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LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B/BL Health Deviations 3 Spring 2012 Edited by: Maricela Arnaud, RN, MSN, FNP Julie Bean, RN, MSN © Long Beach City College Associate Degree Nursing Program, Long Beach, CA 90808 ADN12B Spring 2012 To be turned in on the first day of class. Please this print document for submission. Name________________________________________________ Print legibly ADN12B Spring 2012 LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B Health Deviations 3 Course Syllabus for Theory Content Spring 2012 Edited by: Maricela Arnaud, RN, MSN, FNP Julie Bean, RN, MSN © Long Beach City College Associate Degree Nursing Program, Long Beach, CA 90808 ADN12B Spring 2012 GENERAL INFORMATION ADN12B Spring 2012 Long Beach City College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B - Health Deviations 3 TABLE OF CONTENTS General Information Course Information………………………………………………………..1.0 Course Outline…………………………………………………………….1.2 Theoretical Framework “Orem”………………………………..……….…1.4 Course Requirements-Theory ………………………………………….….1.5 Learning Outcomes for Theory………………………………………….…1.6 Challenge Policy Statement for Advanced Placement………………….…1.7 Challenge Option Specific to ADN 12B ……………….………………....1.8 Application for Challenge by Examination for ADN 12B……...………....1.9 Weekly Schedule………………………………………………………….1.10 Assignment Grading………………………………………...………........1.11 Theory Content Developmental Self-Care Requisites of the Middle Aged Adult……….2.0 Acute Neurological Disorders/ CVA ..…………………………………..3.0 Worksheet: Neurological Diagnostic Tests……………………..3.2 Vocabulary: Neurological ...……………………………………..3.4 Nutritional Support ...................................................................................4.0 Hematological Health Deviations .............................................................5.0 Worksheet: Hematological Drugs .................................................5.2 Blood and Blood Components ..................................................................6.0 Vocabulary: Hematological/Blood...............................................6.1 Study Guide: Blood and Blood Components ................................6.2 Worksheet: Blood Transfusion Reactions ....................................6.3 Acid/Base Balance ....................................................................................7.0 Worksheet: Acid/Base Imbalance ................................................7.1 Acid/Base Practice Sheet ..............................................................7.2 Chronic Renal Failure ...............................................................................8.0 Worksheet: End-Stage Renal Disease ...........................................8.1 Worksheet: Laboratory Tests, Diagnostic Studies ........................8.2 Worksheet: Medications, Diet ......................................................8.3 Liver Disorders .........................................................................................9.0 Worksheet: Diagnostic Tests Used in Liver Disease ....................9.1 Worksheet: Medications Used to Treat Liver Disease ..................9.3 i ADN12B Spring 2012 Diabetes Mellitus ....................................................................................10.0 Worksheet: Laboratory Tests in Diabetes Mellitus ....................10.3 Worksheet: Medications to Treat Diabetes Mellitus ..................10.4 Worksheet: Short Term Complications of DM ...........................10.6 Worksheet: Late Complications of DM ......................................10.7 Immunological Disorders, Connective Tissue ........................................11.0 Worksheet: Immune Modulating Drugs .....................................11.1 Immunological Disorders, AIDS ............................................................12.0 Worksheet: Drugs Used in Treatment of AIDS ..........................12.2 Endocrine Health Deviations ..................................................................13.0 Worksheet: Endocrine Disorders ................................................13.1 Worksheet: Endocrine Drugs ......................................................13.6 Cardiovascular Health Deviations………………………………………14.0 Heart Failure…………………………………………………….14.0 Cardiovascular Health Deviations………………………………………15.0 Myocardial Infarction…………………………………………...15.0 Submodule: Vision and Hearing…………………………………………..……16.0 Course Evaluation Clinical Evaluation Information for ADN 12B and ADN 12BL (to be completed via online survey) ........................................................17.0 ii ADN12B Spring 2012 Long Beach City College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B - Health Deviations 3 Course Information Course Description This course continues to explore the professional role of the nurse and patient demands for increased care necessitated by health deviations in the hospitalized adult. The content emphasizes the nursing process using Orem's Self-Care Theory, specifically the requisites of sufficient intake of water and food, elimination, and excretion. Focus is placed on collaborative management of care, communication, safety, and critical thinking in assuming the expanding role of the registered nurse. Additionally, the effects of specific pathological health deviations and medical treatment modalities for the medical patient are studied with attention to teaching and learning. Time allotment, sequencing and enrollment 2.5 college semester units Class/Lectures: 5 hours per week for 9 weeks, Total of 45 hours This course is offered in the second semester during the second half of each 18 week semester with enrollment as space and resources allow. Concurrent enrollment with ADN 12BL required. Required Texts Deglan, J.H., Vallerand, A.H. & Sanoski, C.A. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia, PA: F.A. Davis Company. Dudek S.G. (2006). Nutrition essentials for nursing practice (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Ladwig, G.B., & Ackley, B.J. (2008). Guide to nursing diagnosis (2nd ed.). St. Louis, MO: Mosby Elsevier. Leifer, G., & Hartston, H. (2004). Growth and development across the lifespan: A health promotion focus. St. Louis, MO: Saunders. Pagana, K.D, & Pagana, T.J. (2006). Mosby’s manual of diagnostic and laboratory tests. St. Louis, MO: Mosby Elsevier. Potter, P.A., & Perry, A.G. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby Elsevier. Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins. EDose One year license. 100% web-based math tutorial. Purchase at the LBCC Bookstore. Staff. ADN 12B course syllabus, 12BL course syllabus. (Fall 2011). Retrievable at the ADN12B/BL website. Staff. Student handbook: Associate degree nursing (year of admission) Teaching Methods Class/lecture discussion Reading assignments Media programs: AV, CD and DVD NCLEX-RN type questions Student Evaluation Quizzes Final Examination Total Points Written assignments Independent study Interactive/web-based case studies Collaborative student presentations Possible Points 150 100 250 Student Course Grade Students must be concurrently enrolled in ADN 12B and ADN 12BL. When students achieve satisfactory clinical performance in ADN 12BL, the percentage of theory grade in ADN 12B will become the course grade for both courses. 1.0 ADN12B Spring 2012 Course Instructors Name & Credentials Office Telephone e-mail Maricela Arnaud, RN, MSN, FNP, Lead I (562) 938- 4170 cell (714) 457-0330 [email protected] Julie Bean, RN, MSN-ED R (562) 938-41781 cell (562) 569-8620 [email protected] Instructor’s office hours are posted on the office door. Other hours may be arranged. Part-time teachers may be reached by special arrangement with the individual teacher (when utilized). 1.1 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B – Health Deviations 3 Course Outline Course Content 1. Developmental Self-Care Requisites of the Middle Aged Adult A. Review Orem's developmental self-care requisites B. Review Erickson's stages of psychosocial development C. Gould's developmental themes D. Health promotion and teaching techniques 2. Acute Neurological Disorders and Cerebral Vascular Accident A. Levels of consciousness B. Stroke/CVA C. Diagnostic tests D. Transient Ischemic Attack E. Medical and nursing treatments F. Rehabilitation following a stroke H. Neurological medications and pharmacology 3. Nutritional Support A. Enteral and parenteral nutrition B. Solutions providing nutritional support C. Types of central venous catheters D. Parenteral and enteral administration standards of care E. Potential complications of parenteral and enteral nutrition 4. Hematological Health Deviations, Blood Administration A. Types of blood components B. Complete blood count (CBC) C. ABO blood groups D. Nursing management of transfusions E. Potential complications of transfusions F. Blood tests and values G. Types of anemia H. Leukemia’s I. Lymphomas J. Bleeding disorders 5. Acid/Base Balance A. Definition and implications of pH i. respiratory/metabolic acidosis ii. respiratory/metabolic alkalosis B. Buffer systems C. Obtaining arterial blood for blood gas analysis D. Measuring oxygenation E. Interpretation of arterial blood gases 1.2 ADN12B Spring 2012 6. Diabetes Mellitus A. Screening recommendations B. Type 1 vs. type 2 C. Management of diabetes D. Oral and parenteral diabetic medications E. Complications and nursing care of diabetes F. Alterations in sexuality with diabetes 7. Liver Disorders A. Portal circulation B. Diagnostic tests C. Drugs related to liver disorders D. Cirrhosis E. Hepatic encephalopathy F. Management of ascites G. Viral hepatitis H. Nutritional needs with liver failure 8. Immunologic Disorders A. Immune system B. Autoimmune disorders C. Hypersensitivity disorders D. Sepsis E. HIV and AIDS 10. Endocrine Health Deviations A. Principles of endocrine function B. Role of pituitary and hypothalamus C. Endocrine disorders-except diabetes mellitus D. Nursing management E. Endocrine and sexuality F. Endocrine drugs 11. Cardiovascular Health Deviations-Heart Failure A. Left and right-sided heart failure B. Nursing and medical management C. Nursing diagnoses and collaborative problems 12. Cardiovascular Health Deviations-Myocardial Infarction A. Coronary artery disease B. Nursing and medical management C. Tests related to diagnosis of MI D. Nursing diagnoses and collaborative problems 1.3 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B – Health Deviations 3 Orem’s Self Care Model Conceptual Framework Curriculum Implementation SELF CARE MODEL THEORY CLINICAL IMPLEMENTATION IMPLEMENTATION Health Deviation Self Care Requisites are needs generated by illness and the medical diagnostic procedures and treatments associated with disease. Developmental Self Care Requisites are needs associated with development throughout the life cycle. The concept of Health Deviation Self Care Requisites is discussed with emphasis placed on the medical patient. Students provide care for two to three acutely ill patients in the hospital medical settings. Whenever possible, patients are selected to correspond with classroom theory. The basic principles of intravenous therapy and administration of intravenous medications are utilized as commonly used medical treatments associated with health deviations. Students apply the entire nursing process of assessing, diagnosing, planning, implementing, and evaluating. The following health problems are studied in depth: 1. Developmental SelfCare requisites 2. Acute neurological disorders 3. Nutritional support 4. Hematologic disorders/Blood administration 5. Chronic renal failure 6. Acid/base disorders 7. Diabetes mellitus 8. Liver disorders 9. Immunology/HIV & AIDS 10. Endocrine disorders 11. Cardiovascular health deviations: HF & MI The Self Care Requisites generated by these health problems and problems with associated diagnostic and treatment modalities are studied. The nursing process considers the Universal Self Care Requisites, Developmental Self Care Requisites, as well as the Health Deviation Self Care Requisites of patients with the studied problems. Developmental Self Care Requisites are applied to the middle aged adult. 1.4 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B – Health Deviations 3 COURSE REQUIREMENTS During this course each student will: 1. Independently review any material from previous required courses as needed. 2. Arrive to class prepared and on time. 3. Prepare prior to class for discussion of each assigned behavioral objective. 4. Complete all required reading, audio-visual, and written work prior to class. 5. Turn in assigned written work on time, using correct format as described in ADN Student Handbook or course syllabus. 6. Initial the attendance roster to demonstrate attendance at lecture and campus lab. 7. Actively participate in class/conference discussions. 8. Assume responsibility for meeting behavioral objectives when absent from class. 9. Take quizzes when scheduled. The quiz number and student ID number must be written on each scantron and bubbled in pencil. Scores will be posted online. 10. Achieve at least 75% overall on all scored materials at the completion of the course. 11. Comply with the standards of the College and Student Handbook Policies on Academic Honesty as published in the Student Handbook and in the College Catalog. 1.5 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B – Health Deviations 3 ADN 12B LEARNING OUTCOMES Upon satisfactory completion of this course, the student will be able to: Develop a comprehensive and holistic understanding of major health deviations of the acutely ill, middle-aged adult in the acute care setting. Professional Role Develop and integrate professional values of caring, integrity, honesty, and respect for human dignity within the professional role as an evolving nursing student. Communication Utilize appropriate communication skills with colleagues and faculty using proper English while displaying respect for cultural diversity. Orem’s Self-Care Theory as it relates to the Nursing Process Apply Orem’s Self-Care Theory and the nursing process to the theoretical care of a middle aged adult in the acute care, medical setting. Apply Orem’s Self Care Theory of nursing practice and the nursing process while integrating critical thinking to case studies discussed in class. Critical Thinking Develop critical thinking and the ability to prioritize the theoretical needs of the patient based on scientific, evidence-based research. Safety Integrate the professional role of the registered nurse utilizing effective communication, patient advocacy/safety, and critical thinking. Teaching and Learning Synthesize knowledge from the arts, sciences, and nursing to assimilate safe nursing practices. Examine self-learning needs and identify appropriate resources for meeting course objectives. Collaborative Management of Care Develop collaborative teaching/learning concepts necessary to safely practice the art and science of nursing. Collaborate with colleagues during group assignments to apply and teach new knowledge while discussing effective methods for success in theoretical applications. 1.6 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B – Health Deviations 3 POLICY STATEMENT Challenge Option for Advanced Placement 1. The challenge option for each course consists of two parts: 1. 1st: challenge of the theory course 2. 2nd: Challenge of the laboratory course 2. An announcement regarding the challenge options will be made at the beginning of every course on the first day of class. 3. The student must have evidence on file in the college and program cumulative folder of formal instruction in this course content. 4. Formal instruction and direct patient care experience (in the content of the course being challenged) must have taken place within the three years previous to the challenge request. 5. If the student satisfactorily passed the clinical exam the grade earned for the course or potion of the course will be the grade achieved on the theory course. 6. The student must utilize both the conceptual framework and the nursing process in the laboratory challenge portion of this option. 7. For details refer to the LBCC Catalog “Nursing Programs and Courses: Policies for Transfer Credit, Advanced Placement and Credit by Examination for the Associate Degree.” 1.7 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B – Health Deviations 3 CHALLENGE OPTION Specific to ADN 12B and 12BL General Announcement Students interested in challenging must let the instructor know by the last day of the first week of the course. The student should complete the department “Application for Challenge by Examination for ADN 12B” and complete the college formal application for challenge by examination. Upon acceptance of the challenge option by the teaching team, an appointment will be made for the student to take the written theory exam at the beginning of the second week of the course. Written Test A 150 point comprehensive, objective (NCLEX style) test will be given. The student must achieve a minimum score of 75% to continue with the challenge. Upon successful completion of the ADN 12B course challenge, the student then proceeds to the next step; the challenge of ADN 12BL. 1.8 ADN12B Spring 2012 APPLICATION FOR CHALLENGE BY EXAMINATION ADN 12B- Health Deviations 3 Student Name________________________________ Date____________________ Student complete section A below: A. Justification of this request: Student Signature_____________________________________ Teaching team complete section B below: B. Decision: Yes________ If yes, write contract below. No________ If no, state reason for denial. C. Contract Written test completed by ___________________________ Signatures: Lead Instructor: _____________________________ Date:___________________ Instructor:__________________________________ Date:___________________ Instructor:__________________________________ Date:___________________ Student:____________________________________ Date:___________________ D. Disposition of Challenge_________________________________________________ 1.9 ADN12B Spring 2012 Monday Lecture C101 0800-1100 W E E K 1 2 LONG BEACH CITY COLLEGE ADN-12B-Health Deviations 3 ADN 12BL – Health Deviations 3 Weekly Schedule, Spring 2012 Clinical Lab Friday Wed /Thurs Lecture 8 hour day Room D237 0800-1000 3/12 Lec: Intro to Course Lec: DSCR EDose test scheduled per team Wed 3/14 Flex Day 3/19 Lec: Blood Wed 3/21 Thurs 3/15 Orientation Medical Center 7 hour day Thurs 3/22 Medical Center 7 hour day 3 3/26 Quiz #1 (50 points) Wed 3/28 Lec: Diabetes 4 5 6 4/9 Wed 4/11 Thurs 4/12 Wed 4/18 Thurs 4/19 Medical Center 7 hour day 4/23 Wed 4/25 3/30 Test: Intradermal 2nd EDose Completed by 1500 4/6 Lec: Nutritional Support 4/6 Test: Neuro Assessment 4/13 4/13 4/20 Lec: Acid/ Base 4/20 Lab: Physical assessment Due: Written Case Studies Pass Vision/Hearing submodule by 1500 5/4 Lec: Immunology-CTD 5/4 Test: Physical assessment 5/11 Lec: Immunology AIDS Thurs 5/3 Medical Center 7 hour day Wed Thurs 5/9 5//10 Medical Center 7 hour day 5/11 Test: Suctioning/trach care Clinical evals due to instructor 5/14 FINAL EXAM (100 points) Wed Thurs 5/16 5//17 Simulation Hospital 5/18 ALL SKILLS DUE BY NOON! 4/30 Lec: Liver 5/7 Quiz #3 (50 points) Thurs 4/26 Break 4/27 Lab: Suctioning/trach Med Center 7 hour day Lec: MI 9 Thurs 4/5 3/30 Lec: Finish Diabetes 4/27 Lec: Heart Failure Quiz #2 (50 points) 8 3/23 Lab: Neuro Assessment Medical Center 7 hour day Endocrine CD-Rom due prior to lecture 7 Thurs 3/29 Medical Center 7 hour day Wed 4/4 4/16 Lec: Endocrine Due: 1st EDose completed by 1500 3/23 Lec: Hematology 3/16 Lab: Managing IV fluids Lab: Intradermal Due: 1stVision/Hearing submodule by 1500 4/2 Lec: Chronic Renal Failure Spring 3/16 Lec: Acute Neuro/CVA Campus Lab C302 Sec 1 1030-1230 Sec 2 1300-1500 Wed 5/2 Intro to 3rd semester ATI Test 1.10 ADN12B Spring 2012 5/18 Clinical Evaluations!!!! Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B Health Deviations 3 Quiz Grades The 12B teaching team reserves the right to administer "pop" quizzes at any time during the course. The total points for 12B will remain 250. Quiz points will be adjusted accordingly if a "pop" quiz is given. Possible Points Quiz # 1 Quiz # 2 Quiz # 3 50 50 50 Final Total 100 250 Points Earned Percent Grade LETTER GRADES A = 91 - 100 B = 83 - 90 C = 75 - 82 D = 67 - 74 (failing in nursing) F = 66 and below Course evaluations will be done on the day of ATI testing via an online survey. AGENCY REQUIREMENTS Annual Tuberculosis skin testing or health clearance Hepatitis B vaccine (3 completed) Proof of varicella, measles, mumps and rubella immunity (titer only). Current professional malpractice insurance Current CPR for health care providers (American Heart Association) Annual influenza vaccine Tdap (Tetanus, diphtheria, Pertussis [whooping cough]) immunization A student folder is maintained by the Nursing Department. All of the above requirements are to be current each semester. The student is responsible to maintain a personal folder with the originals of the required documents. All documents are to be brought to the first day of class for verification if needed. 1.11 ADN12B Spring 2012 THEORY CONTENT ADN12B Spring 2012 THEORY: OREM’S DEVELOPMENTAL SELF-CARE REQUISITES OF THE MIDDLE AGED ADULT BEHAVIORAL OBJECTIVES: 1. Review Orem’s developmental self-care requisite changes and task of the middle aged adult from ADN 12A. 2. Review Erikson’s psychosocial developmental stage of the middle adult from ADN 12A. 3. Compare and contrast Gould’s developmental themes to Havighurst’s’ and Erikson’s developmental tasks for the middle aged adult 35-60. 4. Discuss health promotion activities for the middle aged adult (to prevent poor health or disability on Orem’s list of conditions affecting human development). Prevention of obesity Prevention of cardiovascular disease Early detection of treatable chronic diseases Sexuality 5. Discuss teaching techniques that would be effective in assisting the middle age adult to maintain a positive health status. ASSIGNMENTS: Leifer, G., & Hartson, H. (2004). Growth and development across the lifespan: A health promotion focus. St. Louis, MO: Saunders. Chapter 11, 179-191 Potter, P.A., & Perry, A.G. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby Elsevier, 138-140; 184-189; 428 Smeltzer, S.C, Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 51-52, 697. 2.0 ADN12B Spring 2012 THEORY: NEUROLOGICAL DISORDERS/CVA BEHAVIORAL OBJECTIVES: 1. Independently review the anatomy and physiology of the central nervous and autonomic nervous systems. 2. Discuss the definition, clinical manifestations, and management of the following conditions: Brain tumors: glioma astrocytoma medulloblastoma meningioma angioma 3. Independently define the vocabulary words listed in the Neurological Vocabulary worksheet. 4. Independently review the definition, clinical manifestations, diagnostic evaluation and management of transient ischemic attack. 5. Independently describe the procedure and list nursing responsibilities of diagnostic tests performed to assess cerebral vascular disease found in the Neurological Diagnostic Tests Worksheet. Be familiar with invasive vs. noninvasive procedures. 6. Discuss the following areas related to the care of a patient with acute cerebral vascular accident: Definition Causes Risk factors Clinical manifestations Nursing management to restore normalcy Cultural responses Nutrition Sexual problems Medical management for ischemic and hemorrhagic strokes Surgical management including carotid endarterectomy 7. Compare the clinical manifestations and nursing management of a patient with a CVA in the right hemisphere versus a patient with a CVA in the left hemisphere. 8. Discuss general management of a patient with a stroke after the acute phase including permanent health deviations and common methods of restoring normalcy (the rehabilitation phase). 3.0 ADN12B Spring 2012 9. Independently review the following medications in regard to sub class, action and nursing responsibilities: aspirin warfarin (Coumadin) pentoxifylline (Trental) dexamethasone (Decadron) phenytoin (Dilantin) heparin low molecular weight heparin ranitidine (Zantac) dipyridamole (Persantine) ticlopidine (Ticlid) 10. Describe the goals of heparin and Coumadin therapy. Discuss heparin protocol for a patient with an acute occlusive CVA and teaching needs for the patient on Coumadin therapy. ASSIGNMENTS: Smeltzer, S.C, Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Chapters 60, 61, & 62. (See index) Deglan, J.H., & Vallerand, A.H. (2007). Davis’s drug guide for nurses (10th ed.). Philadelphia, PA: F.A. Davis Company. As needed Article: Cross, S., Walker, C. (2008). Stroke care: a nursing perspective. Nursing Standard, 22,23, 4756. STUDY GUIDES: Neurological Diagnostic Tests Vocabulary: Neurological Health Deviations 3.1 ADN12B Spring 2012 WORKSHEET: HEALTH DEVIATION REQUIRING NEUROLOGICAL DIAGNOSTIC TESTS TEST Description What abnormal findings may be found? Lumbar Puncture Cerebral Angiogram (Arteriogram) EEG (Electroencephalogram) Carotid Flow Studies 3.2 ADN12B Spring 2012 Preparation for the Test Post Test Nursing Care TEST Description What abnormal findings may be found? CT Scan: Computed Tomography MRI: Magnetic Resonance Imaging PET: Positron Emission Tomography Evoked Potential Studies 3.3 ADN12B Spring 2012 Preparation for the Test Post Test Nursing Care VOCABULARY: NEUROLOGICAL HEALTH DEVIATIONS Agnosia Aphasia Receptive aphasia Expressive aphasia Apraxia Diplopia Dyslexia Dysarthria Hemiparesis Hemiplegia Hemianopia Emotional lability Perseveration Proprioception Decorticate Posturing Decerebrate Posturing Babinski Reflex Plantar Reflex Ipsilateral Contralateral Vertigo 3.4 ADN12B Spring 2012 THEORY: HEALTH DEVIATIONS REQUIRING THE ADMINISTRATION OF NUTRITIONAL SUPPORT PARENTERAL NUTRITION AND ENTERAL FEEDINGS BEHAVIORAL OBJECTIVES: 1. Define enteral feeding and parenteral nutrition and common health deviations that may require the need for these particular therapies. Discuss the major factor that determines why one is chosen over the other by the physician. 2. List the advantages and disadvantages, including common complications, of enteral feedings and parenteral nutrition. 3. Define the following enteral formulas and identify and common health deviations that may require the need for these therapies. a. Intact nutrient formulas b. High protein formulas c. High calorie formulas d. Formulas containing fiber e. Specialty formulas for specific diseases f. Elemental formulas 4. Review the nursing care of the patient receiving enteral feedings and provide the rationale for the following nursing standards of care. a. Elevate the head of the bed at least 30 degrees for at least one hour after feedings. b. Check residual every 8 hour shift. If over 50 ml, hold feedings for one hour. c. For NG tubes, check placement at least every 8 hour shift. d. Flush tube with water before and after giving medications per tube and when discontinuing feedings for more than a few minutes. e. Flush tube with water when stopping the feeding. f. Change enteral bag, tubing, and formula every 24 hours. 5. Define peripheral parenteral nutrition (PPN) and total parenteral nutrition (TPN). Identify common health deviations that may require the need for PPN or TPN. Differentiate between the venous access sites used for peripheral parenteral nutrition and total parenteral nutrition. 6. Describe the following types of central venous catheters and explain how the nurse can identify the type of catheter placed in an individual patient. a. Peripherally inserted central catheter (PICC line) b. Subclavian and jugular vein central lines c. Tunneled central lines (Hickman, Broviac) d. Implanted central venous ports. 7. Describe the contents of the solutions used for PPN, TPN and lipid infusions. 8. Using the nursing process as an outline, identify the standard nursing care for patients receiving PPN and TPN nutritional support. 9. Discuss the potential complications of total parenteral nutrition, including central venous catheter considerations. 4.0 ADN12B Spring 2012 ASSIGNMENTS: Dudek S.G. (2010). Nutrition essentials for nursing practice (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 356-384. Potter, P.A., & Perry, A.G. (2009). Fundamentals of Nursing (7th ed.). St. Louis, MO: Mosby Elsevier, 1111-1128. Smeltzer, S.C, Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 1027-1041. Article: McKnight, K., Carter, L. (2008). From trays to tube feedings: Overcoming the challenges of hospital nutrition and glycemic control. Diabetes Spectrum. 21, 233-240. 4.1 ADN12B Spring 2012 THEORY: HEALTH DEVIATIONS OF HEMATOLOGICAL DISORDERS BEHAVIORAL OBJECTIVES: 1. Independently review the vocabulary words listed on the “Vocabulary” worksheet. 2. Independently review the components of the hematological system. 3. Independently review the following laboratory tests, stating the normal ranges and clinical significance of each test: Hemoglobin electrophoresis Coombs’, direct and indirect Bleeding time Prothrombin time (PT) reported as INR (International Normalized Ratio) Activated Partial thromboplastin time (aPTT) 4. Discuss the etiology, clinical manifestations, diagnosis, medical and nursing management of the patient with the health deviation anemia (include avoidance of hazards and promotion of normalcy). 5. Discuss the pathophysiology and special management of the following types of health deviations (anemias). A. Hypoproliferative Anemia Aplastic Anemias in Renal Disease Anemia of Chronic Disease Iron Deficiency Anemia Megaloblastic anemias: Vitamin B 12 Deficiency, Folic Acid Deficiency B. Hemolytic Anemias Sickle cell (include sickle cell crisis) Immune Hemolytic Anemia 6. Discuss the incidence, prognosis and distinguishing features of the following health deviations or hematopoietic malignancies: A. Leukemias Acute myelogenous leukemia (AML) Chronic myelogenous leukemia (CML) Acute lymphocytic leukemia (ALL) Chronic lymphocytic leukemia (CLL) B. Malignant Lymphomas Hodgkins disease Non-Hodgkins lymphoma 5.0 ADN12B Spring 2012 7. Discuss the pathophysiology, clinical manifestations and special management of the following health deviations or bleeding disorders: A. Platelet defects Thrombocythopenia Idiopathic thrombocytopenic purpura (ITP) B. Clotting Factor Defects: Hemophilia Von Willebrand’s disease Disseminated intravascular coagulation 8. List two potential nursing diagnoses and/or collaborative problems associated with each of the hematological health deviations. ASSIGNMENT: Smeltzer, S.C, Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, Chapter 33. Article: McRae, C. (April 26, 2007). Accurate history the key to diagnosis of macrocytic anemias. The Practitioner, 72-77 Simmons, S. (June 2010). Anemia. Nursing 2010. 40(6), 36. 5.1 ADN12B Spring 2012 WORKSHEET: HEALTH DEVIATION OF HEMATOLOGIC DISORDERS DRUGS MEDICATION ACTION IN HEMATOLOGICAL DISORDERS Oral iron supplements Ferrous sulfate Parenteral Iron Iron Dextran Folic Acid Vitamin B12 Cyanocobalamin Erythropoietin Epogen, Procrit Neupogen Vitamin K Phytonadione 5.2 ADN12B Spring 2012 NURSING RESPONSIBILITIES THEORY: HEALTH DEVIATIONS THAT REQUIRE ADMINISTRATOIN OF BLOOD AND/OR BLOOD COMPONENTS BEHAVIORAL OBJECTIVES: 1. Describe the blood components on the study guide, identifying their action, indications and administration guidelines for patients with health deviations that require administration of blood and/or blood components. 2. Describe the individual tests reported in a “complete blood count” (CBC). Discuss the clinical significance of each individual item: RBC (red blood cell count) Hemoglobin Hematocrit MCV (mean corpuscular volume) MCH (mean corpuscular hemoglobin) MCHC (mean corpuscular hemoglobin concentration) Platelets WBC (white blood cell count) Differential leukocyte percentage Absolute leukocyte counts 3. Discuss the clinical significance of the ABO blood groups and Rh type along with the laboratory tests used to match blood for transfusion. 4. Describe the medical management and nursing management before, during and immediately following the administration of blood and/or blood components. 5. Prior to class, complete the blood transfusion reaction worksheet. 6. Identify the health deviations potentially transmitted by blood and blood component transfusions. Indicate the relative risk for such transmission today. 7. Identify the disqualifying factors that blood banks use to exclude people from donating blood. 8. Identify the information on a blood container/bag label. ASSIGNMENTS: Potter, P.A., & Perry, A.G. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby Elsevier, 1022-1027. Smeltzer, S.C, Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 903-910, 967-972. Miller, J., & Starks, B. (2010). Deciphering clues in the CBC count. Nursing2010, 40(7), 52-55. 6.0 ADN12B Spring 2012 VOCABULARY: HEALTH DEVIATIONS OF HEMATOLOGIC/ BLOOD Agranulocytosis Aplasia Ecchymosis Erythrocyte Erythropoiesis Granulocyte Granulocytopenia Hematocrit Hemoglobin Hematopoiesis Hemolysis Histiocyte Hypochromia Leukocyte Lymphocyte Macrophage Monocyte Neutropenia Petechiaae Platelet Polycythemia Reticulocyte Thrombocyte Thrombocytopenia 6.1 ADN12B Spring 2012 STUDY GUIDE: BLOOD AND BLOOD COMPONENTS Name of Component Action Indication Whole Blood Packed Red Blood Cells Platelets Fresh Frozen Plasma (FFP) Albumin Cryoprecipitate Factor VIII/ Factor IX Concentrate 6.2 ADN12B Spring 2012 Administration WORKSHEET: BLOOD TRANSFUSION REACTIONS PROBLEM ASSESSMENT Hemolytic Reactions: a. Immediate b. Delayed Circulatory Overload Febrile Reactions: a. Immune Response to Leukocytes, Platelets b. Bacterial pyogen reaction Allergic Reactions: a. Mild b. severe 6.3 ADN12B Spring 2012 INTERVENTION THEORY: ACID/BASE BALANCE BEHAVIORAL OBJECTIVES: 1. Independently review fluid and electrolyte material from ADN 11A, 12A and science courses. 2. Define pH and describe what the pH scale means. 3. Describe the three mechanisms that regulate acid-base balance. Discuss each mechanism. Identify the importance of each and the speed of corrective action. a. Chemical buffer systems: bicarbonate-carbonic acid; phosphate; and protein b. Respiratory regulation c. Renal regulation 4. List the normal arterial blood gas values. Describe nursing responsibilities to ensure accurate blood gas results. 5. Compare and contrast the accuracy and usefulness of measurements of oxygenation via the following: a. Hemoglobin saturation via pulse oximetry 6. Describe the various oxygen delivery systems from previous courses, including nasal cannula, simple face mask, venturi mask, and non-rebreather mask. 7. Explain the relationship between oxygenation and acid-base balance. 8. Using the Acid Base Practice Sheet, demonstrate the ability to recognize an acid/base abnormality, determine whether the abnormality is metabolic or respiratory in origin, and evaluate the patient’s oxygenation status. 9. Describe the common causes, clinical manifestations, and management for metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. 10. Using the acid/base balance worksheet, determine the probable arterial blood gas health deviation for each of the clinical situations given. ASSIGNMENT: Potter, P.A., & Perry, A.G. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby Elsevier, 971-972; 974-977. Smeltzer, S.C, Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 293-298, 508-509, 637-639, 1297. Articles: Pruit, B. (2010). Interpreting ABGs: An inside look into your patient’s status. Nursing 2010, 40(7), 31-35. RECOMMENDED: Computer Program in Learning Center, “Arterial Blood Gas Interpretation”. 7.0 ADN12B Spring 2012 Hx/Medical Dx Clinical manifestations A 25-year old “high strung’ female hospitalized for treatment of multiple trauma in an auto accident. She is sobbing uncontrollably and crying that she feels like she is dying, and her ands and mouth are tingling. A 39-year old male, insulin dependent diabetic for 10 years, acutely ill with severe gastroenteritis, and diabetic ketoacidosis; admitted from the ED. A 75-year old male, with pneumonitis and pleurisy, with shallow, slow respirations that he is controlling to reduce the pain. He is becoming increasingly confused since the baseline assessment. WORKSHEET: ACID/BASE IMBALANCES Probable Probable Nursing Process Metabolic ABGs r/t Acic-Base Disorder Imbalance Assessment Dx Outcomes Interventions Assessment Dx Outcomes Interventions Assessment Dx Outcomes Interventions 7.1 ADN12B Spring 2012 ACID BASE PRACTICE SHEET LAB RESULTS A B C D pH 7.25 7.62 7.30 7.55 PaCO2 40 30 50 40 PaO2 96 98 80 90 HCO3 16 26 24 40 LAB RESULTS E F G H pH 7.25 7.30 7.58 7.31 PaCO2 60 42 26 50 PaO2 70 92 80 68 HCO3 26 15 24 25 Health Deviation Health Deviation 7.2 ADN12B Spring 2012 THEORY: CHRONIC RENAL FAILURE HEALTH DEVIATION BEHAVIORAL OBJECTIVES: 1. Review the function of the kidneys including fluid and electrolyte regulation, regulation of erythropoesis, and acid/base regulation. 2. Identify the etiology and stages of chronic renal failure health deviation. 3. Identify the metabolic, fluid, and electrolyte disorders and systemic changes that occur with chronic renal failure (end stage renal disease) health deviation. 4. Identify the medications and nutritional support usually ordered to correct or reduce the metabolic, fluid and electrolyte disorders associated with end stage renal disease health deviation. Discuss the need for reduction in dosage of many medications. 5. Discuss peritoneal dialysis, including home self-care requisites of patients choosing peritoneal dialysis. 6. Discuss hemodialysis, including the various types of circulatory access devices. 7. Discuss the nursing interventions for chronic dialysis patients admitted to the acute care hospital. Include alteration of drug dosing, fluids, and diet to accommodate the dialysis schedule. 8. Briefly discuss the social and psychological impact of dialysis upon the patient and the family system. 9. Identify the source of funding for the health care of patients with end stage renal disease health deviation. Discuss the role of free-standing dialysis units in the self-care of these patients. 10. Discuss nursing considerations and health promotion in patients needing kidney transplant surgery. ASSIGNMENTS: Dudek S.G. (2010). Nutrition essentials for nursing practice (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 514-535. Smeltzer, S.C, Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 1325-1333. Complete the course study guide worksheets. ARTICLES: Banerjee, S. (2009). Beyond needle placement: The role of the nephrology nurse in arteriovenous fistula management. Nephrology Nursing Journal, 36(6), 657-659. Beto, J. (2010). Improving first-year mortality in patients on dialysis: A focus on nutrition and exercise. Nephrology Nursing Journal, 37(1), 61-65; 98 Simmons, L. (2009). Dorthea Orem’s self care theory as related to nursing practice in hemodialysis. Nephrology Nursing Journal, 36(4), 419-421. 8.0 ADN12B Spring 2012 Associated Disorder Worksheet End-Stage Renal Disease Pathophysiologic Systemic Changes Basis for Disorder Fluid Volume Excess Fluid Volume Deficit Electrolyte Imbalance: Potassium Acid/ Base Imbalance Waste Elimination Anemia Calcium Balance Hypertension Cardiac Disease Pulmonary Disease Impaired Drug Metabolism 8.1 ADN12B Spring 2012 Treatment Laboratory Test BUN Renal Worksheet: Laboratory Tests, Diagnostic Studies Normal Reference Expected Change with Pathophysiologic Basis for Range Chronic Renal Failure Change Creatinine 24 Hour Creatinine Clearance Diagnostic Study Renal Arteriogram Glomerular Filtration Rate (GFR): Description of Study Pre-Procedure Care KUB CT, MRI Intravenous Pyelogram (IVP) Renal Biopsy 8.2 ADN12B Spring 2012 Post-Procedure Care Potential Complications Renal Worksheet: Medications, Diet Medication Therapeutic Effect Nursing Responsibility Alteration from Normal Diet Rationale Beta Blocker ACE Inhibitor Epoetin Vitamins Nutritional Element Fluid Calories Fat Protein Potassium Sodium Phosphorous Calcium 8.3 ADN12B Spring 2012 THEORY: LIVER DISORDERS HEALTH DEVIATION BEHAVIORAL OBJECTIVES: 1. Independently review and come prepared to discuss the anatomy and physiology of the liver including the portal circulation. 2. Complete the liver diagnostic tests and drug worksheets. 3. Discuss cirrhosis health deviation, including etiology, pathophysiology, clinical manifestations, and medical and nursing management. 4. Discuss ascites health deviation, including the etiology, pathophysiology, and medical and nursing management. 5. Describe the pathophysiology of hepatic encephalopathy health deviation. Describe clinical manifestations, and medical and nursing management. 6. Describe and differentiate between the peritoneal-venous shunt for management of ascites and the portal venous shunt for management of portal hypertension. Briefly discuss the self-care demands and requisites of patients undergoing either one of these shunt procedures. 7. Identify the differences in etiology and prevention of viral hepatitis A, B, C, D, and E health deviations. Discuss the risk of contracting hepatitis for health care workers. Describe the stages, clinical manifestations, medical and nursing management for the patient with viral hepatitis health deviation. 8. Discuss the nutritional self-care demands and requisites of a patient with liver disease. 9. Discuss the influence of cirrhosis on the patient’s sexuality and family relationships. 10. Discuss the relationship between culture and attitudes towards alcohol intake and alcoholism. ASSIGNMENTS: Smeltzer, S.C, Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 1116-1194. Diagnostic Tests and Medication worksheets Articles: McKinley, M.G. (2009). Recognizing and responding to acute liver failure. Nursing2009, 39(3), 38-43. 9.0 ADN12B Spring 2012 ADN 12B - Health Deviations 3 DIAGNOSTIC TESTS USED IN LIVER DISEASE CHEMISTRIES CLINICAL SIGNIFICANCE AND NURSING IMPLICATIONS Albumin, (serum) below normal levels Bilirubin, above normal levels in serum and urine Serum Aspartate Aminotransferase, (AST, old name was SGOT) above normal levels Serum Alanine Aminotransferase, (ALT, old name was SGPT) above normal levels Lactic Dehydrogenase, (LDH), above normal levels in serum Serum Ammonia (above normal levels) Prothrombin Time (PT) or International Normalized Ratio (INR) prolonged 9.1 ADN12B Spring 2012 DIAGNOSTIC STUDIES PROCEDURE AND PURPOSE Non-invasive imaging studies: plain x-ray of abdomen; ultrasound of liver and spleen; CT scan of abdomen; MRI of abdomen; Doppler flow studies of abdominal vessels. Invasive vascular studies: Hepatic vein wedge pressure; abdominal arteriogram Endoscopies: Esophogogastroscopy, endoscopic sclerotherapy, endoscopic “banding” of varices Abdominal Paracentesis Liver biopsy: needle biopsy 9.2 ADN12B Spring 2012 NURSING RESPONSIBILITIES Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B – Health Deviations 3 MEDICATION ACTION IN LIVER DISEASE Lactulose (Cephulac, etc.) 30 to 45 ml po tid-qid Neomycin 1 g po q6h Spironolactone (Aldactone) 50 to 100 mg po bid Vitamin K (menadiol or phytonadione) oral or IM Octreotide Propranolol 9.3 ADN12B Spring 2012 NURSING RESPONSIBILITIES THEORY: DIABETES MELLITUS BEHAVIORAL OBJECTIVES: 1. Review diabetes mellitus material from science prerequisite courses regarding normal blood sugar levels, and factors that affect the homeostasis of blood sugar. 2. Review current screening recommendations made by the American Diabetes Association for subgroups at highest risk. 3. Review Type 1 and Type 2 diabetes in terms of pathophysiology, presenting symptoms, and therapeutic management. 4. Review the five major components of diabetes management: a. Dietary recommendations. Include exchange lists, carbohydrate counting, and glycemic index. b. Exercise guidelines c. Monitoring. Include blood sugar, urine sugar, urine acetone, glycosylated hemoglobin (Hgb A1c), and microalbuminuria. d. Educational needs 1. Medication guidelines: a. Differences between Type 1 and Type 2 b. Considerations for periods of physiologic or psychological stress c. Prevention of renal failure 5. Discuss the clinical use of insulin, identifying the onset, peak action, duration, and nursing responsibilities of insulin given by subcutaneous injection: Rapid Acting Insulin Intermediate acting insulin Insulin Lispro NPH (Humalog) Lente Insulin Insulin Aspart Human insulin modified for (Novolog) long action Fast Acting Insulin Insulin glargine (Lantus) Regular Insulin Ultralente 6. Briefly discuss nursing responsibilities and methods of insulin delivery by IV push and IV drip. 7. Discuss onset, peak action, duration, and nursing responsibilities of the oral diabetic drugs: Sulfonylureas Alpha-glucosidase inhibitors glipizide (Glucotrol) Acarbose (Precose) glyburide (DiaBeta, Miglitol (Glyset) Micronase) Biguanides glimepiride (Amaryl) metformin (Glucophage) Meglitinides Thiazolidinediones repaglinide (Prandin) Pioglitazone (Actos) nateglinide (Starlix) Rosiglitazone (Avandia) 10.0 ADN12B Spring 2012 8. Using the worksheet in the course study guide, discuss the clinical manifestations, medical management, and nursing process for short term complications of Diabetes Mellitus: Hypoglycemia Hyperglycemia with Diabetic Ketoacidosis in persons with Type 1 Diabetes Hyperglycemia with Hyperosmolar Nonketotic Syndrome in persons with Type 2 Diabetes 9. Discuss the health deviations of the late complications of Diabetes Mellitus and show how these affect the self-care needs of persons with diabetes: Macrovascular diseases Coronary Artery Disease Cerebral Vascular Disease Peripheral Vascular Disease Microvascular diseases Diabetic Retinopathy Nephropathy Neuropathy 10. Describe the nursing standards of care for patients with diabetes. Include foot care. 11. Briefly discuss problems with sexuality that commonly occur in persons with diabetes. 12. Be prepared to discuss in class the following nursing diagnosis that often apply to patients with diabetes mellitus (see nursing diagnosis book). a. High Risk for Injury related to decreased tactile sensation in lower extremities b. High Risk for Injury related to diminished visual acuity c. Altered Comfort: burning pain related to diabetic peripheral neuropathy d. Individual Fear related to insulin injections e. Potential ineffective therapeutic management related to complex self-care regimen and inadequate knowledge f. Collaborative Problem: Potential for hypo/hyperglycemia 10.1 ADN12B Spring 2012 ASSIGNMENTS: Dudek S.G. (2010). Nutrition essentials for nursing practice (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 451-484. Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.).Philadelphia, PA: Lippincott, Williams & Wilkins, 1196-1243. Drug Handbook and Internet if needed for newer drugs: www.fadavis.com Complete DM Worksheets prior to class Articles: American Diabetes Association. Nutrition recommendations and interventions for diabetes: A position statement of the American Diabetes Association (2007). Diabetes Care (30)1, S48-S65. Kumar, C. P. (2007) Application of Orem’s self-care deficit theory and standardized nursing languages in a case study of a woman with diabetes. International Journal of Nursing Terminologies and Classifications, 18(3), 103-110. RECOMMENDED: www.diabetes.org 10.2 ADN12B Spring 2012 WORKSHEET: Laboratory Tests in Diabetes Diagnostic Test Rationale for Use of Test Nursing Responsibilities Fasting Blood Sugar Glycosylated Hemoglobin (Hemoglobin A1C) AC and HS glucose monitoring Urine test for acetone/ketones Urinalysis for microalbuminuria 10.3 ADN12B Spring 2012 MEDICATIONS TO TREAT DIABETES MELLITUS Insulins Onset Peak Effect Duration Very Rapid Action Lispro Humalog Rapid Action Regular Insulin Intermediate Action NPH Lente Long Acting Lantus Ultralente Combination 70/30 Insulin 10.4 ADN12B Spring 2012 Nursing Responsibilities Oral Drugs Action Onset Peak Effect Sulfonylurias Glipizide Glucotrol Glyburide Diabeta Micronase Glimepiride Amaryl Meglitinides Repaglinide Prandin Nateglinide Starlix Alphaglucosidase inhibitors Acarbose Precose Miglitol Glyset Biguanide Metformin Glucophage Glitazones Pioglitazone Actos Rosiglitazone Avandia 10.5 ADN12B Spring 2012 Duration Nursing Responsibilities DIABETES MELLITUS: SHORT TERM COMPLICATIONS HYPOGLYCEMIA DIABETIC KETOACIDOSIS Effects of: Food Intake Insulin or Oral Drugs Stress/ Illness Clinical Manifestations: Blood Sugar Ketones in blood and urine Acid/ Base effects Electrolyte effects Signs and Symptoms Treatment: Give glucose/ food Glucagon Insulin Fluids Electrolytes 10.6 ADN12B Spring 2012 HYPEROSMOLAR NONKETOTIC SYNDROME LATE COMPLICATIONS OF DIABETES MELLITUS Large Vessel Disease Cause Clinical Manifestations Screening and Management Coronary Artery Disease Cerebral Vascular Disease Peripheral Vascular Disease Small Vessel Disease Cause Clinical Manifestations Retinopathy Nephropathy Peripheral Neuropathies Autonomic Neuropathies 10.7 ADN12B Spring 2012 Screening and Management THEORY: IMMUNOLOGICAL DISORDERS, CONNECTIVE TISSUE HEALTH DEVIATIONS BEHAVIORAL OBJECTIVES: 1. Review and be prepared to discuss the organs, cells, and immunoglobulins of the normal immune system. 2. Describe the phases of the normal immune response. 3. Describe the four types of hypersensitivity reactions. Discuss anaphylaxis including clinical manifestations, stages, potential complications, and appropriate interventions for each stage. 4. Discuss Systemic Lupus Erythematosus (SLE) health deviation in regard to: Pathophysiology Diagnostic Evaluation Clinical Manifestations Clinical Management Nursing assessing, diagnosing, planning, implementing and evaluation Promotion of normalcy and prevention of hazards 5. Discuss Rheumatoid Arthritis health deviation in regard to: Pathophysiology Diagnostic Evaluation Clinical Manifestations Clinical Management Nursing assessing, diagnosing, planning, implementing and evaluation Promotion of normalcy and prevention of hazards 6. Discuss Scleroderma health deviation in regard to: Pathophysiology Diagnostic Evaluation Clinical Manifestations Clinical Management Nursing Process Promotion of normalcy and prevention of hazards 7. Independently complete the worksheet “Immune Modulating Drugs” and be prepared to discuss their clinical use in various types of immune disorders. ASSIGNMENTS: Deglan, J.H., & Vallerand, A.H. (2007). Davis’s drug guide for nurses (10th ed.). Philadelphia, PA: F.A. Davis Company. As needed. Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.).Philadelphia, PA: Lippincott, Williams & Wilkins, Chapter 50 & 54. ARTICLES: Babin, L.A. (2007). Connective tissue disorders. Dermatology Nursing, 19(3), 200, 207. Pullen, R.L., Brewer, S., & Ballard, A. (2009). Putting a face on systemic lupus erythematosus. Nursing2009, 22-28. 11.0 ADN12B Spring 2012 WORKSHEET: IMMUNE MODULATING DRUGS Drug/Action SYMPTOM CONTROL NSAIDs (COX-1) Salicylates: Aspirin DISEASE MODIFYING Antirheumatic drugs (DMARDS) hydroxychloroquine (Plaquenil) chloroquine (Aralen) Gold-containing compounds sulfasalazine (Azulfidine) penicillamine (Cuprimine, Depen) Methotrexate azothioprine (Imuran) cyclophosphamide (Cytoxan) Cyclosporine (Neoral) ADN12B Spring 2012 Route/Lab Monitoring Side Effects Nursing Management Immunomodulators Rituximab (Rituxan) Epratuzumab (humanized anitCD22 Antibody Antimalarial Medications TNF Blocking Agents Akalimumab (Humira) inflixamab (Remicade) etanercept (Enbrel) golimumab (Simponi) Interleukin-1 receptor antagonist Anakinra (Kineret) Corticosteroids Prednisone 11.2 ADN12B Spring 2012 THEORY: IMMUNOLOGICAL HEALTH DEVIATIONS -AIDS BEHAVIORAL OBJECTIVES: 1. Discuss the current epidemiology of the health deviation HIV including populations affected and routes of transmission. 2. Discuss the spectrum of HIV-1 infection from the primary infection through the late stages of Acquired Immunodeficiency Syndrome (AIDS) with regard to the following: a. b. c. d. e. f. Pathophysiology Diagnostic evaluation Clinical manifestations Clinical management Nursing assessment, diagnosis, planning, intervention, evaluation Promotion of normalcy and prevention of hazards 3. Discuss opportunistic infections, cancers, and syndromes associated with HIV health deviation including clinical manifestations, diagnostic tests, prophylaxis, medical therapies, and symptom management. a. Pneumocystis pneumonia (PCP) b. Mycobacterium avium complex, (MAC) c. Cryptococcal meningitis d. Cytomegalomegalo (CMV) retinitis e. Kaposi’s sarcoma f. B-cell lymphoma g. Tuberculosis h. Oral Candidiasis i. Wasting syndrome j. Progressive multifocal leukoencephalopathy (PML) k. Toxoplasma gondii encephalitis l. Herpes simplex m. Human papilloma virus (HPV) 4. Independently complete the worksheet: “Drugs used in the Treatment of AIDS” and be prepared to discuss the current clinical use of these drugs to treat HIV infections and to prevent post-exposure infection. 5. Identify how cultural differences could influence the patient and care-giver’s response to patients with AIDS health deviation. 6. Identify the changes in sexual behavior that need to occur in persons with AIDS health deviation. 7. Identify and discuss ethical issues that sometimes arise in relation to HIV infections and the treatment of AIDS health deviation in the United States and worldwide. 8. Discuss issues related to self-care demands and requisites of the patient dying of AIDS. 12.0 ADN12B Spring 2012 ASSIGNMENT: Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing. (12th ed.).Philadelphia, PA: Lippincott, Williams & Wilkins, Chapter 52. Dudek S.G. (2010). Nutrition essentials for nursing practice (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 536-561. Recommended for updates on the Internet: http://hivinsite.ucsf.edu – Information data base managed by UCSF AIDS Program at San Francisco General Hospital and the UCSF Center for AIDS Prevention Studies. www.cdc.gov/mmwr – Center for Disease Control Morbidity & Mortality Weekly Report www.aegis.com – AIDS Education Global Information System Article: Palmer, R. (2008). Use of complementary therapies to treat patients with HIV/AIDS. Nursing Standard, 22(50), 35-41. 12.1 ADN12B Spring 2012 WORKSHEET: DRUGS USED IN TREATMENT OF AIDS Drug and Action Food Interactions Side Effects Reverse Transcriptase Inhibitors Abacavir (ABC, Ziagen) Didanosine (ddl, Videx) Lamivudine (3TC, Epivir) Stavudine (d4T, Zerit) Zalcitabine (ddc,Hivid) Zidovudine (ZDVor AZT or Retrovir) Zidovudine + Lamivudine (Combivir) Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) Delavirdine DLV (Rescriptor) Efavirenz (EFV, Sustiva) Neviparine (NVO, Viramune) Etravirine (TMC125, Intelence) 12.2 ADN12B Spring 2012 Nursing Management Drug and Action Protease Inhibitors Route Lab Monitoring Side Effects Indinavir (IDV, Crixivan) Nelfinavir (NFV, Viracept) Ritonavir (RTV, Norvir) Saquinavir (SQV, Invirase) Fusion Inhibitors Enfuvirtide (T20, Fuzeon) Maraviroc (Selzentry) Integrase Strand Transfer Inhibitor Raltegravir (Isentress) 12.3 ADN12B Spring 2012 Nursing Management DRUGS USED TO TREAT OPPORTUNISTIC INFECTIONS Drug and Action Isoniazid INH Infection Treated or Prevented Tuberculosis Rifabutin Mycobacteriu m avium Complex MAC Azithromycin Clarithromycin Mycobacteriu m avium Complex MAC Amphotericin B Cryptococcal Meningitis Foscarnet (Foscavir CMV Retinitis Fluconazole (Diflucan) Cryptoccal Meningitis Side Effects 12.4 ADN12B Spring 2012 Nursing Management THEORY: ENDOCRINE HEALTH DEVIATIONS BEHAVIORAL OBJECTIVES: 1. Independently review the anatomy and physiology of the endocrine system from science courses and the medical surgical nursing textbooks. 2. Define and give examples of negative and positive feedback control mechanisms and target tissues of the endocrine system. 3. Complete the endocrine disorders worksheet and be prepared to discuss the clinical manifestations, medical management, and nursing process for hypo and hyperactivity of the thyroid, parathyroid, and adrenal, and pituitary glands. 4. Identify typical abnormal laboratory values associated with each endocrine condition. Discuss nursing responsibilities and precautions associated with these laboratory values. 5. Discuss the pre and post-op nursing management of the patient following neck surgery including thyroidectomy and parathyroidectomy. 6. Discuss the problems of sexuality related to endocrine dysfunction. 7. Complete the endocrine drug worksheet and be prepared to discuss endocrine drugs listed on the worksheet. REQUIRED ASSIGNMENTS: Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.).Philadelphia, PA: Lippincott, Williams & Wilkins, Chapter 42. Deglan, J.H., & Vallerand, A.H. (2007). Davis’s drug guide for nurses (10th ed.). Philadelphia, PA: F.A. Davis Company. As needed. Articles: Carson, M. (2009). Assessment and management of patients with hypothyroidism. Nursing Standard (23(18) 48-56. doi:219883523. Rosner, M. (2011). Hyponatremia: An Update on the management of SIADH. Renal & Urology News 10(10), 26-29. doi:900102090 13.0 ADN12B Spring 2012 WORKSHEET: ENDOCRINE DISORDERS Condition and Etiology Pituitary Posterior Lobe ADH (Anti Diuretic Hormone) Hypoactivity Clinical Manifestations Diagnostic Tests Diabetes Insipidus Pituitary Posterior Lobe ADH (Anti Diuretic Hormone) Hyperactivity SIADH (Inappropriate Secretion of ADH) 13.1 ADN12B Spring 2012 Medical Management Nursing Process Worksheet: Endocrine Disorders Condition and Etiology Clinical Manifestation Diagnostic Tests Pituitary Anterior Lobe Growth Hormone (GH) Hypoactivity Childhood onset: Pituitary Dwarfism Pituitary Anterior Lobe Growth Hormone Hyperactivity Childhood Onset: Gigantism Adult Onset: Acromegaly 13.2 ADN12B Spring 2012 Medical Management Nursing Process Condition and Etiology WORKSHEET: ENDOCRINE DISORDERS Clinical Manifestations Diagnostic Tests Medical Management Hypothyroidism (Thyroid Hypoactivity) Childhood Onset: Cretinism Adult Onset: Hashimoto’s Thyroiditis Myxedema Hyperthyroidism (Thyroid Hyperactivity) Graves Disease Thyrotoxicosis 13.3 ADN12B Spring 2012 Nursing Process Condition and Etiology WORKSHEET: ENDOCRINE DISORDERS Clinical Manifestations Diagnostic Tests Medical Management Hypoparathyroidism Hypocalcemia Hyperparathyroidism Hypercalcemia 13.4 ADN12B Spring 2012 Nursing Process WORKSHEET: ENDOCRINE DISORDERS Condition and Etiology Clinical Manifestations Diagnostic Tests Adrenal Medulla Hyperactivity Pheochromocytoma Adrenal Cortical Insufficiency Addison’s Disease Excessive adrenocortical activity: Cushing’s Disease Excessive exogenous cortisone: Cushing’s syndrome 13.5 ADN12B Spring 2012 Medical Management Nursing Process WORKSHEET: ENDOCRINE DRUGS Drug and Action Condition Used For Pituitary, Posterior Lobe DDAVP (Desmopressin) Side/ Toxic Effects aqueous vasopressin (Pitressin) chlorpropamide (Diabenese) Lasix (furosemide) Declomycin (demeclocycline) Pituitary, Anterior Lobe Human Growth Hormone Bromocriptine Thyroid levothyroxine (Synthroid) propranolol (Inderal) propylthiouracil (PTU) methimazole (Tapazole) Radioactive Iodine Therapy 13.6 ADN12B Spring 2012 Nursing Process Parathyroid Calcium Gluconate oral Calcium Vitamin D Calcitriol Normal Saline and IV Lasix Pamidronate disodium Estrogen therapy Calcitonin Mithramycin (plicamycin) Adrenocorticosteroids Glucocorticoids: hydrocortisone (Solu-Cortef) dexamethasone (Decadron) Prednisone Mineralocorticoids: fludrocortisone (Florinef) 13.7 ADN12B Spring 2012 THEORY: HEALTH DEVIATIONS OF THE CARDIOVASCULAR SYSTEM - HEART FAILURE LEARNING OBJECTIVES 1. Trace the circulation of the blood through the pulmonary circulation (right side of the heart) and the systemic circulation (left side of the heart). 2. Define the health deviation congestive heart failure; right-sided failure; left-sided failure. 3. List the common predisposing causes of CHF. 4. Discuss clinical manifestations, diagnostic evaluation and medical management of CHF, including dietary restrictions. 5. Discuss the nursing assessment, diagnosis, planning, implementations and evaluation related to cardiac failure. 6. Discuss the use of core measures for CHF. 7. Discuss the drug therapy of CHF. For each medication identify the mode of action, oral dosage range, common side effects, and nursing responsibilities: Loop diuretics: Furosemide (Lasix) Digoxin: loading dose and maintenance dose Angiotensin Converting Enzyme (ACE) inhibitors Enalapril 8. Discuss the clinical use of the following nursing diagnoses and collaborative problems in a patient with CHF: Collaborative Problem: Potential pulmonary edema Potential cardiogenic shock Nursing Diagnosis: Activity Intolerance R/T fatigue and dyspnea secondary to decreased cardiac output Knowledge Deficit regarding low salt diet Anxiety R/T breathlessness and restlessness secondary to inadequate oxygenation ASSIGNMENTS: Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.).Philadelphia, PA: Lippincott, Williams & Wilkins, 684-714; 825-843. Dudek S.G. (2010). Nutrition essentials for nursing practice (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 485-513. Drug Guide as needed 14.0 ADN12B Spring 2012 Articles: Luckson, J. (2009). Managing chronic heart failure. Practice Nurse, 37(4), 39-44. Washburn, S.C., Hornberger, C.A. (2008). Nurse educator guidelines for the management of heart failure. The Journal of Continuing Education in Nursing, (39)6, 236-267. 14.1 ADN12B Spring 2012 THEORY: HEALTH DEVIATIONS OF THE CARDIOVASCULAR SYSTEMMYOCARDIAL INFARCTION LEARNING OBJECTIVES: 1. Define the health deviation myocardial infarction. 2. Describe various tests used to diagnose acute MI (include ECG changes, CK-MB, Myoglobin, and Troponin). Relate the abnormal results to the progression of the occlusion, necrosis, and healing process. 3. Describe the pathophysiology, clinical manifestations, medical management and nursing assessment, diagnosis, planning, and implementation for an acute MI patient. 4. For each medication identify the mode of action, side effects and nursing responsibilities. Oral antiarrhythmics: beta blockers, calcium channel blockers, nitrates, and antiplatelets Thrombolytic agents: streptokinase, tissue plasminogen activator (t-PA) 5. Discuss the following nursing diagnoses and collaborative problems for patients with the health deviation acute MI to determine if self-care requisites are being met: Collaborative Problems/Potential Complications: Potential recurrent myocardial infarction Potential cardiac dysrhythmia Potential cardiogenic shock Potential for bleeding secondary to thrombolytic agents Nursing Diagnoses: Alteration in comfort: chest pain R/T occlusion or narrowing of coronary artery Activity intolerance R/T insufficient oxygenation for ADLs Knowledge deficit regarding medications, diet, or risk factors R/T Anxiety/Fear R/T outcome of acute MI 6. Discuss the educative supportive nurse’s role with sexuality problems that may occur in patients with cardiovascular disease. 7. Discuss the health deviation core measure for patients with myocardial Infarction. Critical Thinking Exercise: Using the critical pathway in Smeltzer and Bare as a guide, explain the provision of care needed during the typical hospital course and home recovery of a 55 year old man who has suffered an acute, uncomplicated MI. He received a thrombolytic agent (tissue plasminogen activator, streptokinase or urokinase) in the emergency room that partially relieved the vessel obstruction. He had an uneventful course in the hospital ASSIGNMENT: Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.).Philadelphia, PA: Lippincott, Williams & Wilkins, 728, 755795. Dudek S.G. (2010). Nutrition essentials for nursing practice. (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, 485-513. Drug Guide as needed 15.0 ADN12B Spring 2012 Submodule 16.0 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B - Health Deviations 3 VISION AND HEARING SUBMODULE I. Introduction A. Purpose: This submodule is designed to encourage the second semester nursing student to improve skills in self-directed learning. B. Method: This submodule is designed as a self-instructional unit. The learning objectives can be accomplished with the Potter and Perry, (newest edition) and Smeltzer, et al., (newest edition). II. Submodule Content A. Theoretical considerations important in vision and hearing in the middle age population. B. Use of the nursing process in the acute care of patients with vision and hearing disorders, both as first aid procedures (any setting) or MD ordered interventions in a health care facility. 1. Assessments relevant to vision and hearing. 2. Clinical decisions 3. Planning and goal setting 4. Implementation - methods/procedures regarding vision and hearing. 5. Evaluation of effectiveness C. Modification of hospital procedures to the home and/or ambulatory setting. III. Learning Objectives A. Vision objectives related to Middle Age Adult. 1. Review and describe the anatomy and physiology of the eye 2. Describe the procedure for safe emergency removal of contact lenses. 3. Discuss the emergency management for the following eye problems: corneal abrasions, foreign body on surface, penetrating injuries, chemical burns and contusions. 4. Describe the pathophysiology, clinical manifestations, diagnostic tests, medical management, self-care requisites, nursing diagnosis, and nursing management on the following listed eye conditions. a. Detached retina b. Conjunctivitis, bacterial and viral c. Uveitis d. Orbital cellulites e. Orbital and ocular tumors 5. Identify benefits and potential complications of LASIK (Laser-assisted in situ Keratomileusis) 16.1 ADN12B Spring 2012 6. Describe the actions, side effects and nursing interventions for the following ophthalmic drugs used to treat the eyes locally (eye drops, ointments, pledgets) a. Anti-infectives: ciprofloxacin, gentamycin, sulfacetamide b. Corticosteroids and Nonsteroidal Anti-inflammatory drugs: dexamethasone, prednisolone c. Ocular irrigants and Lubricants: Dacriose, Methyl or Hydroxypropyl cellulose (artifical tears) B. Hearing objectives related to Middle Age Adult 1. Review and describe the anatomy and physiology of the ear. 2. Identify common ear infections and their treatments. 3. Discuss the following drugs that cause an ototoxic effect and the nursing responsibilities for them: antibiotics and loop diuretics. a. Anti-inflammatory agents: salicylates (aspirin), indomethacin b. Anti-infectives: Aminoglycosides such as toabramycin, gentamycin, neomycin, streptomycin. Other antibiotics: erythromycin, polymyxin c. Diuretics: furosemide (Lasix), acetazolamide d. Antimalarial agents: quinine, chloroquine e. Cheomotherapeutic agents: cisplatin 4. Review the procedure for administering eardrops and for irrigating the external auditory canal to remove cerumen. 5. Describe the clinical manifestations, diagnostic evaluation, medical/surgical care, and nursing management of Meniere’s disease, labyrinthitis, acoustic neuroma, and perforated tympanic membrane. 16.2 ADN12B Spring 2012 IV. Assignments A. Smeltzer et al. (newest edition) as needed. B. Potter and Perry: (newest edition) as needed. C. Davis’s Drug Guide: (newest edition) as needed. V. Evaluation of Learning Objectives The criteria for successful completion of this submodule is passing the multiple-choice test "Vision and Hearing" with 85% accuracy on the first testing. The test is to be scheduled at the student's convenience in the Learning Center. If the student does not achieve an 85% or better score the first time, the test can be retaken. A score of 88% must be achieved on the second attempt. If the student does not achieve an 88% or better score the second time, the test can be retaken after student has met with the instructor. A progress note will be written and placed in the student's cumulative file. The learning objectives must be written out and given to the responsible instructor. A score of 90% must be achieved on the third attempt. If the student does not achieve a 90% or better score on the third time, the student must meet with the teaching team instructor who is responsible for the vision and hearing submodule. Any other remediation is at the discretion of the teaching team. The student is to retake the test until passed. If the submodule is not completed and the test passed, a course grade of “incomplete” will be given. Please review submodule policy in the ADN Student's Handbook for further details. 16.3 ADN12B Spring 2012 COURSE EVALUATION 17.0 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B - Health Deviations 3 ADN12B COURSE EVALUATION INFORMATION The course evaluation will be done via an on-line survey. The survey will be done in the computer lab located in the LAC library on the day ATI testing is scheduled. Access to the survey will be provided at that time and done just before ATI testing. The survey should take 10-15 to complete and your comments, feedback and input are welcomed, and appreciated. 17.1 ADN12B Spring 2012 LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12B Health Deviations 3 Course Syllabus For Campus Laboratory and Clinical SPRING 2012 Edited by: Maricela Arnaud, RN, MSN, FNP Julie Bean, RN, MSN, ED © Long Beach City College Associate Degree Nursing Program, Long Beach, CA 90808 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL - Health Deviations 3 Laboratory TABLE OF CONTENTS General Information Course Information………………………………………………………………………..1.0 Course Outline………………………………………………………………………….…1.2 Theoretical Framework……………………………………………………………………1.3 Course Requirements…………………………………………………..……………….…1.4 Entry and Exit Skills………………………………………………………………………1.5 Learning Outcomes for Laboratory & Clinical………………………………….……...…1.6 Challenge Policy…………………………………………………………………………..1.7 Application for Challenge by Exam 12BL………………………………………………..1.8 Skills Assessment Expectations…………………………………………………….…….1.9 Attendance Policy and Make-up Assignment……………………………………...…..…1.10 Campus Laboratory Content Skill Lab: Neurological Assessment ........................................................................................... 16.0 Study Guide: Levels of Consciousness ................................................................................ 16.2 Worksheet: Neurological Assessment ................................................................................. 16.5 Skill Assessment: Neurological Assessment........................................................................ 16.7 Skill Lab: Intradermal Skin Testing............................................................................................ 17.0 Skill Assessment: Intradermal Injections ............................................................................. 17.2 Skill Lab: Care of the Patient with a Tracheostomy ................................................................... 18.0 Skill Lab: Suctioning Nasally, Orally, or by Tracheostomy....................................................... 18.1 Skill Lab: Tracheostomy Care .................................................................................................... 18.2 Skill Assessment: Suctioning the Patient with a Tracheostomy Tube ................................. 18.4 Skill Assessment: Tracheostomy Care ................................................................................. 18.5 Intravenous Therapy........................................................................................................19.0 Skill Lab: Advanced Management of IV Fluid Replacement .............................................. 19.0 Worksheet for Intravenous Therapy, Part I ................................................................... 19.1 Skill Lab: IV Drip Calculations ........................................................................................... 19.4 IV Drip Calculation Worksheet ........................................................................................... 19.5 Physical Assessment ................................................................................................................... 20.0 Skill Assessment: Physical Assessment of the Dependent Patient ...................................... 20.2 Nursing Care Worksheet for Physical Assessment .............................................................. 20.3 i ADN12B Spring 2012 Case Study Guidelines, including format ................................................................................................ 21.0 Information on APA Style ............................................................................................. 21.3 Grading Criteria for Case Study ................................................................. …..……….21.4 General Information for Clinical Clinical Practice Experiences in ADN 12BL ....................................................................... 22.0 Clinical Orientation Day ...................................................................................................... 23.0 Self-Orientation to a Nursing Unit………………………………………......……….23.1-23.5 Guidelines for Selection of Patient Assignment .................................................................. 24.0 Student Assignments Form .................................................................................................. 25.0 Behavioral Objectives for Group Leader ..................................................................... 26.0-26.3 Patient Information Worksheet for Group Leader ....................................................... 26.4-26.5 Medication Worksheet for Group Leader .................................................................... 26.6-26.7 Peer Evaluation Sheet .......................................................................................................... 26.8 Sample Daily Schedule for Team Member……………………………………………...…27.0 Nursing Care Plan Assessment Guidelines .......................................................................... 28.0 Medical/ Surgical Nursing Care Plan with drug therapy worksheet ............................ 29.0-29.2 Ambulatory Care Experience ............................................................................................... 30.0 Student Clinical Evaluation Evaluation tool……………………………………………………………………..31.0 ii ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL - Health Deviations 3 Laboratory Course Information Course Description On-campus lab practice and application of course content utilizing Orem's Self-Care Theory and the nursing process in the live nursing situation. Skill activities include intravenous therapy, physical assessment, and medical and surgical aseptic practice with related skills. Students assume the professional role of the registered nurse while collaborating and managing the safe care of a multiple patient assignment in the medical areas of the acute care facilities. Communication, teaching and learning, and critical thinking skills are emphasized. Time allotment, sequencing and enrollment 1.5 college semester units, 9 week course Clinical/campus labs: 9 hours per week, 2 hours campus lab; 7 hours clinical; Total 81 hours. This course is offered in the second semester during the second half of each 18 week semester with enrollment as space and resources allow. Concurrent enrollment with ADN 12B required. Required Texts 1. All texts required for ADN 12B Health Deviations 3 Recommended Texts 1. All texts recommended for ADN 12B Health Deviations 3 2. Supplementary readings: Nursing journal articles to be found in the Learning Center and Library. Teaching Methods Campus lab discussions Reading assignments Case studies Skills demonstration and skills testing Clinical written work/Nursing care plans Laboratory assignments Media programs: AV, CD, DVD Student compliance with clinical agency requirements All students must comply with clinical agency requirements for documentation of health status and training. The student is to keep original documents. Copies of the following documents must be maintained in the student’s file in the program director’s office: Hepatitis B vaccine (completed series unless previously positive) Annual TB screening Proof of varicella, measles, mumps, and rubella immunity (titer) Current professional malpractice insurance and CRP for health care providers. Annual influenza immunization Tdap (Tetanus, diphtheria, Pertussis [whooping cough]) immunization 1.0 ADN12B Spring 2012 Student clinical evaluations See Student Clinical Evaluation forms and Clinical Behavioral Objectives in syllabus. Student Course grade The theory and lab portion of this course must be taken concurrently and both theory and lab must be passed in order for the student to proceed in the program. The student will receive the same letter grade for theory and for lab unless he/she is less than satisfactory clinically in which case the policy in the Student Handbook for marginal or unsatisfactory clinical ratings will be followed. A minimum theory grade of 75% (C) is required to satisfactorily complete the course. Course Instructors Name & Credentials Office Telephone e-mail Maricela Arnaud, RN, MSN, FNP, Lead G office (562) 938-4170 cell (714) 457-0330 [email protected] Julie Bean, RN, MSN- ED R office (562) 938-4178 cell (562) 569-8620 [email protected] Full-time teachers' office hours are posted on their office doors. Other hours may be arranged. Part time teachers may be reached by special arrangement with the individual teacher. 1.1 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL Health Deviations 3 Laboratory Course Outline Course Outline 1. Neurological Assessment A. Components of neurological examination B. Neurological assessment C. Neurological abbreviated exam D. Pupillary assessment E. Assessment of corneal, gag, and Babinski reflexes F. Neurological assessment of the comatose patient G. Neurological assessment of the alert patient F. Use of the Glasgow Coma Scale 2. Intradermal Skin Testing A. Common diagnostic tests B. Standard technique for intradermal placement C. Patient instructions D. CDC method of reading TB skin tests 3. Naso/Oral Pharyngeal and Tracheostomy Suctioning and Tracheostomy Care A. Suctioning and care of tracheostomy equipment B. Procedure for naso pharyngeal suctioning C. Hazards of suctioning D. Rationale for tracheostomy care E. Procedure for tracheostomy care 4. Advanced Management of Intravenous Fluid Therapy A. Fluid replacement B. Drip calculations 5. Physical Assessment A. Synthesize all of the previously learned components of physical assessment B. Perform a head-to-toe assessment C. Document assessment findings 6. Case Study Presentations 7. Performance of basic nursing skills in the assigned clinical facility. 1.2 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL – Health Deviations 3 Lab Orem’s Self Care Model Conceptual Framework Curriculum Implementation SELF CARE MODEL THEORY CLINICAL IMPLEMENTATION IMPLEMENTATION Health Deviation Self Care The concept of Health Students provide care for Requisites are needs Deviation Self Care two to three acutely ill generated by illness and the Requisites is discussed patients in the hospital medical diagnostic with emphasis placed on medical settings. Whenever procedures and treatments the medical patient. possible, patients are associated with disease. selected to correspond with The basic principles of classroom theory. intravenous therapy and administration of Students apply the entire intravenous medications nursing process of are utilized as commonly assessing, diagnosing, used medical treatments planning, implementing, associated with health and evaluating. deviations. The nursing process The following health considers the Universal problems are studied in Self Care Requisites, depth: Developmental Self Care Requisites, as well as the Diabetes mellitus Endocrine disorders Health Deviation Self Care Requisites of patients with Neurological the studied problems. disorders Blood and blood products Acid/Base disorders Hematology. Cardiovascular deviations MI Heart failure Developmental Self Care The Self Care Requisites Requisites are needs generated by these health associated with problems and problems development throughout with associated diagnostic the life cycle. and treatment modalities are studied. Developmental Self Care Requisites are applied to the middle aged adult. 1.3 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL – Health Deviations 3 COURSE REQUIREMENTS During this course each student will: 1. Independently review any material from previous required courses as needed. 2. Arrive to campus lab and clinical well-prepared and on time. 3. Prepare prior to class for discussion of each assigned behavioral objective. 4. Complete all required reading, audio-visual, and written work prior to class and/or conference. 5. Turn in assigned written work on time, using correct format as described in ADN Student Handbook or course syllabus. 6. Initial the attendance roster to demonstrate attendance at campus lab. 7. Actively participate in lab and conference discussions. 8. Assume responsibility for meeting behavioral objectives when absent from campus lab and completing a make up assignment if absent from clinical. 9. Achieve a minimum of 75% overall on all scored materials at the completion of the course. 10. Comply with the standards of the College and Student Handbook Policies on Academic Honesty as published in the Student Handbook and in the college catalog. 1.4 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program AND 12BL- Health Deviations 3 ENTRY AND EXIT SKILLS Entrance Skills Upon entrance to ADN 12BL, the student will demonstrate the following skills, concepts and/or information: 1. Continuing mastery of all procedural skills taught in previous courses in the ADN program. 2. Application of nursing theory taught in all previous courses in the ADN program. 3. Demonstrate readiness to participate in skills taught in this course. Exit Skills Upon successful completion of ADN 12BL, the student will demonstrate competence in the following skills, concepts and/or information: 1. Application of theory taught in ADN 12B to the adult in the medical/surgical nursing units and relevant diagnostic labs in an acute care hospital. 2. Continuing application of theory taught in all previous courses in the ADN program. 3. Competency in the ADN 12BL procedural skills required in nursing care to the patient with complex medical problems, such as: neurological assessment, complete head to toe physical assessment, tracheostomy care and suctioning, and standard precaution skills. 4. Continuing competency in all procedural skills taught in all previous lab courses in the ADN program. 5. Progressive competency in the RN role as demonstrated by adequate functioning as a group leader on the medical nursing unit. 6. Organization and time management skills needed to complete a multiple patient (2-3) bedside care assignment and function as a team member on the acute medical nursing unit. 7. Application of the proper principles of English usage and mechanics to the health care setting by communicating with patients, instructors, and staff verbally and in writing; and by preparing nursing care plans and recording the application of the nursing process in the medical record. 1.5 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL – Health Deviations 3 ADN 12BL LEARNING OUTCOMES Upon satisfactory completion of this course, the student will be able to: Professional Role Illustrate professionalism, effective communication, and collaborative nursing care in the clinical setting. Assimilate and integrate professional values of caring, integrity, honesty, patient advocacy, and respect for human dignity within the professional role. Communication Utilize appropriate communication skills with colleagues, clinical staff, and faculty using proper verbal and written English and document care utilizing the clinical agency’s set protocols and formal method of communication (e.g. SBAR). Demonstrate respect for cultural diversity and unique individual differences in communication style and preference. Orem’s Self Care Theory and the Nursing Process Coordinate Orem’s Self-Care Theory and the nursing process in the care of a multiple patient assignment in the acute medical setting. Develop and implement a plan of care for acutely ill medical patients using Orem’s Self-Care Theory and the nursing process. Critical Thinking and Safety Utilize critical thinking and clinical judgment in the provision of safe care to the hospitalized medical patient. Integrate core competencies of critical thinking and scientific inquiry with ethical principles as a basis for making professional judgments and assimilate new content to adapt for safe clinical practice. Teaching and Learning Assess and evaluate learning needs of the medical patient and develop a plan of care to teach fulfillment self-care deficits. Promote health seeking behaviors; teach illness prevention, risk reduction, and disease management to patients and families in the clinical setting. Seek out patient assignments to apply new skills and theoretical knowledge to meet learning needs and ask for guidance/assistance when needed. Collaborative Management of Care Collaborate with the interdisciplinary health care team to promote optimal patient outcomes and coordinate/delegate patient care in the clinical setting to accomplish the interventions and goals set forth for each patient. 1.6 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL – Health Deviations 3 CHALLENGE OPTION ADN 12BL General Announcement Students interested in challenging must let the instructor know by the last day of the first week of the course. The student should complete the department “Application for Challenge by Examination for ADN 12BL” and complete the college formal application for challenge by examination. Upon acceptance of the challenge option by the teaching team, an appointment will be made for the student to take the written theory exam at the beginning of the second week of the course. Written Test A 150 point comprehensive, objective (NCLEX style) test will be given. The student must achieve a minimum score of 75% to continue with the challenge. Upon successful completion of the ADN 12B course challenge, the student then proceeds to the next step; the challenge of ADN 12BL. Challenge of ADN 12BL The student submits the department “Application for Challenge by Examination for ADN 12BL” and the college application for challenge by examination. Case Study The student will complete a written case study to be assigned by the instructor. The case study is due by the last day in the second week of the course. Clinical Clinical assessment will be individualized to evaluate the clinical competency of the student. The student is advised to attend clinical orientation day. The student and instructor will plan a specified number of days, not less than two, on a medicalsurgical nursing unit. During this time, the student is to demonstrate competencies expected of a student at the end of ADN 12BL. Grade for ADN 12BL If successful, the grade earned for ADN 12BL will be the same that is earned in the challenge of ADN 12B. Completion of the Challenge Option for both ADN 12B and ADN 12BL All the components of the challenge are to be completed by the end of the third week. 1.7 ADN12B Spring 2012 APPLICATION FOR CHALLENGE BY EXAMINATION ADN 12BL- Health Deviations 3 Student Name________________________________ Date____________________ Student complete section A below: A. Justification of this request: Student Signature_____________________________________ Teaching team complete section B below: B. Decision: Yes________ If yes, write contract below. No________ If no, state reason for denial. C. Contract Case study completed by ___________________________ Clinical assessment completed by __________________________ Signatures: Lead Instructor: _____________________________ Date:___________________ Instructor:__________________________________ Date:___________________ Instructor:__________________________________ Date:___________________ Student:____________________________________ Date:___________________ D. Disposition of Challenge_________________________________________________ 1.8 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL Health Deviations 3 Laboratory SKILLS ASSESSMENT EXPECTATIONS The philosophy of the Associate Degree Nursing Program faculty includes the concept that students should be held accountable for all skills learned previously in the nursing program. In the original “SKILLS ASSESSMENT STATEMENT” in the 11B syllabus, the following criteria can be found: The critical elements for specific skills are listed on Campus Lab and Skill Assessment Sheets. All of the parts of the skill MUST be performed in order that the skill is evaluated as having been done satisfactorily. Skill Assessment sheets are kept on file to validate that the student has successfully completed the skill. Skill competency may be tested at any time throughout the program in scheduled campus labs. Students are expected to meet the critical elements of any skill after testing at any time in the hospital setting. See also Skills Testing in the Student Handbook. Previously learned skills are listed in the Clinical Behavioral Objectives in this syllabus. The student is responsible for being prepared to perform these skills in the clinical area under supervision, with minimal on-the-spot review or teaching. The student must follow appropriate standard precautions for each skill learned. If self-assessment by the student demonstrates that he/she is not able to safely perform previously learned skills, the following are suggested resources: 1. 2. 3. 4. 5. 6. Review media in the learning center. Review appropriate syllabus pages to see that all critical elements are being met. Make an appointment with a Skills Adjunct Lab teacher. Practice in the skills lab with a peer who is proficient in the skill. Make an appointment with your clinical instructor for help. Review the hospital procedure manual. If the student is unable to perform a previously learned skill with 100% accuracy in the clinical area during this course, the student will receive an overall clinical marginal until remediation is achieved and clinical practice of skills is satisfactory. 1.9 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL Health Deviations 3 Laboratory ATTENDANCE POLICY AND MAKE-UP ASSIGNMENT 1. Attendance: (from the Associate Degree Nursing Student Handbook) 1.1 The Long Beach City College Associate Degree Nursing Program mission and goals include preparation of nurses for entry-level registered nurse positions. Reliable and prompt attendance at the assigned time and nursing unit is both a professional responsibility and a minimal expectation of employers of entry level registered nurses. Therefore, during the nursing program, students must demonstrate reliable attendance and promptness behaviors. For each nine-week course the following guidelines shall apply: 1.1.1 Overall Course Attendance: The college policy shall be enforced, i.e., “Attendance is the student’s responsibility. In the event of excessive absences, the instructor may drop a student from a course or lower a student’s grade. Students who are absent more than twenty percent of the total class hours or for two consecutive weeks shall be automatically dropped from the class.” See current college catalog. 1.1.2 Clinical and campus laboratory hours 1.1.2.1 Any combination of three episodes of absences and/or tardiness within a course shall result in the student receiving a Progress Report and a “Must Improve” rating in the appropriate area of the clinical evaluation. Any further absences and/or tardiness in the same course shall result in an “Unsatisfactory” rating in the appropriate area of the clinical evaluation and an overall clinical marginal rating for the course. (Approved 3/96) Making up a clinical day is not always an option. It is not possible to make up a clinical day; a written assignment may be required. 2. Make-up assignment for ADN 12BL Missing clinical time may result in the student not meeting behavioral objectives for the course. At the discretion of the teaching team, a student missing clinical time may be asked to make up the clinical day, schedule simulation in the Simulated Hospital, or be given a written assignment to help make up for the lost clinical time. The exact assignment and due date will be established on an individual basis by the teaching team. 1.10 ADN12B Spring 2012 ADN 12 BL Health Deviations 3 Laboratory CAMPUS LABORATORY ADN12B Spring 2012 ADN 12BL – Health Deviations 3 Laboratory SKILL LAB OVERVIEW: NEUROLOGICAL ASSESSMENT BEHAVIORAL OBJECTIVES: 1. Describe methods of assessing each of the six components of a complete neurological examination by completing the neurological assessment worksheet prior to class. 2. Describe patient behavior associated with levels of consciousness. Relate these descriptive states to the Glasgow coma scale. 3. Describe decerebrate and decorticate posturing and the implications of these findings. 4. Describe the components of a complete neurological examination as performed by an MD or neurologist, a neurological screening assessment as performed by an MD or psychologist, and a neuro check as performed by an RN. 5. Describe and be prepared to demonstrate the neuro check of an alert patient. 6. Describe and be prepared to demonstrate the neuro check of a comatose patient. 7. Use correct terminology in reporting and recording neurological findings. CRITICAL ELEMENTS: 1. If patient is awake, ask questions to determine orientation to time, place, and person 2. Assess pupils for size, equality, and shape. 3. With flashlight, assess briskness of pupillary response to light. 4. Assess upper extremity strength by asking patient to squeeze nurse’s fingers, and compare to normal. 5. Assess lower extremity strength by asking the patient to dorsi-flex and plantar-flex each foot. 6. Score the Glasgow Coma Scale of an awake patient accurately. 7. If the patient is comatose, assess level of consciousness by using the correct order of stimulation: calling the patient’s name, stimulating by touch, and stimulating by deep pain. 8. Demonstrate the correct method of assessing response to deep pain and note the reaction to stimulation. 9. Assess pupils for size, equality, and shape. 16.0 ADN12B Spring 2012 10. Assess protective reflexes: gag and corneal. 11. Assess plantar reflex. 12. Score Glasgow Coma Scale accurately for a comatose patient and be able to record neurological assessment data on the flow sheet provided in the syllabus. 13. Complete neurological assessment of both awake and comatose patient within 10 minutes. ASSIGNMENTS: Potter, P.A., & Perry, A.G. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby Elsevier, 631-640. Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.).Philadelphia, PA: Lippincott, Williams & Wilkins, 18421850; 1859-1864. Syllabus: Levels of Consciousness Glasgow Coma Scale Worksheet: Neurological Assessment HOW THIS SKILL WILL BE TESTED: On-campus lab, with 100% accuracy, according to critical elements. 16.1 ADN12B Spring 2012 Study Guide: LEVELS OF CONSCIOUSNESS Level of Consciousness Term Awake/ Alert Lethargic, drowsy Stupor Semi coma Vegetative State Deep Coma Brain Death Description Arouses easily. Responds to verbal stimulus. May or may not follow commands or be oriented. Goes to unconscious state at intervals. Responds slowly, but is responsive. May or may not follow commands or be oriented. Requires repeated or moderate verbal stimuli or painful/noxious stimuli to arouse. Will lapse into sleep if not stimulated. May move spontaneously without stimuli. Little purposeful movement. Confused and disoriented when awake, may reorient briefly. Purposefully withdraws from pain. A partial or mild comatose state. May be aroused with stimulus, but returns to unconscious state when not stimulated. Response to noxious stimuli is organized. Protective reflexes (corneal, gag) are present. As in Semi comatose state, but may open eyes and may track (follow examiner with eyes), but does not follow commands. Little or no response to deep pain. Protective reflexes may not be present. No or minimal spontaneous movement, flaccid. Irreversible cessation of all functions of the brain, including the brain stem. Determined by a neurologist. Generally accepted standards include: fixed, dilated pupils, no gag or corneal reflex; no activity on EEG x3, several hours apart; no spontaneous respirations during apnea test (ventilator turned off), no eye movement when cold water injected into ear canal (cold calorics), negative doll’s eyes. Temp >35 and no sedatives. 16.2 ADN12B Spring 2012 Study Guide: GLASGOW COMA SCALE Pupil Scale Scoring of Eye Opening (in mms) 4=patient opens eyes spontaneously 3= patient opens eyes in response to speech (spoken or shouted) 2=patient opens eyes only in response to painful stimuli Pressure at proximal end of nail bed with pencil Pressure to supra orbital ridge 1= patient does not open eyes in response to painful stimuli C=if eyes are closed by swelling Pupil Reaction + =reacts Ø =no reaction S=sluggish C=eyes closed Scoring of Best Motor Response 6=patient can obey a simple command 5=patient purposefully tries to remove the painful stimulus from more than one area 4=patient responds to painful stimuli by attempting to withdraw from source of pain 3=Decorticate posturing: patient has an abnormal spastic flexion of the upper extremities and simultaneous rigidity of the lower extremities either spontaneously or in response to tactile/painful stimuli 2=Decerebrate posturing: patient has an abnormal spastic extension of both upper and lower extremities either spontaneously or in responds to tactile/painful stimuli 1=patient has no motor response to pain in any limb 16.3 ADN12B Spring 2012 Reflexes Corneal= cornea lightly stroked with a wisp of cotton, the patient automatically blinks if the corneal reflex is intact. Gag=elicited by stroking each side of the mucous membrane of the posterior pharynx with a tongue blade or suction catheter. Plantar=Normal reflex. Plantar (downward) flextion of the toes. Scoring of Best Verbal Response 5=patient is oriented to time, person and place 4= patient is able to converse although not oriented to time, place or person 3=patient only speaks in words or phrases that make little or no sense 2=patient responds with incomprehensible sounds such as groans or moaning without recognizable words 1=patient does not respond verbally at all Babinski=Abnormal reflex. Extension or dorsi flexion of the big toe. May have fanning of the toes. += present Ø= absent B =Babinski Muscle Strength: Hand and Foot Strong Weak Ø Flacid Muscle Strength 5=raises limb and holds against pressure 4=raises limb and holds against light touch 3=raises limb but unable to hold against gravity 2=weak contraction, movement, but not against gravity 1=isometric contraction but no movement 0=no movement 16.4 ADN12B Spring 2012 ADN 12BL – Health Deviations 3 Laboratory WORKSHEET: NEUROLOGICAL ASSESSMENT Part I, Mental Status Area Techniques Normal/Abnormal Speech Orientation Memory Attention Span Calculations Judgment Abstract Reasoning Part II, Level of Consciousness – Glasgow Coma Scale Area Techniques Normal/Abnormal Eye Opening Motor Response Verbal Response 16.5 ADN12B Spring 2012 Part III, Motor Function Area Techniques Normal/Abnormal Upper Extremities Lower Extremities Part IV, Peripheral Sensory Function Area Techniques Normal/Abnormal Light Touch Pain Temperature Part V, Reflexes Area Techniques Normal/Abnormal Pupils (PERRLA) Corneal Blink Reflex Gag Plantar Reflex Deep Tendon Reflexes 16.6 ADN12B Spring 2012 ADN 12BL - Health Deviations 3 Laboratory Skill Assessment: NEUROLOGICAL ASSESSMENT Name: _________________________________ Date _________________________ Evaluator: CRITICAL ELEMENTS Pass Fail Comment 1. Accurately assess patient’s neurological status. 2. Perform maneuvers that cause only mild or no distress. PROCEDURAL ELEMENTS For Alert Patient: 1. Ask questions to determine orientation to time, place and person. 2. Assess pupils for size, equality, shape, and reaction to light. 3. Assess upper and lower extremity motor strength. 4. Score the Glasgow Coma Scale accurately. For Comatose Patient: 1. Assess level of consciousness using correct order of stimulation. 2. Demonstrate correct method of assessing response to deep pain. 3. Assess pupils for size, equality, shape, and reaction to light. 4. Assess protective reflexes: gag and corneal blink reflex. 5. Assess plantar reflex. 6. Score GCS accurately for comatose pt. 1. Record neurological assessment data including normal and abnormal findings for both the alert and comatose patient on the flow sheet chart provided. 2. Complete all critical elements within 10 minutes. RETEST: Date:_________________________ Skills Evaluator:___________________________ 16.7 ADN12B Spring 2012 NEURO CHECK FLOW SHEET Glasgow Coma Scale Score Alert Coma 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1 Spontaneously To Verbal To Pain No Response Obeys Verbal Localizes Pain Flex Withdrawal Decorticate Decerebrate No Response Oriented/Converses Disoriented Inappropriate Words Incomprehensible No Response Eye Open Response Best Motor Response Best Verbal Response Glasgow Coma Score for Alert Patient=______________________ Glasgow Coma Score for Comatose Patient=__________________ +/- +/- + - + RLE LLE R L R L R L R L R L R L od/os Alert Patient Coma Patient - + / / / / Pupil Reaction to Light: Motor Strength B=Brisk S=Sluggish N=Non-Reactive S=Strong M=Moderate W=Weak A=Absent 16.8 ADN12B Spring 2012 - Lower Extremity thigh Rxn / Size od os/ od os Upper Extremity knee Plantar B=Babinski Foot Cough shoulder Gag elbow Time Corneal Reflex hand Date Pupil Check ADN 12BL – Health Deviations 3 Laboratory SKILL LAB: Intradermal Skin Testing BEHAVIORAL OBJECTIVES: 1. Briefly describe the delayed-reaction allergic response (cell mediated hypersensitivity) of the skin. 2. List the diagnostic tests commonly performed by intradermal (ID) skin tests. 3. Discuss who is legally qualified to: a. Order diagnostic skin tests b. Place ordered intradermal skin tests c. Read diagnostic skin tests d. Interpret the results of diagnostic skin tests. 4. Describe and demonstrate the standard technique for intradermal placement of 0.1 ml of solution. a. Selection of needle and syringe b. Selection of site c. Preparation of skin d. Insertion with needle bevel up or needle bevel down. e. Angle and depth of needle insertion f. Injection of test solution and size of bleb in the skin g. State the actions to be taken if a bleb is not raised in the skin 5. List the instructions to the patient for care of the site. 6. Identify the Center of Disease Control and Prevention (CDC) specified time for test reading for TB skin tests. 7. Describe CDC method of reading TB skin tests if agency policy allows. CRITICAL ELEMENTS 1. 2. 3. 4. 5. Five rights are used in preparation and administration of intradermal test solution. Sterile technique is maintained during preparation and administration of test solution. Verbalization of need to raise a bleb of 6 to 10 mm with the ID injection Accurate instruction is provided for the patient. Verbalization of the time and method for accurate reading of a skin test. 17.0 ADN12B Spring 2012 HOW THIS SKILL WILL BE TAUGHT: 1. 2. 4. 3. Clarification of learning objectives in campus lab setting. Demonstration of techniques/procedures to meet the critical elements. Practice injection technique on injection arm. Student return demonstration of simulated ID injections on another student using 0.1 ml normal saline and syringe without a needle and return demonstration of actual injection using ID practice arm. HOW THIS SKILL WILL BE TESTED: 1. On campus laboratory situation as scheduled on weekly schedule. Return demonstration of an intradermal injection with 100% accuracy according to the critical elements. TEACHER RESPONSIBILITY: 1. 2. 3. 4. Clarify behavioral objectives. Demonstrate each step of the procedures Provide equipment for practice on ID practice arms. Provide equipment and supervise practice of students in simulated ID injection on another student and actual ID injection using practice arm or other teaching device. STUDENT RESPONSIBILITY: 1. Come to lab prepared to learn and practice intradermal injection technique. 2. Perform steps as directed by instructor in lab. 3. Simulate technique for ID injections on another student. Inject 0.1ml intradermally using ID practice arm or other teaching device. Verbalize correct actions if a 6-10 mm bleb was not raised. 4. Verbalize time and method of measuring skin test. ASSIGNMENT Potter, P.A., & Perry, A.G. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby Elsevier, Chapter 35. Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing. (12th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins, 1612-1613. 17.1 ADN12B Spring 2012 ADN 12BL - Health Deviations 3 Laboratory SKILL ASSESSMENT: INTRADERMAL INJECTIONS Student Name: Date: ______ Classroom Evaluator: ________________________________ CRITICAL ELEMENTS Pass Fail COMMENTS 1. Verify written order for PPD or other ID test 2. Use the five rights in administration of test. Maintain sterile technique in preparation and administration of intradermal test. 3. Use the correct technique for ID injection. Simulate injection on another student using syringe without needle. Inject test solution intradermally using ID practice arm or other teaching device. Verbalize the need to raise a bleb of 6 to 10 mm in the skin. Document on back of form the correct instructions to patient. Document time and method to read a PPD test including positive results on back of form. RETEST: Date:_________________________ Skills Evaluator:____________________________ 17.2 ADN12B Spring 2012 ADN 12BL- Health Deviations 3 Laboratory SKILL LAB: TRACHEOSTOMY BEHAVIORAL OBJECTIVES: 1. List the reasons why a tracheostomy is performed and maintained as the primary airway for some patients. 2. Identify and recognize types of tracheotomies including cuffed and fenestrated. 3. Identify and recognize the parts of a tracheotomy tube including inner/outer cannula, neck flange, cuff, inflating tube and pilot balloon, obturator, and fenestration cannula. 4. Review infection control procedures related to tracheostomies and their care. 5. Identify potential hazards of tracheotomies as well as preventive measures and correct nursing responses to untoward events such as tracheostomy occlusion or dislodgement. STUDENT RESPONSIBILITIES: 1. Come to lab–ready to discuss the behavioral objectives, identify and practice the critical elements, and having read the required textbook pages. 2. Demonstrate the ability using critical thinking skills to identify appropriate actions in the event of a problem with the tracheostomy. TEACHER RESPONSIBILITIES: Clarify and review behavioral objectives. ASSIGNMENT: Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing. (12th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins, 648-652, 673. 18.0 ADN12B Spring 2012 ADN 12BL – Health Deviations 3 Laboratory SKILL LAB: SUCTIONING NASALLY, ORALLY, OR BY TRACHEOSTOMY BEHAVIORAL OBJECTIVES: 1. Identify the clinical manifestations that indicate a need for suctioning the patient with a tracheostomy tube. 2. Describe the possible complications and infection transmission concerns related to suctioning. 3. List the equipment needed and the sequence of steps for nasally and orally suctioning a patient. 4. Demonstrate oral and nasal suctioning. 5. Describe the sequence of steps for suctioning the patient with a tracheostomy. 6. Demonstrate suctioning of the patient with a tracheostomy. 7. Identify care of the equipment following suctioning. 8. Identify items to be recorded and reported following suctioning. 9. Demonstrate safe and effective suctioning of the patient with a tracheostomy tube. CRITICAL ELEMENTS: 1. The patient’s airway will be cleared. 2. The patient’s oxygenation status will not deteriorate unnecessarily. PROCEDURAL ELEMENTS 1. Position the patient to facilitate removal of secretions. 2. Set correct pressure on suction source (-80 to 120 mm Hg). 3. Set up sterile equipment before connecting catheter to suction tubing. 4. Verify patency of suction catheter. 5. Apply suction continuously only when withdrawing catheter for a maximum of 10 seconds at a time. 6. Protect patient and self from contamination. STUDENT RESPONSIBILITIES: 1. Come to lab prepared to discuss the behavioral objectives and critical elements. 2. Practice procedure in lab and independently on own time asking for help as needed. TEACHER RESPONSIBILITIES: 1. In lab, demonstrate suctioning a patient with tracheostomy tube and be available for questions in lab. 2. Test according to critical elements in campus lab. ASSIGNMENTS: Potter, P.A., & Perry, A.G. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby Elsevier, 931-950. Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins, 648-652; 673. 18.1 ADN12B Spring 2012 ADN 12BL- Health Deviations 3 Laboratory SKILL LAB: TRACHEOSTOMY CARE BEHAVIORAL OBJECTIVES – NURSING PROCESS APPLICATION: 1. Assessment a. Define what is meant by the term ‘tracheostomy care’. b. Identify the standard frequency as well as physical findings and behaviors in patients that indicate the need for tracheostomy care. c. Identify and list all the equipment necessary to perform tracheostomy care at the bedside. 2. Planning a. Review Standard Precautions and the tracheostomy care implementation section; identify nursing skills and techniques necessary to protect both the patient and nurse from possible contamination. b. Explain the rationale for suctioning the patient before tracheostomy care. 3. Implementation a. Suction patient unless trachea is clear. b. Open tracheostomy cleaning tray using aseptic technique. c. Pour hydrogen peroxide and NS into one compartment of the tray and NS in the other. d. Put on sterile gloves provided in the kit. e. Remove inner cannula and discard if cannula is disposable. f. If inner cannula is not disposable, place the cannula in the hydrogen peroxide/ NS chamber. Using the small brush and gauze that are in the tray, clean the inner cannula. g. Rinse the inner cannula in normal saline. h. Reinsert the new or cleaned inner cannula into the outer cannula locking it in place. i. Remove the tracheostomy dressing. j. Cleanse stoma and tracheostomy area with cotton swabs moistened with normal saline. k. Place a fresh tracheostomy dressing while stabilizing the cannula and cuff. l. If the tracheostomy ties are soiled replace them in a safe manner. m. Empty the solutions and throw away the tray, remove gloves, and wash hands. 4. Evaluation a. Identify and describe expected outcomes for tracheostomy care including the following: i. Patient remains ventilated, without respiratory distress ii. Secretions continue to be easily suctioned iii. Tracheostomy site remains free from infection. CRITICAL ELEMENTS: 1. The patient’s airway is not compromised. 2. Cleanliness is maintained surrounding the tracheostomy stoma. 18.2 ADN12B Spring 2012 STUDENT RESPONSIBILITIES: 1. Come to lab ready to discuss the behavioral objectives, identify and practice the critical elements, and having read the required textbook pages. 2. Perform critical and procedural element steps during practice sessions, seeking assistance as needed. 3. During skill testing be able to perform tracheostomy care with 100% accuracy per the critical elements. TEACHER RESPONSIBILITIES: 1. Clarify and review behavioral objectives. 2. Demonstrate the steps/critical elements of tracheostomy care. 3. Provide tracheostomy care supplies and observe students during practice session, assisting prn. ASSIGNMENT: Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins, 648-650. SKILL TESTING: Will be tested in on-campus laboratory, on date indicated on schedule. 18.3 ADN12B Spring 2012 ADN 12BL – Health Deviations 3 Laboratory Skill Assessment: SUCTIONING A PATIENT WITH A TRACHEOSTOMY TUBE Name: _________________________________ Date _________________________ Classroom Evaluator: ___________________________________ CRITICAL ELEMENTS Pass Fail Comment 1. The patient’s airway was cleared 2. The patient’s oxygenation status did not deteriorate. PROCEDURAL ELEMENTS 1. Set correct pressure on suction source 2. Set up sterile equipment before connecting catheter to suction tubing 3. Verify patency of suction catheter 4. Apply suction continuously only when withdrawing catheter no more than 10 seconds at a time 5. Protect patient and self from contamination 6. Complete procedure within 5 minutes. RETEST: Date: ______________________ Skills Evaluator: ______________________________ 18.4 ADN12B Spring 2012 ADN 12BL – Health Deviations 3 Laboratory SKILL ASSESSMENT: TRACHEOSTOMY CARE Name_______________________________________________ Date______________ Evaluator____________________________________________ CRITICAL ELEMENTS Pass 6. The patient’s airway is not compromised. Cleanliness is maintained surrounding the tracheostomy stoma. PROCEDURAL ELEMENTS Suction the patient if needed before cleaning the inner cannula Set up sterile tracheostomy cleaning materials before beginning procedure. Apply sterile gloves without contamination. Remove inner cannula while steadying outer cannula plate. Discard disposable inner cannula, or clean and rinse thoroughly before replacing it. Replace inner cannula while steadying outer cannula. 7. Remove soiled tracheostomy dressing. 1. 2. 1. 2. 3. 4. 5. Fail Comments 8. Cleanse stoma and tracheostomy area; replace tracheostomy dressing. 9. If indicated, change ties. Verbalize safe procedure for changing tracheostomy ties. 10 Practice standard precautions throughout the procedure. RETEST: Date:_____________________ Skills Evaluator:________________________________ 18.5 ADN12B Spring 2012 LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL Health Deviations 3 Laboratory SKILL LAB: INTRAVENOUS THERAPY-ADVANCED MANAGEMENT OF INTRAVENOUS FLUID VOLUME REPLACEMENT LEARNING OBJECTIVES 1. Analyze clinical situations when the ordered fluid volume may be behind or ahead of schedule and determine flow rates to get back on schedule. 2. Discuss patient health deviations and needs that should be considered when deciding to make up missed intravenous fluid intake. 3. Discuss how IV therapy is included in Intake and Output for the shift. HOW THESE SKILLS WILL BE LEARNED 1. Discuss and clarify learning objectives in scheduled lab. 2. Practice placing time lines and setting IV rates in campus lab 3. Practice analyzing the situations and calculation problems on the worksheets 4. Record complicated intake and output totals on the IV Credit Problems/Exercise STUDENT RESPONSIBILITIES: 1. Come to lab ready to discuss the behavioral objectives, identify and practice the critical elements, and having read the required textbook pages. 2. Review ADN 12 AL Parental Infusion Guidelines and Critical elements for maintaining intravenous therapy. TEACHER RESPONSIBILITIES: 1. Clarify and review behavioral objectives. ASSIGNMENT: Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins, 303-310. SKILL TESTING: Math computation skills will be tested on the ADN 21B/BL quizzes and exams. Managing IV therapy will be assessed for satisfactory performance in the clinical setting. 19.0 ADN12B Spring 2012 WORKSHEET FOR INTRAVENOUS THERAPY – PART I IV CREDIT PROBLEMS/EXERCISE CALCULATE IV CREDIT FOR THE IV’S LISTED BELOW: 1. The night shift RN hung a 1000cc bag of 5%D/W at 1:00 a.m. which infused at 100cc per hour. At 6:00 am the night shift RN recorded ml IV intake on the I and O sheet. Credit for the 7-3 shift is ml. 2. The night shift RN hung a 1000cc bag of 5%D/NS at 12 midnight. The IV infused at 80cc/hour. At 6:00 am the night shift RN recorded ml IV intake on the night shift I and O sheet. Credit for the 7-3 shift is ml. 3. The night shift RN hung a 1000cc bag of 5%D/NS at 12 midnight. The IV infused at 50cc/hour. At 5:00 a.m. the physician ordered the IV rate increased to 75cc per hour and the RN made this adjustment. At 6:00 am the night shift RN recorded ml IV intake on the night shift I and O sheet. Credit for the 7-3 shift is ml. 4. At the beginning of the day shift you note that your patient has an IV of D5W to run at 100 cc/hour. At 6:00 a.m. the night shift RN gave the day shift an IV credit of 300cc of 5D/W. At 9:00 am a bag of 1000cc of 5%D/NS was hung to infuse at 75cc/hour. The IV infused all shift without any interruptions. Record the day shift intake (at 1400) for both IV fluids. a. IV Intake: 1. Ml 5D/W. 2. ml 5D/NS. b. Credit for 3-11 shift is ml 5D/NS. I N T A K E 5. Record the IV intake from problem #4 for the day shift on the record below: D E N 24 hour D E N 24 hour Oral Tube Feeding IV IV IV Blood/Blood Products O U T P U T TOTALS Urine Emesis Gastric Other Feces Liquid/Formed TOTALS 19.1 ADN12B Spring 2012 6. At the beginning of the day shift you note that your patient has an IV of D5½NS to run at 90 cc/hour. At 6:00 a.m. the night nurse gave the day shift an IV credit was 800cc of D5½NS. At 8:00 am this IV was turned off and 250cc of packed cells were infused over 2 hours. At 10:00 a.m. 500cc of Hespan was given over 1 hour. At 11:00 am the IV of D5½NS was increased to infuse at 125cc/hour. Complete the IV intake for 7a-3p shift: a. ml D5½NS. b. ml Packed Red cells. c. ml Hespan. d. Credit for the 3-11 shift is ml of D5½NS 7. Record the intake from problem # 6 on the record below. D I N T A K E O U T P U T E N 24 hour Oral Tube Feeding IV IV IV Blood/Blood Products TOTALS Urine Emesis Gastric Other Feces Liquid/Formed TOTALS ANSWERS: 1.Night shift recorded 500 ml credit for 7-3 500 ml 2. Night shift recorded 480 ml credit for 7-3 520 ml. 3. Night shift recorded 325 ml credit for 7-3 675 ml. 4. a. 1. 300 ml. 5 D/W 2. 375 ml. 5 D/NS b. 625 ml 5. IV D5W IV D5NS 6. IV D5½NS IV Hespan Packed Red cells 6. d.245 cc credit of D5½NS D 300 375 D 555 500 250 19.2 ADN12B Spring 2012 D E N 24 hour LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL Health Deviations 3 Laboratory SKILL LAB: IV Drip Calculations LEARNING OBJECTIVES 1. Describe reasons for medications to be given by IV drip. 2. Discuss the hazards associated with continuous IV drip medication. 3. For each of the listed medications, describe the desired medication effects, side effects, and hazards and identify the unit dose per unit of time that the drug is given in. Heparin Magnesium Sulfate Regular Insulin Pitocin 4. Given a dose of IV drip medication in a quantity of IV fluids, calculate the ml per hour rate required to administer a specified dose of medication. 5. Be prepared to calculate the dose of IV medication infusing in the clinical area and on tests. HOW THESE SKILLS WILL BE LEARNED 1. Discuss and clarify learning objectives in the scheduled lab. 2. Use practice problems to validate skill acquisition. 3. Prepare to demonstrate learning on tests and in the clinical area. STUDENT RESPONSIBILITIES: 1. Come to lab ready to discuss the behavioral objectives, identify and practice the critical elements, and having read the required textbook pages. 2. Review ADN 12 AL Parental Infusion Guidelines and Critical elements for maintaining intravenous therapy. TEACHER RESPONSIBILITIES: 1. Clarify and review behavioral objectives. ASSIGNMENT: Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins, 303-310. SKILL TESTING: Math computation skills will be tested on the ADN 21B/BL quizzes and exams. Be prepared to calculate the dose of IV medication infusing in the clinical area 19.3 ADN12B Spring 2012 LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL Health Deviations 3 Laboratory IV Drip Calculation Worksheet PROCEDURE: 1. Identify the unit and time measure of the drug to be given. Ex: Heparin is given in units per hour. 2. Given an ordered dose of medication to be given by IV drip and a quantity of drug in an IV bag, use D/H x Q to calculate the Ml/hour rate needed to deliver the ordered dose. Ex: Your patient is to receive 250 units per hour of Heparin. The pharmacy sends a bag labeled Heparin 25,000 units in 500 Ml D5W. What is the Ml/hour rate required to infuse the Heparin at the desired dose? Desired: 250 units On Hand: 25,000 units Quantity: 500 Ml 250/25,000 x 500 = 5 Ml/ hour 3. Given a quantity of drug in an IV bag, and a Ml/hour rate of drug infusion, calculate the amount of medication that the patient is receiving per hour. Ex: Your patient has an IV bag hanging labeled Heparin 25,000 units in 500 Ml. The IV pump is set to run at 20 Ml/hour. What dose of Heparin is the patient receiving? Desired: X units On Hand: 25,000 units Quantity: 500 Ml Ml/ hour rate: 20 Ml/hour X/25,000 x 500 = 20 Cancel out: X/50 = 20 X = 1000 The patient is receiving 1000 units per hour of Heparin Practice Questions: 1. The patient is to receive an IV drip of Regular Insulin at 2 u/ hour. The bag hanging is Regular Insulin 100 units in 100 cc. What rate should the pump be set for? 2. The nurse needs to administer 1200 U/hr of Heparin. The label states there are 25,000 U/500 ml of fluid. Calculate the rate for the IV pump. 3. At the beginning of the shift, the nurse notes that Theophylline 1gm/ 500ml is infusing at 20 ml/hr. The order is for Theophylline at 60 mg/hr. Is the rate correct? 19.4 ADN12B Spring 2012 Key to Practice Questions: 1. 2 mL/hour 2. 24 mL/hour 3. No, the pump should be set at 30 mL/hour 19.5 ADN12B Spring 2012 ADN 12BL – Health Deviations 3 Laboratory SKILL LAB: PHYSICAL ASSESSMENT OF THE DEPENDENT PATIENT BEHAVIORAL OBJECTIVES: 1. Independently review previously learned physical assessment skills. a. Baseline assessment taught in preparation for long-term care facility in ADN 11AL. b. Exam of the Lower Extremities in ADN 11BL c. Assessment of thorax and lungs in ADN 11BL d. Exam of the abdomen in ADN 11BL e. Cardiovascular assessment in ADN 12AL f. Neurological assessment in ADN 12BL 2. Discuss variations in techniques that may be necessary or useful in ill patients who are resting in bed. 3. Discuss sequencing of physical assessment techniques for facilitating an efficient and accurate basic nursing assessment, such as required for admission to a nursing inpatient unit. 4. Discuss the process of assessment of all body regions to determine important areas for hygiene care. CRITICAL ELEMENTS: 1. Abnormalities and normal variations in the basic clinical findings of the patient will be accurately identified 2. The clinical findings will be accurately recorded on the ADN 12AL Nursing Care Worksheet. 3. The patient will remain comfortable during the examination. PROCEDURAL ELEMENTS 1. Position patient (student) in bed, moving patient no more than necessary to perform an accurate assessment. 2. Following a pre-determined sequence, correctly carry out all physical assessment procedures previously learned. 3. Complete all relevant portions of the assessment column of the ADN 12AL Nursing Care Plan, using terminology according to ADN 12AL guidelines. 4. Complete the above tasks in 15 minutes or less. 20.0 ADN12B Spring 2012 STUDENT RESPONSIBILITIES 1. Come to lab prepared to function as both a nurse and a patient. Bring a stethoscope and BP cuff and dress appropriately to facilitate a physical examination. 2. Practice previously learned techniques if necessary. Develop a systematic sequence to follow. Request assistance as needed. TEACHER RESPONSIBILITIES 1. Clarify behavioral objectives and critical elements. 2. Demonstrate a procedure to meet the critical elements. 3. Test students according to critical elements in scheduled campus lab. ASSIGNMENTS: 1. Potter, P.A., & Perry, A.G. (2009). Fundamentals of Nursing (7th ed.). St. Louis, MO: Mosby Elsevier, 854-862. 2. Giddens, J.F. (2007). A survey of physical assessment techniques performed by RNs: Lessons for nursing education. Journal of Nursing Education, 46, 83-87. 3. Review previously assigned textbook materials regarding physical assessment. 4. Review course study guides from ADN 11A, 11BL and 12AL for relevant information. 5. Review videos in learning center if needed: selected portions of video: Head to Toe Assessment. Written and filmed by LBCC faculty. HOW THIS PROCEDURE WILL BE TESTED During scheduled campus lab, the student will demonstrate a complete basic nursing physical assessment according to critical elements with 100% accuracy. 20.1 ADN12B Spring 2012 ADN 12BL – Health Deviations 3 Laboratory SKILL ASSESSMENT: PHYSICAL ASSESSMENT OF THE DEPENDENT PATIENT Student Name_________________________________________ Date______________ Student Signature: _____________________________________ Evaluator____________________________________________ CRITICAL ELEMENTS Pass Fail Comments 1. Performs examination in pre-determined sequence to include maneuvers that will complete the basic nursing assessment and identify abnormalities and normal variations of clinical findings of the patient. 2. Documents clinical findings accurately on the Nursing Care Worksheet. 3. The patient remains comfortable during the examination. PROCEDURAL ELEMENTS: 1. Position patient as if on bed rest. Move patient only as necessary to perform assessment. 2. Assesses mucous membranes of mouth. 3. Complete a neurovascular assessment. 4. For cardiac assessment, listens over all four valvular areas. 5. For thorax assessment listens over several areas of the anterior and posterior lung fields. 6. For abdominal assessment listens in all four quadrants and lightly palpates for tenderness. 7. For musculoskeletal assessment, checks muscle strength in all four extremities. 8. For lower extremities, checks bilaterally: (a) pedal pulses and (b) ankle and pre-tibial edema 9. For skin assessment, views posterior as well as anterior portions of the body. Assess for hygiene needs. 10. Records findings in appropriate areas of Nursing Care Worksheet. 11. Completes the basic nursing assessment within 15 minutes. RETEST: Date:_______________________ Skills Evaluator:________________________________ 20.2 ADN12B Spring 2012 Associate Degree Nursing Program Nursing Care Worksheet for ADN 12BL – Health Deviations 3 Laboratory Student _________________________ Physical and Functional Assessment Mental & Psychosocial Assessment Cardiorespiratory Assessment GI, Metabolic Assessment GU, Fluid and Electrolyte Assessment MS, Integument & Comfort Assessment 20.3 ADN12B Spring 2012 CASE STUDY ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL – Health Deviations 3 Laboratory GUIDELINES AND FORMAT FOR CASE STUDY A. Policy for written work in the nursing program: 1. Eight and a half by eleven standard size white paper is to be used for all written assignments. 2. All written assignments are to be typed or written legibly in ink on one side of the paper only. 3. The following format is to be used for all written work. a. Title on the first page with student’s name, date and clinical instructor’s name in the center of the page. b. All pages are to be numbered (including the title page) c. The text of the paper is to be double-spaced. d. Assignments of more than one page must be stapled together. The average length of the case study for second semester should be 8-10 pages. e. Each section of the case study is to be identified by a heading. f. References should be cited throughout the paper. 4. Documentation style must be APA (American Psychological Association) except where otherwise directed by these guidelines (see Information on APA Style). B. Select one of your assigned patients to present in the case study. Discuss the selection with your clinical teacher during the hospital day. The selected patient must be approved by your clinical teacher. C. The case study will be submitted in writing to your clinical instructor and will be presented orally to your clinical group on an assigned day. A visual aid must be used for your presentation. See your clinical instructor for suggestions. D. Format for the case study Basic conditioning factors Include all information from the top of the nursing care worksheet. Be sure to include the developmental level on a separate paragraph. Define the developmental level. Provide a rationale for why the patient has achieved or failed to achieve resolution of the appropriate Erickson’s developmental level using the definition of the developmental level. Remember to cite information. Anatomy and Physiology of the involved organs Include a brief statement about the structure and function of each of the involved organs. Include anatomy so it is easier to explain the patient’s pathology. This section is not to be copied verbatim from a textbook but is to be paraphrased, in your own words, from knowledge gained from biology and nursing textbooks. It is considered plagiarism if copied verbatim. Remember to cite all of your material. 21.0 ADN12B Spring 2012 Pathophysiology This section must include general information including statistics regarding the incidence (how many patients have this condition/year) of the condition, predisposing and/or precipitating factors, and the most common causes of the selected pathophysiology. Describe what went wrong for this particular patient, the cause (if known), and any signs and symptoms that your patient exhibited. Briefly describe any surgical or procedures that were performed. Remember to cite all material. Medical Orders List the orders in effect for this patient (when you were assigned to that patient). 1. Activity, diet, IV fluid replacement, drains, etc., as the MD wrote the orders. 2. List all medications as the MD wrote: drug, dose, frequency, and route. Add the expected therapeutic effect upon this particular patient. 3. List the results of the major diagnostic tests/procedures, including labs tests and state how they contributed to the diagnosis. Health Deviations (Two parts) Balance Between Solitude and Social Interaction 1. For each category of the Universal Self-Care Requisites, describe the patient’s health deviations that were caused by the illness (from the patient’s diagnosis). 2. For each category of the Universal Self-Care Requisites, describe the patient’s health deviations that were brought on by diagnostic tests and treatments. Nursing Diagnosis Identify the PRIORITY nursing diagnoses (one) and the PRIORITY collaborative problem (one) with specific goals and interventions. Attach your nursing care plan that you wrote for this patient on the assigned day. If your nursing care plan was unsatisfactory, redo the nursing care plan. Attach both nursing care plans with your paper. References Include a list of references, with publication dates within 5 years. Use APA style. Include and attach a copy of a RESEARCH NURSING article that relates to the patient’s problems and was helpful in writing this case study. Use the Cumulative Index of Nursing and Allied Health Literature (CINAHL) in the college library or one of the health data bases to help you find appropriate articles. Proquest is an excellent data base. There is a Proquest tutorial link on the website at: http://nursing.lbcc.edu/ This may assist your search in finding an appropriate journal article. The article should be from a refereed journal. Articles that cite nursing research are preferred. Refereed journal means that all articles are reviewed by peers before publication. The article MUST be referenced in the body of your paper at least once. Give a short synopsis of the article in the body of your paper and state how this article relates to your topic. 21.1 ADN12B Spring 2012 Recommended: Visit the LAC LBCC library. The library has health care databases, with many health care journal articles that are in full text on the database. For students who have Internet access at home, the databases may be searched externally. Below is the link to a Proquest tutorial that will help to narrow the search for appropriate articles (courtesy of Karen Vogel, LBCC Librarian). The tutorial may also be found on the internet at the LBCC RN homepage. http://nursing.lbcc.edu/ProQuest%20Tutorial%20Nursing.htm 21.2 ADN12B Spring 2012 LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL – Health Deviations 3 Laboratory INFORMATION ON APA STYLE The American Psychological Association (APA) style of documentation differs from the Modern Language Association (MLA) style taught in the English composition courses at LBCC in English 1 and higher courses. The APA style, commonly used by the discipline of nursing, emphasizes the date of publication. Sources more than five years old are considered outdated, although there may be older sources with historical value (classics). APA maintains a Web site where up-to-date information is provided at: www.apastyle.org 21.3 ADN12B Spring 2012 Long Beach Community College District LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL – Health Deviations 3 Laboratory GRADING CRITERIA FOR CASE STUDY Attach this page to the back of your case study. Student Name __________________________________Date______________________ Correct ITEM TO BE EVALUATED Assignment typed in black ink on one side of 8 1/2” by 11” white paper. 2. Page formatting is according to APA 6th edition. Student’s name, date, and clinical instructor’s name is centered on the title page. Pages are numbered and bound together. Each section of the case study is identified by heading. 3. The format and content are college level. Documentation style is APA 6th edition. Paragraphs are organized and logical. Sentences are complete and grammatically correct. Style is appropriate for a documented essay. Spelling is correct. All content taken from sources is referenced and paraphrased or correctly quoted. 4. The patient selected was approved by the clinical teacher. 5. A visual aid was utilized in the oral presentation. 6. Basic Conditioning Factors included all information. 7. The rationale for the selected Erikson’s developmental level was reasonable, defined and supported with evidence. 8. Anatomy and physiology (structure & function) of the involved organ is complete and accurate. 9. Pathophysiology of the patient’s health deviations is correct. Statistics regarding incidence are given. Predisposing and/or precipitating factors are listed. Most common causes are identified. Source of the information is correctly cited. 21.4 ADN12B Spring 2012 Not Correct Comments Correct ITEM TO BE EVALUATED 10. Pathophysiology of the selected patient is complete. Possible causes for the disease in this patient are given. The disease process is discussed (correlate the theory with your patient) Diagnostic test results including laboratory studies related to the disease are given. Interpretations are given. 11. Medical orders in effect are listed: Medications are listed along with expected therapeutic effect and nursing responsibilities are discussed and supported. Medical treatments and the patient’s response to those treatments are included. 12. Health Deviations are listed according to Universal Self-Care Requisite categories and are described according to: 1. Health Deviations brought on by illness are identified accurately 2. Health Deviations brought on by diagnostic tests and treatments. 13. Nursing Diagnoses are listed and PRIORITY. Nursing Diagnoses accurately reflect patient needs. Collaborative problems are included and are accurate. Goals are specific for the patient and the nursing diagnosis or collaborative problem. Interventions are specific for the patient and the nursing diagnosis or collaborative problem addressed. 14. The satisfactory Nursing Care Plan is attached. 15. A copy of a nursing research article is attached. The article was approved by the clinical instructor. This article is used in the case study and is correctly referenced. The article was cited once in the body of the paper (give a synopsis of the article and state how it relates to the paper) 16. The list of references is included. 21.5 ADN12B Spring 2012 Not Correct Comments GENERAL INFORMATION FOR CLINICAL ADN12B Spring 2012 LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL - Health Deviations 3 Laboratory CLINICAL PRACTICE EXPERIENCES IN ADN 12BL Clinical Practice Your clinical practice in this course will be in medical nursing units in an acute care medical center. You will be working with patients who have, in addition to any chronic illnesses, acute illnesses that are commonly treated by advanced medical interventions that require twentyfour hour nursing services. Medical patients may be combined with surgical patients on some medical/surgical floors. The laboratory course time is 10 hours a week, the same as in ADN 12AL. The laboratory time is divided into a single 8-hour clinical day and a 2-hour campus lab. You will continue to monitor and add IV fluids to existing intravenous access catheters. In local acute care hospitals all intravenous fluids and medications are administered by registered nurses. By California regulations, only registered nurses may give ordered intravenous medications by IV push. In every case the nurse administering intravenous medications does so following agency policies. You must read and follow the LBCC policies regarding IVs that are provided in the campus laboratory material. You will also be assigned to be a group leader at some point during the rotation. In this role, you will be supervising a group of students. In addition you will also be assigned one or more days off the nursing unit to observe/participate in special procedure areas where nurses play a vital role in monitoring and maintaining the health and safety of the patient. Follow the guidelines in the course study guide for these learning assignments. The Team Member student must prepare ADN 12BL Nursing Care Plans on all of his or her assigned patients each week. The completed Nursing Care Plan is to be submitted to your clinical instructor during the clinical day. The time of submission of the care plan will be arranged with your individual instructor. The goal for the semester is to complete all care plans and have them turned in within two hours of the beginning of the shift. You are expected to do preliminary work on the Nursing Care Plan at home after choosing your patient in the clinical facility. The care plan must be completed with all ordered treatments and medications, whether or not you carried out the nursing activities. If you are ill or unable to attend clinical, you must notify the instructor and if you have posted an assignment, the floor on which you are assigned. Failure to notify both the instructor and the assigned floor may result in a progress note. Your instructor may ask that you make up the assigned day by coming in for another clinical day or by completing a written assignment. 22.0 ADN12B Spring 2012 Written Work 1. Each clinical day as Team Member: a. Before arrival on the unit, have the names of medication to be given by you, along with the nursing responsibilities, written on the Drug Therapy Worksheet. The nursing responsibilities of any new medications to be given will be looked up before giving the medication. b. Early in the shift, by 0800, have your initial assessment and vital signs completed on all of your patients and be prepared to discuss the patient’s assessment, orders including medications, laboratory data, and your plan for the day. Complete the assessment portion of your Nursing Care Plan. Vital signs are to be charted in the patient’s chart immediately after completing them. c. Have the assessment in the patient’s chart completed by 0900. d. The DAR notes that are to be charted on each of your patients are due by 1130 so that they can be checked by your instructor. e. Nursing Care Plans are to be completed and turned in to the instructor during your shift. The Nursing Care Plan is intended to be a plan of care for the day therefore they are to be completed early in the shift at a time designated by your instructor. Group leaders will collect the care plans and begin reviewing them before the instructor begins grading them. 2. Each clinical day as Group Leader: a. Complete observational rounds on each assigned patient and have the completed “Patient Information Worksheet for Group Leader” ready to review with your instructor by 0800. b. Complete the medication times grid on the “Medication Information Worksheet for Group Leader” including all members of your team by 0800. Your instructor will need this information to properly supervise the students. c. Complete a brief evaluation of each student addressing strengths and areas needing improvement. Review this evaluation with each of the group members. 5. When assigned to an observational experience, complete an ambulatory care experience assignment and turn in to your instructor on Friday. 22.1 ADN12B Spring 2012 LONG BEACH CITY COLLEGE School of Health and Science Associate Degree Nursing Program ADN 12BL Health Deviations 3 Laboratory CLINICAL ORIENTATION DAY BEHAVIORAL OBJECTIVES: Bring the “Self-Orientation to Nursing Unit,” this page and your entire clinical manual with you on the hospital orientation day. During your assigned clinical orientation day: 1. Complete a “Self –Orientation to a Nursing Unit” by identifying: a. The physical arrangement of the clinical area. b. The names and roles of staff members. c. The location of emergency equipment: CPR cart and fire equipment. d. The usual times for daily activities. e. The agency medication procedure and legal checks. f. The types and location of various sections of the patient chart. g. Forms on chart and elsewhere which must be completed as part of patient care. h. Documentation procedures used at the assigned agency. 2. Provide nursing care for patient as assigned. 3. Document in the agency flow sheets, following agency policy. 4. Identify the various ethnic minorities and socioeconomic groups served by this clinical agency. 5. Discuss the health care need of at least two of the identified ethnic minorities and/or socioeconomic groups. 6. Discuss how the health care agency works to meet the identified health care needs of the identified ethnic minorities and/or socioeconomic groups. 23.0 ADN12B Spring 2012 Long Beach City College Associate Degree Nursing Program Self-Orientation to a Nursing Unit Student Name: Agency: You will be assigned to many different nursing units during your educational program. It is important that you develop the ability to assess a unit and its routines rapidly. The following form gives a format for self-orientation and is to be completed on your hospital orientation day. Your clinical instructor will give you additional directions as necessary. Share information with each other. Go about the orientation quietly, to keep confusion to a minimum. Ask staff for clarification only after you have exhausted all other sources. Any further questions will be clarified in conference. I. General A. What is the usual daily routine? 1. Change of shift report time AM Place Who listens to this report? 2. Patient meal times: Breakfast PM Lunch Who passes out trays? 3. Routine vital signs times 4. Conference time Place B. Where are the Nursing Policy and Procedures manuals? C. When are visiting hours? D. List name and title of four staff members on the unit today: _____________________________ _____________________________ ______________________________ ______________________________ E. Identify room numbers in the corridors. Locate sterile supply room, linen and utility rooms, medication rooms, medication room (cart), unit pharmacy. 23.1 ADN12B Spring 2012 II. Communication A. Where is the daily staff assignment sheet posted? Who makes this out? When Where is student assignment sheet posted? B. How do you know which patients are NPO? C. How and who would you notify if you were going to be tardy or absent? D. Investigate the floor’s call light system. How do you turn off the patient call light? ________________ III. Safety A. Where is the crash cart located? Who is responsible for checking the cart? How often? B. Where are the fire extinguishers? Fire Hoses? C. What do you do when a fire code is announced? D. How do you initiate an emergency CPR event? E. How is an emergency CPR event announced? F. What is your responsibility as a student in an emergency CPR event (code)? IV. Medication A. Identify the medication record and the correct method of charting medications as given or not given. ______________________________________________________________ B. Where are medications including refrigerated IVPBs kept? ______________________________________________________________________________ C. How is the medication record checked with the medical orders? __________________________________________________________________ 23.2 ADN12B Spring 2012 D. How do you obtain a missing oral or parenteral medication? __________________________________________________________________ E. Where are the IV fluid bags stored? _____________________________________ Where are the IVPB and other IV medication kept? ________________________ What kind of needleless system is used? _________________________________ F. Where are narcotics kept? _____________________________ If there is a key, who carries it? How are narcotics signed out? __________________ ______________________________ H. How are you notified of a change and/or new medication order? __________________________________________ V. Patient Care A. You are to take vital signs. What type of thermometer is used? Where is it located? lubricant? Where is rectal thermometer? BP Cuff scales? stethoscope Where is the TPR recorded? ____________________ B. You are preparing to give AM care. There is no equipment in the room. Where would you find the following? clean linen dirty linen receptacle soap bedpan wash basin water pitcher sterile urine specimen bottle ________________ denture cup _____________ C. You are to insert a Foley catheter. Where would you find the following? Sterile cath tray extra catheter extra sterile gloves drainage bag How is the patient charged for what is used? flash light _____________ D. You are going to change a dressing. Where are the supplies such as tape, 4x4’s? etc.? ADN12B Spring 2012 How do you charge for what is used? 23.3 E. An IV is to be started. Where are supplies stored? IV Solutions IV pole tubing IV catheter ____ pumps _____________________ F. What does AM Care mean? G. Where do you put full soiled linen bags? H. Where do you put items to be returned for cleaning and sterilization? VI. Paper Work A. What kind of time is used? B. Where do you chart voiding? Meals BM __________________________________________________ C. Who charts vital signs on the flow sheet? When __________________________________ D. What type of nursing notes are done and where are they charted? (format) __________________________________________ _____ E. Where are the bedside I & O worksheets kept? F. When is the end of shift I & O totaled? Where is it recorded? ___________________________________ Who is responsible for totaling the I & O G. How are nurses notified of new orders? Where and how are charts with new orders handled? ______ ____________ ______ VII. Patient Population A. Identify the two most populous ethnic minorities or socio-economic groups served by the agency. 1. 2. 23.4 ADN12B Spring 2012 B. Discuss how the health care needs of these identified groups may be different from those of the majority or affluent members of our society. 1. 2. C. Discuss how the agency works to meet the needs of these identified groups. 1. 2. 23.5 ADN12B Spring 2012 Long Beach Community College LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL - Health Deviations 3 Laboratory GUIDELINES FOR SELECTION OF PATIENT ASSIGNMENTS 1. Independently review these guidelines prior to planning the clinical day. Communicate with other members of the student team to coordinate the selection of patients. The staff nurses will appreciate your helping each other by relaying information rather than asking the nurses the same question several times. 2. Avoid going to the hospital at change of shift time. 3. Go to the nursing unit in business-type clothing or navy blue scrubs with your white uniform jacket, including patch and name pin. Casual dress, such as open-toed shoes and blue jeans, are not appropriate attire. Bring all the needed worksheets and some extra paper. 4. Upon arrival at the nursing unit look for a student assignment sheet to determine if patients have already been selected. If you are the first student to be selecting patients, post a Student Assignments form on which you will post your assignments. 5. Review the patients on the unit for acuity, number of IVs, and complexity by reviewing charts or the computer and by asking staff on the unit. The nurses may know whether patients will likely to be going home before your assigned day. 6. You may introduce yourself to your assigned patients. 7. Post your patient selection by room number and patient’s name on the “LBCC Nursing Student Assignment” form and post in the designated area only. 24.0 ADN12B Spring 2012 LONG BEACH CITY COLLEGE School of Math, Health and Science Associate Degree Nursing Program- ADN12BL Health Deviations 3 STUDENT ASSIGNMENTS Nursing Unit _______________________ Instructor: __________________________ Cell # __________________ Day and Date:________________________ Time on unit:____________ STUDENT ASSIGNMENT Bed # and Pt’s Initials Group/Team Leader Member Member Member Member Member Member Member Member Off the ward Location Comments: 25.0 ADN12B Spring 2012 Assigned RN/Lunch Time Long Beach Community College LONG BEACH CITY COLLEGE Associate Degree Nursing Program ADN 12BL - Health Deviations 3 Laboratory BEHAVIORAL OBJECTIVES FOR GROUP LEADER A. Demonstrate increasing competency in the role of nurse manager of care by: 1. Assuming responsibility of selecting or arranging with the student group members to select patients for the next day’s clinical experiences as directed by written guidelines and the instructor’s verbal instructions. 2. Performing the role of the group leader according to the written guidelines and the verbal instructions of the clinical instructor. 3. Demonstrating increasing ability of how to prioritize nursing care for a group of patients/patients. 4. Demonstrating increasing effectiveness of communication and work skills needed to lead a work group. B. Specific behavioral objectives for the clinical day: 1. Under the direction of the instructor and the staff registered nurses, serve as a student group leader on the day shift. 2. With the assistance of the registered nurse team leader, assume professional nursing responsibility for the group of patients assigned to the student group members. 3. Serve as a liaison for the nursing instructor. GUIDELINES FOR GROUP LEADER Group Leader Preparation Several days before the scheduled clinical experience 1. Independently review these behavioral objectives and guidelines for the group leader role. 2. Prepare a five-minute presentation on a topic pertinent to the course that you believe will be new information for the other students. Please have the topic approved by your clinical instructor prior to the clinical day. You will present the short topic during clinical conference. 26.0 ADN12B Spring 2012 Before the scheduled clinical experience 1. Contact the other members of your student group and obtain the room numbers, names, and diagnoses of assigned patients. 2. Prepare a tag to add to your name pin: “GROUP LEADER.” The day before the scheduled clinical experience 1. After exchanging information with all group members, prepare a 12BL “Patient Information Worksheet for Group Leader”. Include all of the patients assigned to the student group. Prepare this in pencil. 2. Prepare the “Medication Worksheet Information for Group Leader” for each assigned patient. Write in the medications to be given in the correct hour box, using only one line for each patient. When completed, this will give you a grid of patients, times, and medications to be given including IV medications. 3. Remember to prepare for the clinical day by gathering the information needed to care for the patients assigned to your group. This information includes reviewing or researching the pathology and nursing care associated with the various medical diagnoses, surgical procedures, and prescribed therapies. Before the shift begins 1. Wear your group leader tag identifying yourself as the student group leader. 2. Verify that all of the patients assigned yesterday are still there. Verify that no students have called in sick or tardy. 3. Make sure the up-to-date student assignment is posted in the correct area. Initial beside your name to indicate you are on duty. 4. When staff assignments have been made, write the name of the staff person co-assigned with each student on your worksheet. C. During the morning 1. Remind students to listen to report on their patients. Coordinate efforts to fill in for each other for the change of shift report. If report is delayed, begin your “Quick Look” rounds. 2. Listen to report on the patient assigned to your group. Listen to report on as many patients as possible to obtain up-to-date information on all of the assigned patients. 3. Quickly visit each patient assigned to your group to perform “Quick Look” rounds. 26.1 ADN12B Spring 2012 By one hour after the start of the shift 1. Early in the shift, confer with each student group member at the bedside. Review the observational rounds assessment and planned interventions with the student for completeness and accuracy. 2. Complete and or revise the medications' time schedule for the instructor to review. 3. Assign student group members to their breaks and lunch times so that at least one member of each group is on the unit at all times. During the morning 1. Show the instructor your completed “Patient Information Worksheet for Group Leader” and discuss any concerns or questions relevant to the care of the patients. 2. Show the instructor your completed medication worksheet. 3. Assist with finding new learning experiences on the unit. 4. Identify students who need more practice with desired skills. Help them seek out opportunities to perform these skills. 5. Assist group members as needed with their assigned patients. 6. Serve as liaison for the instructor to: a. Identify needed student supervision or instruction b. Identify problems as they occur 7. About two hours after the start of the shift, check the patient charts to see that the morning agency assessments are recorded. 8. Collect nursing care plans from students as directed by your instructor. 9. Expect the other students to have most of the morning care provided for their patients by 1100. 26.2 ADN12B Spring 2012 Afternoon, after lunch 1. Ensure that all tasks for assigned patients have been completed. If there are tasks that will not be completed, advise the responsible nurse now. 2. Assess how you and other students have functioned during the shift. Complete the evaluation form for your student group members. 3. Visit each patient again for observational rounds and review charts for completion. End of Student Shift 1. Give report on your group’s patients to the registered nurse team leader. 2. Assess how you and other students have functioned during the shift. Complete the evaluation forms for yourself and for each of the other students. You may do this after conference if necessary or convenient. 3. Check that all students have reported off to their RN and are ready to leave. Have students go to the assigned conference room. E. Scheduled Conference 1. Present previously approved five-minute information session. 2. Clinical will be dismissed by the instructor following conference. No one is to leave until all tasks, including documentation, are completed. 26.3 ADN12B Spring 2012 Long Beach City College Associate Degree Nursing 12BL – Health Deviations 3 Laboratory PATIENT INFORMATION Worksheet for Group Leader Student Group/Team Leader___________________________ Date:_______________________ Student member RN Observational Rounds “Quick Look” Rm/bed Name M/F Age Admitted: Medical Dx Vital Signs Observational Rounds “Quick Look” Rm/bed Name M/F Age Admitted: Medical Dx Wounds Drains Out Sig. labs Priority New orders Need/Prob. Info. from report Out Sig. labs Priority New orders Need/Prob. Info. from report Out Sig. labs Priority New orders Need/Prob. Info. from report Site Condition Saline Lock [ ] Fluids Rate Fluids: Vital Signs Resp. status Activity: LOC, Comfort, PRN Treatments: Nutrition F&E oral enteral In IV Fluids Begin Shift Wounds Drains Site Condition Saline Lock [ ] Fluids Rate Medical Orders: Diet: Appointments/procedures RN In IV Fluids End Shift NA Student member Nutrition F&E oral enteral Begin Shift Medical Orders: Diet: Appointments/procedures RN LOC, Comfort, PRN End Shift NA Student member Resp. status Observational Rounds “Quick Look” Rm/bed Name M/F Age Admitted: Medical Dx NA Medical Orders: Diet: Appointments/procedures Fluids: Vital Signs Resp. status Activity: LOC, Comfort, PRN Treatments: Nutrition F&E oral enteral In IV Fluids Begin Shift Site Condition Saline Lock [ ] Fluids Rate End Shift Fluids: Activity: 26.4 ADN12B Spring 2012 Wounds Drains Treatments: Student GTL RN “Quick Look” Rm/bed Name M/F Age Admitted: Medical Dx NA Signs status Comfort, PRN oral enteral IV Fluids Site Condition Saline Lock [ ] Fluids Rate Begin Shift Drains labs Need/Prob. Info. from report Out Sig. labs Priority New orders Need/Prob. Info. from report Out Sig. labs Priority New orders Need/Prob. Info. from report End Shift Medical Orders: Diet: Fluids: Activity: Treatments: Appointments/procedures Student GTL RN Observational Rounds “Quick Look” Rm/bed Name M/F Age Admitted: Medical Dx NA Vital Signs Resp. status LOC, Comfort, PRN Nutrition F&E oral enteral In IV Fluids Begin Shift Wounds Drains Site Condition Saline Lock [ ] Fluids Rate End Shift Medical Orders: Diet: Fluids: Activity: Treatments: Appointments/procedures Student GTL RN Observational Rounds “Quick Look” Rm/bed Name M/F Age Admitted: Medical Dx NA Medical Orders: Diet: Vital Signs Resp. status LOC, Comfort, PRN Nutri tion, F&E oral enteral In IV Fluids Begin Shift Site Condition Saline [ ] Fluids Rate End Shift Fluids: Activity: Appointments/procedures 26.4 ADN12B Spring 2012 Wounds Drains Treatments: Long Beach City College Associate Degree Nursing 12BL -Health Deviations 3 Laboratory Medication WORKSHEET Information for Group Leader Group Leader ________________________ Date MEDICATION TIMES Student Rm/bed Patient DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: DX: IV: 0700 0800 0900 1000 1200 1300 1400 po IM IV po IM IV po IM IV po IM IV po IM IV po IM IV po IM IV po IM IV po IM IV po IM IV po IM IV po IM IV po IM IV po IM IV 26.6 ADN12B Spring 2012 1100 PRN MEDICATIONS Directions: Include any prn medications given by team members here. Rm/ Drug Name Subclass PRN Nursing Name generic and brand Action for Responsibilities TASK COMPLETION CHECK LIST Directions: When performing as the student group leader, use this form to verify that the student team members that you are supervising have completed all of the assigned tasks. Student Nurse Team Member LDA 08 VS Nrs A/I Meds Treatments I & O 12 VS charted done & charted charted recorded Charted charted Rm/Bed _____ Patient __________________ Rm/Bed _____ Patient __________________ Rm/Bed _____ Patient __________________ Student Nurse Team Member LDA 08 VS Nrs A/I charted done & charted Meds Treatments I & O 12 VS charted charted recorded Charted LDA 08 VS Nrs A/I charted done & charted Meds Treatments I & O 12 VS charted charted recorded Charted LDA 08 VS Nrs A/I charted done & charted Meds Treatments I & O 12 VS charted charted recorded Charted Rm/Bed _____ Patient __________________ Rm/Bed _____ Patient __________________ Rm/Bed _____ Patient __________________ Student Nurse Team Member Rm/Bed _____ Patient __________________ Rm/Bed _____ Patient __________________ Rm/Bed _____ Patient __________________ Student Nurse Team Member Rm/Bed _____ Patient __________________ Rm/Bed _____ Patient __________________ Rm/Bed _____ Patient __________________ 26.7 ADN12B Spring 2012 PEER EVALUATION SHEET Group Leader Name ____________________ Date __________________________ Student __________________________ Strengths: Student __________________________ Strengths: Areas to improve: Areas to improve: _____________ _________________ Evaluator Student Signature Student __________________________ Strengths: _____________ ___________________ Evaluator Student Signature Student __________________________ Strengths: Areas to improve: Areas to improve: _____________ ____________________ Evaluator Student Signature Student __________________________ Strengths: _____________ ____________________ Evaluator Student Signature Student __________________________ Strengths: Areas to improve: Areas to improve: _____________ ___________________ Evaluator Student Signature Student __________________________ Strengths: _____________ ___________________ Evaluator Student Signature Student __________________________ Strengths: Areas to improve: Areas to improve: ____________ Evaluator ___________________ Student Signature _____________ Evaluator 26.8 ADN12B Spring 2012 ___________________ Student Signature PEER EVALUATION SHEET Group Leader Name ____________________ Date __________________________ Student __________________________ Strengths: Student __________________________ Strengths: Areas to improve: Areas to improve: _____________ _________________ Evaluator Student Signature Student __________________________ Strengths: _____________ ___________________ Evaluator Student Signature Student __________________________ Strengths: Areas to improve: Areas to improve: _____________ ____________________ Evaluator Student Signature Student __________________________ Strengths: _____________ ____________________ Evaluator Student Signature Student __________________________ Strengths: Areas to improve: Areas to improve: _____________ ___________________ Evaluator Student Signature Student __________________________ Strengths: _____________ ___________________ Evaluator Student Signature Student __________________________ Strengths: Areas to improve: Areas to improve: ____________ Evaluator ___________________ Student Signature _____________ Evaluator 26.8 ADN12B Spring 2012 ___________________ Student Signature ADN 12BL -- Health Deviations 3 Laboratory SAMPLE DAILY SCHEDULE for TEAM MEMBER The evening before: 1. Go to the medical center the day before to select your own patients. Arrange with your group leader the time and method of communication. 2. Write, in pencil, on the “Drug Therapy Worksheet” the names, action, and nursing responsibilities of the medications to be given to each patient. 3. On the “Drug Therapy Worksheet” complete (in pencil) the names, action, and nursing responsibilities of the medications you will be giving. Include the PRN medications that you might give. 4. Review any laboratory studies that you are unfamiliar with using your Diagnostic Studies reference book. 5. Review the medical and surgical diagnoses of your assigned patients, using your medical/surgical nursing text and other reference material. Each clinical day: Arrive and get prepared for the shift. Initial the assignment sheet to show that you are on duty. Introduce yourself to the responsible RN when he/she arrives. Verify that your medication worksheet and grid are complete. Write in the planned nursing interventions on the “Nursing Care Plan.” Meet with the Group Leader to review medications times and patient care priorities. Exchange and clarify information regarding the planned care for the day. Vital signs must be on the medical record immediately after they are obtained. The physical assessment should be on the chart within two hours from the start of the shift. With clinical instructor give oral, IM and Sub-Q medications at scheduled times. Have any nursing responsibilities, such as taking blood pressure, completed just prior to calling your instructor to give medications. Carry out planned nursing interventions including daily bath and linen change. Complete your nursing care plans. These care plans are plans of care for the day and are to be completed early in the shift. Your instructor will specify the time that they are to be collected by the group leader. 27.0 ADN12B Spring 2012 After lunch, write DAR notes for your assigned patients and review them with your instructor before writing them in the chart. Complete all nursing tasks and documentation. Complete the intake and output record as directed by your assigned RN. Report off to the responsible staff RN and to the Group Leader. When you are finished go to the assigned conference room for clinical conference. 27.1 ADN12B Spring 2012 Long Beach City College Associate Degree Nursing Program Nursing Care Plan Assessment Guidelines Mental and Psychosocial: *Level of Consciousness, Orientation, Affect Communication deficits including language, hearing, speech, sight. Significant other, home caregiver *Spiritual or psychosocial concerns, quote patient/family as needed Cardio respiratory: *Vital signs, include pulse ox if appropriate with oxygen delivered. Respiratory pattern, skin color, c/o dypsnea if applicable *Lung sounds, Heart sounds Cough?, productive?, appearance of sputum *Edema *Pulses, cap refill GI Metabolic: *Appetite, % of diet taken Difficulty eating? Dentures? Any nausea? Mouth: mucous membranes Recent blood sugar if diabetic, insulin coverage? *Body habitus: cachexic, normal, obese; Height and weight if abnormal. Any enteral or IV feedings with type and rate, residual amount. *Abdominal assessment: bowel sounds, soft or firm to palpation *Last BM with amount, consistency, color if known GU, Fluid and Electrolyte: *Skin turgor *Mucous membranes *IV site, solution, rate Daily weight: include admission wt if available (if ordered or appropriate) Abdominal girth if ordered daily *Urine color, amount Intake and output from previous day: esp. in CHF, renal failure pts. Continent? Musculoskeletal, Integumentary, and Comfort: *Activity level Assistive devices Skin condition: lesions? Dressings Continent? *Muscle strength Posture/ alignment Amputations? Deformities? Restraints? DVT prevention? Level of wakefulness: restless? lethargic? *Pain, discomfort with scale *Sleep report *To be included even if normal 28.0 ADN12B Spring 2012 Long Beach City College ADN Program Medical-Surgical Nursing Care Plan ADN12BL Student ________________________Date______________Patient’s Initial_______RM/Bed#_________Adm Date_______________ Responsible Nurse_________________Coassigned NA MD Medical Diagnosis Reason Pt Nsg Care Basic conditioning factors: Age Sex Religion Occupation Ethnicity Family Role Develop level Allergies Code status Predisposing factors/Past medical hx Universal Self Care Requisites Maint. of balance between Solitude & Social Interaction Physical Assessment Lab Data – Dx tests Self Care Deficits Nursing Dx, r/t, 2º, AEB Collaborative problems CNS & Psychosocial Cardio-respiratory Maint. of Sufficient Intake of Air Maint. of Sufficient Intake of Food GI metabolic Elimination Process Maint. of Sufficient Intake of Water GU, Fluid, electrolytes Elimination Process MS, Integument, & Comfort Maint. of Balance between Activity & Rest ****** Star the priority problem ****** ADN12B Spring 2012 29.0 Goals Nursing Interventions Independent, Collaborative, Dependent and Drugs Nsg Agy TASK WORKSHEET for Team Member Include medications and tasks to be completed Rm/Bed Patient 0700 0800 VS 0900 Px. As. 1000 1100 Note Describe the pathophysiology of the patient’s disease process. DAR/PIE/Outcome Nursing Notes: 29.1 ADN12B Spring 2012 1200 VS 1300 1400 Long Beach City College ADN12BL Drug Therapy Worksheet Student___________________________ Date_______________________ Pt initials and room #____________ Drug Name Generic/Brand and Dose Route Class of Drug Drug Action Reason prescribed to THIS patient 29.2 ADN12B Spring 2012 Nursing Responsibilities/ Labs/Drug levels Normal Dose Range Laboratory or Test Name Normal Range Patient Results for previous days Patient Results for assigned day Wbc Hbg Hct plt eGFR BUN Creatinine K+ Na+ Mg++ Ca++ Glucose AST ALT Bili T & D INR PTT PT UA Urine Cx Wound Cx CXR MRI 29.3 ADN12B Spring 2012 Nursing Responsibility, Clinical Implications Probable cause of any abnormals ADN 12BL - Health Deviations 3 Laboratory AMBULATORY CARE EXPERIENCE BEHAVIORAL OBJECTIVES Type the behavioral objectives on a separate sheet of paper and submit to your clinical instructor on the Friday following the experience. 1. List and describe three (3) of the roles of the RN observed in the assigned area. 2. Describe the critical thinking necessary to work in the assigned area and give one example of critical thinking you observed. 3. Identify the primary concern of three (3) patients you cared for and write one complete nursing diagnosis for each of the patients. 4. List and provide details for three (3) procedures you observed. 5. List and describe three (3) procedures you performed. 6. Describe any new nursing skills or critical thinking activities that you observed. 7. State how this experience will assist you in future clinical rotations. 30.0 ADN12B Spring 2012 STUDENT CLINICAL EVALUATION 31.0 ADN12B Spring 2012 LONG BEACH CITY COLLEGE Associate Degree Program ADN 12 BL Health Deviations 3 STUDENT CLINICAL EVALUATION Student Name _______________________________________________ Dates of Course ______________________________ Theory: _______%, Course Letter Grade: _______ (Do not put your grade in this box, your instructor will) Overall Clinical Rating: ( ) Satisfactory, ( ) Marginal, ( ) Unsatisfactory Dates:____/____/________Through:____/_____/_____ Clinical Agency: _______________________________ Clinical Absences:__________ Tardies: _____________ Lab Absences:____________ Tardies: _____________ Introduction: The student is expected to satisfactorily participate as a member of the clinical team; to complete all assigned course outcomes while safely, effectively, and consistently using acceptable principles of client care. Directions: Both the student and instructor will evaluate each student’s performance. The student evaluates self in the indicated column. If the instructor agrees, no additional mark will be made. If the instructor’s evaluation differs with that of the student, the instructor will circle the student’s mark and initial. The instructor will then mark the column indicating the evaluation of the student. Criteria: --Overall Satisfactory Rating At the end of the course, each student is expected to receive a satisfactory rating on 75% or more of the clinical days to receive a passing grade. --Overall Clinical Marginal Rating An overall clinical marginal rating may be based on one overriding area of safety or on a group of behaviors that have been identified as “Marginal” (Must Improve) in 50% to 74% of the behavioral objectives for the course. --Unsatisfactory Clinical Rating An unsatisfactory clinical rating will be given for clinical practice whenever the student receives a second Overall Clinical Marginal Evaluation, or whenever the student demonstrates unsafe clinical practice, i.e., patient safety or welfare is compromised, or meets less than 50% of the behavioral objectives for the course. See Student Handbook for explanation of process and options. Criteria Definition: -A check in the S (Satisfactory) column indicates that 75% or more of the time, the student demonstrated appropriate behavior, knowledge, and skills consistent with the current level of student experience. -A check in the M (Marginal) column indicates that 50% to 74% of the time, student behavior does not meet the expected objective(s). Documented comments should clarify the problem area(s). -A check in the U (Unsatisfactory) column indicates that the student met their objectives less than 50% of the time, and that behavior is below the acceptable level of performance. A behavior compromising the safety of the client will result in an unsatisfactory evaluation. Unsatisfactory areas will be documented in the appropriate section(s) on the evaluation. -A check in the N (Not Applicable, or not observed) column indicates that the behavior was not evaluated. ADN12B Spring 2012 Clinical Outcomes for Health Deviations 3 At the completion of this course the student will satisfactorily complete the following clinical outcomes for the medical patient. I. Professional Behaviors 1. Assimilates and integrates professional values of caring, integrity, honesty, patient advocacy and respect for human dignity within the professional role. 2 Practices within the ethical, legal, and regulatory frameworks of nursing and standards of professional nursing practice in the Health Deviations 3 course. a. Attendance - follows student handbook policy. b. Promptness - on duty on time, returns on time from break. c. Appearance - follows dress code. Refer to student handbook. d. Provides up-to-date Health and Safety requirements. e. Upholds the Honesty Policy. f. Meets clinical agency requirements. 3. Demonstrates responsibility and accountability for one's actions and learning needs. a. Preparation - comes with proper materials and written preparation to perform assigned role. b. Submits all assignments within designated time frame, including make-up assignments. c. Calls attention to own errors and reports situation accurately d. Maintains professional boundaries in the nurse-patient relationship e. Performs with reasonable composure f. Requests supervision when needed. g. Shows initiative in meeting learning needs. 4. Maintains organizational and patient confidentiality/abides by HIPAA standards. 5. Maintains professional and collegial relationships with the healthcare team and instructor ADN12B Spring 2012 S> 75% M 50-74% U < 50% N/A Comments II. Communication S> 75% M 50-74% U < 50% N/A Comments S> 75% M 50-74% U < 50% N/A Comments 1. Utilizes effective communication skills with colleagues, clinical staff, and instructor using proper verbal and written English. 2. Communicates relevant, accurate, and complete information concisely. a. Communicates clearly in English both verbally and written. b. Agency charting and nursing notes are relevant, accurate, complete, and clear. 3. Reports and documents assessments and interventions and progress toward patient outcomes. a. Documents according to LBCC and agency policy and guidelines. 4. Utilizes appropriate channels of communication to achieve positive patient outcomes. a. Identifies self as caregiver and delineates responsibilities to the co-assigned licensed personnel and staff at the beginning of the shift. b. Gives report prior to leaving unit. c. Utilizes agency’s designated communication/hand-off tool (e.g. SBAR). 5. Applies speech communication skills in oral case study presentation to the clinical group. III. Orem’s Self-Care Theory as it relates to the Nursing Process 1. Utilizes Orem's Theory to establish each patient's database. a. Considers patients developmental self-care requisites and their ability to provide self-care. b. Collects and validates data pertinent to the patient's condition to determine deficits in the USCR. c. Utilizes appropriate nursing agency when providing for patients' self-care deficits 2. Nursing Process a. Assessment i. Performs a thorough head-to-toe assessment; elicits subjective data. ii. Collects and validates additional data pertinent to the patient's condition to determine ADN12B Spring 2012 III. Orem’s Self-Care Theory as it relates to the Nursing Process (Continued) b. Diagnosis i. Selects a minimum of two priority patient-specific NANDA approved nursing diagnoses for each patient. ii. Selects a minimum of one priority collaborative patient-specific problem for each patient. iii. Supports diagnoses with defining characteristics. c. Planning/Outcomes i. Develops a comprehensive/holistic plan of care based on assessment data i. Identifies goals/outcomes (i). Formulates specific, measurable, attainable and realistic goals/outcomes within a time frame that correlate with nursing diagnoses (SMART). (ii). Formulates a nurse oriented goal/outcomes that correlates with the collaborative problem. d. Implementation i. Identifies a minimum three patient-specific nursing interventions appropriate to achieve goals/outcomes for each nursing diagnosis and collaborative problem. ii. Assists the patient to obtain optimum comfort and functioning iii. Demonstrates empathy when providing nursing care. iv. Provides for privacy at all times. v. Demonstrates respect and caring behavior towards the patients, significant others vi. Shows interest in the patient's needs and responds in a positive manner e. Evaluation i. Evaluates interventions for efficacy. ii. Re-evaluates patients' response to care. 3. Submits two to three complete nursing plans of care at the time specified per syllabus. ADN12B Spring 2012 S> 75% M 50-74% U < 50% N/A Comments IV. Critical Thinking S> 75% M 50-74% U < 50% N/A COMMENTS S> 75% M 50-74% U < 50% N/A COMMENTS 1. Utilizes clinical judgment throughout the nursing process in providing care. a. Utilizes critical thinking and verbalizes rationale in providing care with minimal verbal cues. i. Demonstrates application of theory to clinical situations. ii. Correlates patients' pathophysiology with relevant lab values and medications. iii. Utilizes assessment data, lab values, and clinical judgment in administering medications. 2. Uses clinical judgment in prioritizing nursing care for a three patient assignment. 3. Utilizes evidence-based information to support clinical decision-making. a. Builds upon previous knowledge and applies newly learned content to clinical setting. 4. Formulates a written case study as per course requirements. V. Safety 1. Provides accurate and safe performance of nursing skills. a. Demonstrates continuing progress in mastering previously learned skills. b. Performs newly learned skills with minimal verbal skills and increasing competency. 2. Reports actual/potential unsafe practices to instructor and co-assigned licensed personnel a. Provides a safe physical and psychosocial environment for the patient. b. Identifies and reports any potential safety hazards in the clinical setting. 3. Administers medications safely to assigned patients each clinical day. a. Utilizes agency's policy to properly identify patients. b. Respects patients' five rights before administering any medication. c. Prepares, administers & manages oral, IM, SQ, ID medications safely with minimal verbal cues. d. Prepares, administers & manages intermittent intravenous medications safely with minimal verbal cues. e. Administers medications with 100% accuracy and monitors drug regimen. f. Manages intravenous fluid therapy with minimal verbal cues. 4. Completes total patient care on a three patient assignment in a safe manner. ADN12B Spring 2012 VI. Teaching and Learning S> 75% M 50-74% U < 50% N/A COMMENTS S> 75% M 50-74% U < 50% N/A COMMENTS 1. Identifies and plans for the learning needs for the patients. 2. Provides the patient and significant others with accurate information and skills needed to achieve desired goals/outcomes. a. Provides simple explanations and instructions to patients. b. Instructs the patient prior to interventions and procedures. c. Documents and reports patient's response to instruction. VII. Collaborative Management of Care 1. Collaborates with the interdisciplinary health care team to achieve optimal patient outcomes. 2. Practices within guidelines of ADN 12BL; individual knowledge and expertise; and seeks assistance for care beyond level of knowledge. 3. Acts as a team member in the multidisciplinary care of patients. 4. Provides leadership and support to peers as a group leader. 5. Manages a two to three patient assignment in an organized and efficient manner completing care within allotted time frame. ADN12B Spring 2012 Student Comments Strengths: Areas Needing Improvement: Instructor Comments: Problem Areas: Student Signature ____________________________ (Do not sign until you meet with your instructor) Date ____________________________ Instructor Signature ____________________________ ADN12B Spring 2012
