Download Nursing Interventions - University of Colorado Denver

INTEGRATION I
SIMULATION EXPERIENCE I
Patient Information Sheet
University of Colorado Health Sciences Center School of Nursing
Student Name:
Age:
Gender:
Allergies:
Date:
Unit :
Patient Initials:
Date of Admission to Hospital:
Medical Diagnosis:
Reaction:
Code Status:
Current Hospitalization: (history of presenting illness/course of hospitalization, surgeries/medical procedures, – include date if
pertinent):
Past Medical/Surgical History (Prior illnesses, surgeries, chronic illnesses – include dates):
Social – Economic – Family Factors (Support person, coping mechanisms, spiritual needs, ESL needs, economic status):
1
Pathophysiology: Briefly explain the pathophysiology of the major disease process and/or surgical procedure as it relates to the
patient’s signs and symptoms. Reference your source (Author, yr, page#s): (*Generate 3-5 potential problems for your patient
based on data mining and patho, i.e. Diabetes: 1. pain r/t neuropathy, 2. impaired wound healing r/t poor peripheral circulation,
3. infection r/t high blood sugar and poor circulation*)
2
Nursing Care Plan  CJT
Student Name:
Patient Initials:
Date:
Patient Medical Diagnosis:
Nursing Diagnosis #1 (Use PES format): (Note: use information from medical chart to complete evidence portion)
Assessment Data
(Include at least two
subjective and/or
objective pieces of data
that lead to the nursing
diagnosis)
Goals/Outcome Criteria
(Use SMART format:
pt/family specific;
measurable; actionoriented; realistic ; and
time-specific.)
Nursing Interventions
(List all nursing and
multidisciplinary
interventions that will
assist this patient in
meeting goals; include
teaching and discharge
planning)
3
Rationale
(Provide reason why
intervention is
indicated/therapeutic;
provide references as
appropriate)
Outcome Evaluation
and Replanning
(Was goal(s) met? How
would you revise the
plan of care according
the patient’s response
to current plan of care?)
INTEGRATION I
SIMULATION EXPERIENCE 2
Patient Information Sheet
University of Colorado Health Sciences Center School of Nursing
Student Name:
Age:
Gender:
Allergies:
Date:
Unit :
Patient Initials:
Date of Admission to Hospital:
Medical Diagnosis:
Reaction:
Code Status:
DISCHARGE PLANNING (If not observed/participant, approach from a theoretical perspective. Examples: 1) Evaluate:
a)Adequate support system in place? i.e., discharge to home; home w/home health care; transitional care; rehab; skilled
nursingfacility; hospice? b) Adequate financial resources? c) Home safety. 2) Teaching: r/t a) medications, b) S/Sx’s to report to
physician, c) wound care, d) therapies/self-cares, e) health promotion/illness prevention, f) assistive devices, g) activity
limitations/restrictions, h) diet, i) follow-up with physician(s):
4
MEDICATION CARD
(Complete the medication card for all scheduled and PRN medications prescribed for your patient prior
to medication administration) Even if medication is not scheduled for administration during your shift,
you should be monitoring for effectiveness if given on prior shift
Generic and Brand Name:
Classification:
Dosage/Route/Frequency
Prescribed and any
special considerations for
administration:
Is the prescribed dose
YES
NO
within the recommended If no, what is the recommended dosage range:
dosage range for an
adult?
Why is YOUR patient
receiving this medication?
Relevant patient teaching
points for the inpatient
setting, i.e. side effects,
food-drug interactions?
What was the desired
effect of the medication
during your clinical shift?
Was this achieved?
5
MEDICATION CARD
Generic and Brand Name:
Classification:
Dosage/Route/Frequency
Prescribed and any
special considerations for
administration:
Is the prescribed dose
YES
NO
within the recommended If no, what is the recommended dosage range:
dosage range for an
adult?
Why is YOUR patient
receiving this medication?
Relevant patient teaching
points for the inpatient
setting, i.e. side effects,
food-drug interactions?
What was the desired
effect of the medication
during your clinical shift?
Was this achieved?
6
MEDICATION CARD
Generic and Brand Name:
Classification:
Dosage/Route/Frequency
Prescribed and any
special considerations for
administration:
Is the prescribed dose
YES
NO
within the recommended If no, what is the recommended dosage range:
dosage range for an
adult?
Why is YOUR patient
receiving this medication?
Relevant patient teaching
points for the inpatient
setting, i.e. side effects,
food-drug interactions?
What was the desired
effect of the medication
during your clinical shift?
Was this achieved?
7
MEDICATION CARD
Generic and Brand Name:
Classification:
Dosage/Route/Frequency
Prescribed and any
special considerations for
administration:
Is the prescribed dose
YES
NO
within the recommended If no, what is the recommended dosage range:
dosage range for an
adult?
Why is YOUR patient
receiving this medication?
Relevant patient teaching
points for the inpatient
setting, i.e. side effects,
food-drug interactions?
What was the desired
effect of the medication
during your clinical shift?
Was this achieved?
8
Topic: Lines, Drains, Airway, Wounds and Wires
Objectives: To identify use of common medical devices.
To describe basic safety measures associated with medical device use.
To describe assessment and location of alterations in patient skin integrity.
Instructions:
Part I: Assess patient for the following items and use the diagrams above to draw an arrow to location and label:
1. Intravenous lines
2. Drains
3. Chest tube
4. Telemetry leads
5. Airway and/or oxygen tubing
6. Wounds, pressure ulcers, and/or incisions
7. Urinary and/or bowel diversions
8. Feeding tubes
9. DVT compression device
10. Other:
______________________________________________________________________________
Part II: Describe in a short paragraph the purpose and safety considerations of each identified item.
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Pt. Name/Rm:
Sex/Age/Dx:
800
900
Weight:
Code Status:
1100
1000
VITAL SIGNS
Time:
BP
T
HR
H
g
b
N
a
RR
1200
Precautions:
Allergies/Rxn:
1300
1400
1500
CARE/ADLs
Nurse/CNA:
Date:
1600
1700
LABS
□ Linen
□ Glucose
□ Bath
□ IS
□ Oral
□ Turn
Na
□ Cath Care
□
K
Cl
BUN
Gluc
CO2 Cr
Activity Orders:
Other labs:
IV/PCA,solution,
rate:
SpO2
O2
I/O
C
l
Neuro:
B
U
N
Respiratory:
W
B
C
GI:
P
l
t
Pain:
G
l
u
c
H
Diet:
B %:
ASSESSMENT
CV:
L%:
D%
REPORT / NOTES / ORDERS
Renal:
Musculoskeletal:
SkiN
10
Hgb
WBC Plt
Hct
1800
11