Level 3 Direct Patient Care Documentation 1

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Level 3 Direct Patient Care Documentation 1
Adult Health I (Chamberlain University)
Studocu is not sponsored or endorsed by any college or university

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CLINICAL LEARNING – DIRECT

PATIENT CARE DOCUMENTATION
LEVEL 3 CLINICAL COURSES
PAGE 1 OF 10
41153991 20221209
Student Name: D#: Date:
November 2022
Course: NR324 Adult Health Session and Year:
Directions
This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning setting.
All information within this packet must be handwritten, (with the exception of the reflection journal) reviewed with your faculty on your assigned clinical
day and submitted within 24 hours (or as directed by course coordinator). If additional space is needed, please use the back of each page.
• Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the Clinical Learning Evaluation. Satisfactory rating meets the following:
– Clinical Learning Competency: Completes all clinical learning experiences and requirements successfully (PO 5).
• Performance Descriptor: Completes all assignments related to the clinical learning experience within established guidelines.
• I-SBAR: Utilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been received. Students should
deliver a hand-off report at the end of their shift to the bedside nurse.
• Assessment Findings, Labs and Healthcare Provider Orders: Document your initial and ongoing assessment findings, lab results with why they were
drawn specifically for your patient and healthcare provider orders with why they were specifically ordered for your patient.
• ATI® Active Learning Templates Required:
– Diagnostic Procedure: Select one diagnostic procedure from the healthcare orders table and complete one Active Learning Template: Diagnostic Procedure.
The selected diagnostic procedure should be one in which you have not previously completed a template for this session.
– Therapeutic Procedure: Select one therapeutic procedure from the healthcare orders table and complete one Active Learning Template: Therapeutic Procedure.
The selected therapeutic procedure should be one in which you have not previously completed a template for this session.
– Nursing Skill: Select one nursing skill from the healthcare orders table and complete one Active Learning Template: Nursing Skill. The selected
nursing skill should be one in which you have not previously completed a template for this session.
– Medications: List medications below and complete one Active Learning Template: Medication for each medication classification in which you
have not previously completed a template.
Time Due Drug/Classification Clinical Significance

0400, 1200, 2000
Cefuroxime 1.5 g IV q8 hrs Antibiotic to stop growth of bacteria
0800 Lisinopril 10 mg PO qAM To treat high blood pressure and heart failure
0800 Prednisone 40 mg PO qAM For acute exacerbation of COPD
1900 Ipratropium and albuterol nebulization Per RT INH q4 hrs To bronchodilate air passages
0800 Nicotine Patch 21mg Transdermal Daily Cessation of smoking
1900 Methyprednisolone 60 mg IV Once To relieve inflammation
• Nursing Diagnosis:
Identify three nursing diagnoses for your patient and list them by priority below. Complete one concept map for your top nursing diagnosis listed below.
1. Impaired Gas Exchange 2. Risk for Infection
3. Ineffective Airway Clearance
• Reflection Journal:
Complete a reflection journal and submit to your faculty within 24 hours of completing your clinical learning experience. Reflective journaling provides a format
to share your knowledge, skills, experiences and personal reflection related to concepts and strategies learned throughout your program. The reflection journal
is required to be typed, Word document, Times New Roman 12-point font. Minimum of one page and no more than three pages.
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PAGE 2 OF 10
I-SBAR
Your Name: Kaitlyn Hughes

I
D#: 41092772
Your Title:Student Nurse
Introduce Yourself
Reason for being there:
Patient: Ben Bundy Attending Physician: Dr. Tate

Age: 75 y/o Patient Chief Complaint/Primary Medical Diagnosis and Clinical
Gender: Male Significance:
Height/Weight: 72 in / 68 kgs Acute COPD exacerbation characterized by a shortness of breath
Race/Ethnicity: Caucasin
S Allergies: No known Allergies
Code Status: DNI
Situation Advance Directive (Durable Power of Attorney, Living Will, Other) & Pathophysiology of Primary Medical Diagnosis:
Clinical Significance: Inflammation or destruction of the alveoli and bronchioles causing inadquate
perfusion and air trapping
Privacy Code:
Date of Care/Time:2000
**Include clinical significance with each**

B
Past Medical History: Past Surgical History:
COPD from hisotry of smoking None
Background Hypertensive, normotensive on medication
Social History/Socioeconomic Factors: Retired Farmer, Married for 55 years, No alcohol or substance on record, tabacco use 60 year/40 pack-year history,
Vital Signs:
B/P HR RR TEMP SP02 PAIN
A 130/80 100 38 100.1 F 82% 0/10
Assessment
Falls risk: low Accu check:

IV Site: Right Forearm IV Fluids: D5NS
Isolation Isolation Precautions N Y Contact Air Droplet
RESPIRATORY inspiratory and expiratory wheezes noted. Reports SOB. Productive cough with green sputum
CARDIOVASCULAR Regular Rate and rhythm. Pulses equal in to all extremities. Denies Chest pain.
NEUROLOGICAL Alert and oriented x 4. Speech is clean. Motor function, sensation grossly intact. PERRLA.
GI/GU Soft, non-tender, no organomegaly. Normoactive bowel sounds in all quadrents. No visible lesions or scars.
250 ml urine output
I&O
INTEGUMENTARY Skin is clean, dry, intact, pink, warm and well perfused. No rashes, wounds, or lesions. Skin is hydrated with no tenting.
PSYCHOLOGICAL Denies changes in concentration, anxiety, panic, depression, irritability, insomnia, suicidal ideations, and abuse history.
Has a wfire with two sons and a daughter. All has four sibilings.
FAMILY - SUPPORT
SAFETY Teaching needed: Low fall risk from history of falls

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

Patient is at low fall risk with protocal, bed rest with bathroom privileges
REQUEST/ Provide other methods of communication while patient is having difficulty breathing
Educate the patient on pursed lip breathing
RECOMMENDATION Add a humidifer to oxygenation for dry mucous membranes

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Initial Assessment Findings and Time: Ongoing Assessment Findings and Time:
Vital signs: Vital signs:
T: 100.1 F P: 88 Resp: 26 Sp02: 86% T: 100.1 F P: Resp: Sp02:
BP: 128/82 Height: 72 in Weight: 150 lbs Apical HR: BP: Height: Weight: Apical HR:
Pain scale used with rationale: 0/10 pain Pain scale used with rationale: 0/10 pain
P (Palliative, Provocative) What makes the pain better/worse? P (Palliative, Provocative) What makes the pain better/worse?
Q (Quality) How is the pain described? Q (Quality) How is the pain described?
R (Radiation) Does the pain travel or spread anywhere else? If so, where? R (Radiation) Does the pain travel or spread anywhere else? If so, where?
S (Severity) What is the intensity of the pain? S (Severity) What is the intensity of the pain?
T (Temporal) Is the pain constant, or does it come and go? T (Temporal) Is the pain constant, or does it come and go?
Head and Neck (inspect and palpate scalp, hair and skull, facial Head and Neck (inspect and palpate scalp, hair and skull, facial
expression/symmetry, trachea): expression/symmetry, trachea):
No visible or palpable masses, depressions or scaring. The trachea is midline No visible or palpable masses, depressions or scaring. The trachea is midline
Respiratory (lung sounds, breathing effort, accessory muscles): Respiratory (lung sounds, breathing effort, accessory muscles):
inspiratory and expiratory wheezes noted. Reports SOB. Productive cough with green sputum
Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm):
Regular Rate and Rhythm. No murmur or gallop. Cap refill to finger is 3 seconds
Abdomen (inspection, bowel sounds, palpation, contour): Abdomen (inspection, bowel sounds, palpation, contour):
Normoactive Bowel sounds in all quadrents
Bowel incontinence: None Bowel incontinence:
Bowel plan: None in place Last BM: Not stated Bowel plan: Last BM:
Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils):
Alert and oriented x 4. Speech is clean. Motor function, sensation grossly intact. PERRLA.
Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength
of upper and lower extremities): of upper and lower extremities):
Full range of motion in all extremities. Strength is 5/5 bilaterally.
Genitourinary (burning with urination, frequency, color of urine): Genitourinary (burning with urination, frequency, color of urine):
Deffered. Patient states no concerns
Urinary incontinence: Toileting plan: Urinary incontinence: Toileting plan:

None None in place
Pelvic (female: LMP): Pelvic (female: LMP):

Rectal (bleeding, hemorrhoids): Rectal (bleeding, hemorrhoids):
Integumentary (rashes, lesions, wounds, etc.): Skin is clean, dry, intact, pink, warm and well Integumentary (rashes, lesions, wounds, etc.):
perfused. No rashes, wounds, or lesions.
Specialty assessment (mental health exam, fetal heart rate, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.):
Consult Respiratory Therapist
Abuse screen (physical, elderly, child, sexual, etc.): Abuse screen (physical, elderly, child, sexual, etc.):
States no abuse.
IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type
of IV fluid, assessment of IV site, last dressing change): of IV fluid, assessment of IV site, last dressing change):
IV in place of right forearm. D5NS 75 mL/hr continous. IV site is continous with no redness or
inflammation.

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Telemetry Rhythm Strip:

Attach your patient’s rhythm strip below and determine the following information:
PRI: QRS: QT: Rate: Rhythm:
No Strip was provided.

Interpretation: Normal electrical conduction with sinus tachycardia at 105.
Labs
Result/ Reason out of norm/reason for drawing Result/ Reason out of norm/reason for drawing
Test Norm Test Norm
Date if normal or N/A if not drawn Date if normal or N/A if not drawn
WBC 14,021 4000-10 Glu 121 70-130
000
RBC 5.2 mil 4.5-5.9 BUN 20 8-21
mil
Hgb 13.3 14-18 Na 138 135-145
Hct 48 42-54 K 3.5 3.5-5.1
Plt 217 150-399 Cl 101 95-102
Chol 200 or < Creat 1.01 0.6-1.3 To assess kidney function
Trig <150 CO2 29 22-29 To see how much CO2 is trapping
LDH <100 Ca 10.5 8.7-10.7 To screen for a disease afffected by

it
PT 11-13.5 Phos 3.0-4.5 Suspected diabetes or hormone
sec imbalance
APTT 30-40 Mag 1.3-2.1 For other electrolyte abnormailites
secs
AST 4 3-44 T. Pro 6-8.3 to measure amount or protein
ALT 4 0-40 Alb 3.4-5.4 Measure amount of protein in blood
Tdl* Tdl*
* Therapeutic drug level

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Healthcare Provider Orders
Items Order/Frequency Reason (explain specifically why ordered for this patient)
Diet General
I/O
VS Every 4 hours
Activity Bedrest with
Accu-check
Foley
NG tube
PEG tube
PEJ tube
Chest tube
Trach
Suctioning
Drains
Ostomy
Dressing change
and/or wound care
Treatments
Special equipment
Other

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Concept Map
Brianna Kellner
Student Name: Date:
Intervention for Nursing Diagnosis Signs and Symptoms
Assess respiratory rate, depth, use of COPD Exacerbation

accessory muscles, and abnormal Inspiratory and expiratory wheezes
breathing patterns. Cyanosis to Lips
Monitor patients behavior and mental Low eTCO2
status for onset of restlessness, Barrel Chested
agitation, confusion, and lethargy. Lab Values Related
Observe nail beds, cyanosis, note color to Nursing Diagnosis
of tongue and oral mucous membranes.
CO2 lab value is high but still in
Monitor oxygen saturation continuously.
expected range.
Low levels of hemoglobin which
decrease the uptake of oxygen.
Nursing Diagnosis
Rationales for Interventions Imapired Gas Exchange
Change in rate, depth and use of

accessory muscles affect gas
exchange.
Changes in behavior and mental status
can be early signs of impaired gas
exchange.
Cyanosis of tongue and oral mucosa is
indicative of hypoxia
Pulse oximetry is a useful tool to detect
changes in oxygenation. Medication(s) r/t Diagnosis
Medications:
Prednisone 40 mg
Ipratropium and albuterol nebulization
Methylprednisolone 60 mg Medication Side Effects
Patient Outcome(s)
Patient maintains clear lung fields and Prednisone: depression, euphoria,

remains free of signs of respiratory hypertension, anorexia, nausea,
distress. decreased would healing,
Patient engages in procedures to ecchymoses, fragility, petechiae,
optimize oxygenation. adrenal suppression, muscle wasting
Patient maintains optimal gas Ipratropium and Albuterol: diziness,
exchange, oximetry results within headache, blurred vision, sore throat,
normal range, blood gases within cough, hypotension, palpitations
normal range, and baseline HR for Methylprednisolone: acne, hirsuitism,
patient. osteoporosis, cushingoid appearance

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Active Learning Template:

Diagnostic Procedure
Student Name:
Procedure Name: Chest X-Ray Review Module Chapter:
Description of Procedure
A safe and painless test that used radiation to get a picture of the chest seeing the lungs, heart and other organs located
CONSIDERATIONS
Indications Nursing Interventions (pre, intra, post)
A chest x-ray is used for to see the condition of your lungs Remove all metal products from the patient. Ensure the patient is
such as an infection or cancer. not pregnant or suspected to be pregnant. Assess the patients
Heart related lung problems such as fluid in the lungs from HF. ability to hold ones breath. Provide appropriate clothing to the
The size and outline of heart, looking for changes in size. patient since they will have to remove clothing from the waist up.
Looking at blood vessels for things like aneurysms Instruct the patient to remain still during the procedure.
Looking at fractures of spine or rib.
Used after placement of a pacemaker. No special care is needed after. Provide comfort for the patient
and reposition if necasssary.
Interpretation of Findings Client Education
The x-ray produces black and white imgages. An expert or Patient will have the procedure explained to them and what to
doctor analyzes the images looking for signs and clues that expect by the doctor or radiologist.
suggest you may have what it is suspected.
Explain to patient why jewlery or metal products need to be
removed. Also educate them about not moving during the
procedure.
Potential Complications Nursing Interventions
You are exposed to a small amount of radiation which is not Remove all metal products from the patient. Ensure the patient is
entirely harmful since its a smaller amount. not pregnant or suspected to be pregnant. Assess the patients
It is harfum to an unborn child so its important to tell your ability to hold ones breath. Provide appropriate clothing to the
doctor about being pregnant or potentially pregnant. patient since they will have to remove clothing from the waist up.
Instruct the patient to remain still during the procedure.
No special care is needed after. Provide comfort for the patient


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Therapeutic Procedure
Student Name: Brianna Kellner
Procedure Name: Chest X-Ray Review Module Chapter:
Description of Procedure
CONSIDERATIONS
Outcomes/Evaluation Client Education
Patient will have the procedure explained to them and what to

expect by the doctor or radiologist.

procedure.



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Nursing Skill
Student Name:
Skill Name: Chest X-Ray Review Module Chapter:
Description of skill
CONSIDERATIONS
Outcomes/Evaluation Client Education

The x-ray produces black and white imgages. An expert or Patient will have the procedure explained to them and what to
doctor analyzes the images looking for signs and clues that expect by the doctor or radiologist.
suggest you may have what it is suspected.
procedure.



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Medication
Kaitlyn Hughes
Student Name: Medication:
Review Module Chapter: Category Class:
PURPOSE OF MEDICATION
Expected Pharmacological Action Therapeutic Use
Complications Medication Administration
Contraindications/Precautions Nursing Interventions
Remove all metal products from the patient. Ensure the patient is
not pregnant or suspected to be pregnant. Assess the patients
ability to hold ones breath. Provide appropriate clothing to the
patient since they will have to remove clothing from the waist up.
Interactions Client Education
Evaluation of Medication Effectiveness


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lOMoARcPSD|8625666

Level 3 Direct Patient Care Documentation 1

Adult Health I (Chamberlain University)

Studocu is not sponsored or endorsed by any college or university

CLINICAL LEARNING – DIRECT

Time Due Drug/Classification Clinical Significance

3. Ineffective Airway Clearance

CLINICAL LEARNING – DIRECT

Your Name: Kaitlyn Hughes

Patient: Ben Bundy Attending Physician: Dr. Tate

**Include clinical significance with each**

Falls risk: low Accu check:

Isolation Isolation Precautions N Y Contact Air Droplet

SAFETY Teaching needed: Low fall risk from history of falls

R Hand off report to: From:

1-180405 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA

CLINICAL LEARNING – DIRECT

Bowel incontinence: None Bowel incontinence:

Urinary incontinence: Toileting plan: Urinary incontinence: Toileting plan:

Pelvic (female: LMP): Pelvic (female: LMP):

1-180405 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA

CLINICAL LEARNING – DIRECT

Telemetry Rhythm Strip:

PRI: QRS: QT: Rate: Rhythm:

No Strip was provided.

Hct 48 42-54 K 3.5 3.5-5.1

Plt 217 150-399 Cl 101 95-102

Chol 200 or < Creat 1.01 0.6-1.3 To assess kidney function

Trig <150 CO2 29 22-29 To see how much CO2 is trapping

LDH <100 Ca 10.5 8.7-10.7 To screen for a disease afffected by

ALT 4 0-40 Alb 3.4-5.4 Measure amount of protein in blood

* Therapeutic drug level

1-180405 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA

CLINICAL LEARNING – DIRECT

Healthcare Provider Orders

Activity Bedrest with

1-180405 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA

CLINICAL LEARNING – DIRECT

Intervention for Nursing Diagnosis Signs and Symptoms

Assess respiratory rate, depth, use of COPD Exacerbation

Change in rate, depth and use of

Patient maintains clear lung fields and Prednisone: depression, euphoria,

1-180405 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA

CLINICAL LEARNING – DIRECT

Active Learning Template:

Procedure Name: Chest X-Ray Review Module Chapter:

Indications Nursing Interventions (pre, intra, post)

Interpretation of Findings Client Education

Potential Complications Nursing Interventions

No special care is needed after. Provide comfort for the patient

1-180405 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA

CLINICAL LEARNING – DIRECT

Active Learning Template:

Student Name: Brianna Kellner

Procedure Name: Chest X-Ray Review Module Chapter:

Indications Nursing Interventions (pre, intra, post)

Outcomes/Evaluation Client Education

Patient will have the procedure explained to them and what to

Explain to patient why jewlery or metal products need to be

Potential Complications Nursing Interventions

Include clinical significance with each