pressure 5. Pulse oximetry 6. Weight on admission or eal ‘weight is indicated AS ies or Tea 7, Rate pain level on scale of 1 to 10; note ability to tolerate pain. 8, Pain reassessment, if appropriate Neurologic System 1, Byes open: 2. Spontaneously b, Name . Motor response . Verbal response Gi 5. tips aa sength bi 1 sheng caper shicgin278 UNITIV Integration: Putting t All Together 6. Lowes mos rng don WE Lag ox ehier 9, Communication yess eee 10. Ability to ral fe pinta a | Dicken pase ace Respiratory 1. Oxygen by mask, nasal prongs; check fitting WR 2, Foz 3. Respiratory effort COMIOOOOQ 4, Auscultate breath sounds: Anterior lobes: Right upper ee Left upper Right middle Right lower Left lower Clow Posterior lobes: Left upper Cita Right upper ear Left lower Right lower Cough and deep breathe; any mucus? Check color and amount. — AG MUACQLS Educate on use of incentive spirometry, if ordered. Cardiovascular System 1, Auscultate rhythm at apex: regular, irregular? regalac 2. Check apical versus radial pulse. : 3. Assess heart sounds in all auscultatory areas: first with diaphragm, repeat with bell. 4, Check capillary refill. NSS dine Yreee secon & 5. Check pretibial edema. aR at bL__ae 6. Palpate posteriog tibial pulse, aR Tf De 7. Palpate dorsalis pedis pulse. aR yr br |e 8. Pulses by Doppler, if assigned 9. IV fiuid and rate, if present Skin (may be integrated with rest of assessment) ~ Color . Temperature . Pinch up a fold of skin under the la . Note any lesions; check any dressings. ». Note skin around IV site, _ V1 5. Standardized scale regarding skin breakdown Settings and application of specialized surface, if present or on the forearm. —qnimvecliake reco) MOY RENECHAPTER29 Bedside Assessment and Electronic Health Recording 279 ‘Abdomen 1. Contour of abdomen: fst, rounded, protuberant aja 2. Bowel sounds in all four quadrants — haat cae LEE LenesesesesHeISTE EEE: 3, Check any tube drainage and site. 4, Inquire if passing flatus or stool. 5. Can patient tolerate current diet? Should diet be advanced or changed? Genitourinary L. Inquire if voiding regularly. rOplot 2. Urine for color, clarity, quantity 3. Bladder scan, if indicated __NO SCN Activity 1. fom bed rest, check heed of bed, sk for skin breakdown Tio} gn byl Yet 2. Any SCDs, TED hose foot pumps? Musybe hooked upon YRS 3. Transfer to chair 4. Nat any sstaos nese, how how overt is tolerated, distance walked to chair, ability to turn 0_Qssis 5, Need for any ambulatory aid or equipment _ WGIKye 6, Standardized scale regarding falling a. Closure as +15 415 410 1. Return bed to lowest height. : 2. Verify that brakes are locked. 3, Make sure appropriate rails are up. 4, Ensure call bell is available. 5. Verify bed alarm, if indicated, 6. Thank the patient for his or her attention and cooperation. 7. Initiate or continue appropriate plan of care. 8. Complete assessment and document into computer ‘The SBAR framework (Situation, Background, Assessment, Recommendation) is used in many hospital units to improve verbal communication and reduce medical errors. Practice with the SBAR form on the next page. It will keep your message concise and focused on the patient, yet give your colleague enough information to grasp the current situation and make a decision.BRADEN SCALE — For Predicting Pressure Sore Risk SERENE Tod ave <9. HASH Tle 012 ° MopeUAE MEE Taal sore 124." 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Permbsion should bezougnt to usethts ERADEN SCALE eee1. List current medications (include ovesthe-counter and herbel drugs). Ask yourself whether any ofthe petiet’ problems could be related to any of the medications (remember SODA), ‘Side effect? Overdose? Drug interaction? lergy oF Adverse reaction? 2, List current and past allergies, diseases, surgeries, or traume. ‘3, Consider whether any of the petient’s curent problems are related to questions 1 ar 2 above. 4. Complete the following checklist: {Circle those that apply) is there a probiom with breathing? & @ & Is there a probiom with erultion? a8 Pos Is hare problem with comfort? Yes a8 Pos Is there problem with nutron? "veg ae Pos Is there a problém with unary or bovel elimination? Yes aR Pos {s there a problem with fluid or electrolyte balance? Yes AR Pos. 's there @ problem with aby w think or pocee Yes) AR Fos environment? Is there a peobiam wlth communication? % Wm fos {s there a problem with safety (risk for injury or falls)? No AR Pos Is there a problom with sleeping or exercising? No AR es Istheree fektorinfocion eiortransmissiontoother)? = YS GAR es Is there «risk for imped skin icegy? @ w- mA Pos Is there & problem with coping or stress? No AR Pos «. Ip there 9 psychologic, developmental, soltesteem > MR Pos problem? Is there @ socio-cultural problem? Yes & AR Pos Is there # problem with ois, elatonships, or senusity? Ree aa ee Does the person have prob with taking medications? ‘Yes. aR Pos Does the patient requis reecing? Yes MAR Pos Is there a problem with health maintenance at home? Yes Gy AR Pos |s is admission going to couse dificutes et home? ves SAR Pos Is there a problem with personal or religious bales? yes Ne aR Pos Is there @ roblem with coring or menaging sess? No AR Fos Could his person be pregnant? aa Pos ‘Soutes: ©2016 R. Alero LeFevre, werwAlferdTeachSmarteam AR-=At rik for problem {no signs and symptoms present but disk factors are evident) a Poss Possible probiem (nsulficont data, but you suspect a problem). 6. Determine what's causing or contributing to the problems. + Always ask yourself whether is posible thet medications, medical problems, or allergies are causing the problems. Ifs0, activate the chain of command to notify the professional most qualified to manage the problem. + Askthe patient and significant others ifthey can identify factors that are contributing othe problems. + Consider whether there are factors related to age, disease process, treatments, medications; or life changes that could be contributing to the problems.NU 306 Fundamentals of Nursing Resident Demographic Student Name:_AUyiy Hosur Resident Initials; S€ Date:_l\) Is /)G Resident Demographics Age:JD _ Gender: E race: ole : “Brise Religious reference: Cnyoke Occupation(s): AWC Grccayintcia, ‘Covi Setnniewo)| Martial Status: whee mayvigss Significant family members or friends: “Goi fntrels Th TB me, dss dd seo feurnily oRer Hobbies:_Sa\i}0N ‘Travel Experiences: \VQ19 Hovis Erickson’s Growth & Development Stage: Dekors NS, Dasypinn , SE dopouid sips St wows Loy ond Staley lruch Si€ 4h other: MW, oD 10 despair wen Draw a Representation of your Resident Below ei 8&Resident's Problem List (State whether it is actual or potential) ._\(List in accordance of priority) ONKY YR OC Whee #2 Nursing Diagnosis # ae Diagnosis [RIT or a k Factors:_O\ bin eco ny Mich value, monhne a dr Defining Characteristics (AEB): ir 2 aS balm 3) 1 2 Chumtidunte Bl Sos Uninet cre Defining Characteristics (AEB): i lar on (- vole for 3 Ee ee no Th taeResidents’s Initials: 5€ CARE PLAN Assessment Data S38 = A eda. Walln Uwe ar Joc wrgonech ~ Mcsalnene mt = Rama sin, noled ‘ayy Shan Ma oh of ‘owkrea Nursing Diagnosis - gl aE 4 Alferadion tr : fee scale, Lhnild Vihawre/ was Nursing Interventions Li Vellnce 1. Bigeupe thin ist 4 - Make specific to your Resident 1 assessment/Iteaching /1 direct care/1 other Rationales - Evidence Based (EB) In clude source and page numbers Desired Outcomes (SMAR’ Residual isill Gal 4s cinny er HO ree PRISE, irc A Wot veshwaomn rssh. OF ot NB Tes Br me Adack coil uncaotard Wrporsouwa oF 9 lain v1 UVM eb 3 MUArst ud OSA. one a Evaluation Redorred HOA Cur Yani ae ey ai ip) ere den Sal Brenment Londo. Beers Regi é ywure Oe oe 4 ey Fes 2 £9 2. Ue Cone EN fa oa a "0 ‘oe ae se blag ( $10) rarer cigs Pee vie ee leew? See shoe Chi ws) * 1S opestien, nr wth om woA\Kadl Je Huang, | Ph es Rat i Sieg gee be glu of Outcomes: RY eee sdf