Med Sheet

MEDICATION WORKSHEET Student Name___________________________________ Pt. Initials_________ RM#__________ Dr.
____________________________ Diagnosis: ____________________________________ Allergies: _____________________________________________Last BM: ___________

MEDICATION (Brand/Generic) Lanoxin/digoxin Dose: 0.25mg PO Frequency: daily Time: 0900 MEDICATION (Brand/Generic) KCL/Potassium chloride Dose: 20 mEq PO Frequency: daily Time: 0900 MEDICATION (Brand/Generic) Lasix/furosemide Dose: 20 mg PO Frequency: BID Time: 0900, 1800 MEDICATION (Brand/Generic) Keflex/cephalexin Dose: 500 mg PO q 6 hr Frequency: Time: 0900, 1500, 2100, 0300 CLASS Loop diuretic Normal Dose: 20-80 mg PO per day CLASS Antinfective 1st generation cephalosporin Normal Dose: 1-2 gm PO qd LAB RELEVENT TO MED K+ 4.2mEq/L Other electrolytes (see above) LAB RELEVENT TO MED Culture results Hepatic enzymes WBC: 14.3 Urinalysis Bacteria LAB NORMS K+ 3.5-5.5mEq/L CLASS Antidysrhythmic Cardiac glycoside Normal Dose: 0.063-0.5mg PO daily CLASS Electrolyte replacement Normal Dose: 40-100 mEq PO divided LAB RELEVENT TO MED Digoxin level 1.5ng/ml K+ 4.2mEq/L Ca+ 9.1 mg/dl Mg+ 1.7mg/dl LAB RELEVENT TO MED K+ 4.2mEq/L LAB NORMS Dig: 0.5-2ng/ml K+: 3.5-5.5mEq/L Ca+: 8.4-10.2 mg/dl Mg+: 1.6-2.6 mg/dl LAB NORMS K+ 3.5-5.5mEq/L IMPLEMENTATION Take Apical pulse x 1 min, hold if <60 or >100. Notify MD for changes in rate,quality Monitor I&O, weight Assess lungs for rales, crackles Adverse effects: Symptoms of CHF: dyspnea, weight gain, edema Signs of toxicity: abd pain, N&V, bradycardia, visual disturbances, IMPLEMENTATION Monitor pulse & BP Take with food for GI upset Adverse effects: Hypo K+ (weakness, fatigue, arrhythmias, polyuria, polydipsia) Hyper K+ (fatigue, muscle weakness, paresthesia, confusion, dyspnea) IMPLEMENTATION Monitor BP, pulse, weight, I&O. Adverse effects: Low electrolyte levels Hypotension, tinnitus, blurred vision, weakness, cramps, photosensitivity. IMPLEMENTATION Note allergies May give on full or empty stomach Administer around the clock Refrigerate oral suspension Adverse effects: Dizziness, diarrhea, anorexia, N&V, superinfection REASON FOR TAKING CHF Slows and strengthens heart REASON FOR TAKING Replace K+ due to diuretic use PATIENT TEACHING Do not double dose How to take pulse Report dyspnea, weight gain, edema
REASON FOR TAKING Remove fluid and decrease hypertensio n REASON FOR TAKING Mild UTI
PATIENT TEACHING Avoid salt substitutes. Report weakness, tingling, fatigue, diarrhea, N&V. Foods high in K+: Avocados, bananas, broccoli, tomatoes, peaches, nuts, potatoes, cantaloupe, dried fruit, peaches, spinach. PATIENT TEACHING Change positions slowly, eat foods high in K+ (see above), Use sunscreen
LAB NORMS WBC 5.0-10.0 x 10 3rd No bacteria
PATIENT TEACHING Finish all med Take missed dose ASAP, do not double dose. Report failure to resolve Notify MD fever, diarrhea
COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING OBJECTIVE CRITERIA FOR GRADING NURSES NOTES Your charting is expected to reflect a level significantly beyond the nurses aid ability as you move through this program. Your assessments, observations, and documentation must reflect professionalism and technical ability. From now until graduation your charting will be evaluated almost daily. The following criteria provide guidelines for the daily evaluations. If, after being instructed to improve in an area, a student consistently fails to improve or to follow through, or requires repeated reminders, the student shall receive an unsatisfactory grade. Know and apply the following guidelines and you will be able to successfully meet the charting objectives. 1. Record legibly. 2. Properly record information pertaining to the patient which will assure safety for the patient, hospital, or health worker. 3. Describe the exact time, effect, and reaction of the patient to therapy or treatment rendered. 4. Describe the character and amount of drainage, vomitus, stools, urine, or hemorrhage (bleeding) from the body. 5. Describe the type, onset, location, and duration of pain. 6. Note the time, visit, examination, and reaction of the patient to the visit of physician or other health worker. 7. Describe the patients condition - usual, unusual, or changed. 8. Adapt to requirements of different health facility requirements. 9. Use clear, concise terms which plainly describe a situation pertaining to the patient and will be quickly understood. 10. Record facts, do not include opinions or feelings
SO always looks to provide you, a nursing professional, with important tips to help you avoid malpractice. Below is an example to save for you files.
DO'S AND DON'TS OF DOCUMENTATION

These tips will help you improve your charting. Not only can good documentation help you defend yourself in a malpractice lawsuit, it can also keep you out of court in the first place. You have to make sure its complete, correct, and timely. If its not, it could be used against you in a lawsuit. The documentation dos and donts included in this article can help. Theyre excerpted from the Nurses Service Organizations 1-day seminar Avoiding Nursing Malpractice.
DOS
Check that you have the correct chart
before you begin writing.
DONTS
Dont chart a symptom, such as c/o pain, without also charting what you did about it. Dont alter a patients record. This is a criminal offense. Do not use white out or obliterate. Place a single line through the mistake only. Dont use shorthand or abbreviations that arent widely accepted. Dont write imprecise descriptions, such as bed soaked or a large amount. Dont give excuses, such as medication not given because not available. Dont chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately. Dont chart care ahead of time. Something may happen and you may be unable to actually give that care youve charted. Charting care that you havent done is considered fraud
Make sure your documentation

reflects the nursing process and your professional capabilities.
Write legibly Chart the time you gave a

medication, the administered route, and the patients response.
Record each phone call to a

physician, including the exact time, message, and response.
Chart a patients refusal to allow

treatment or take medication. Be sure to report this to your manager and the patients physician.
Chart patient care at the time you

provide it. If you remember an important point after youve completed your documentation, chart the information with a notation that its a late entry. Include the date and time of the late entry.
PRACTICE NURSES NOTES

Rm:________ Initials: ________ Dx: ______________ Students Name: __________________________ Facility:________________________ Date 2/19 Time 0730
0830
0840 0915
1140
1220
#3 Acute pain r/t ineffective relief of leg spasm AEB S frequently verbalizes reports of inadequate relief. States most of the time 9/10 on pain scale. O moaning softly, facial grimacing, pulse 118, B/P 162/88. I1: Instructed in abdominal breathing during muscle spasms. ---------------------------------------------------------------------------------L. Cleveland, SVN. #3 I2: Coached during episode of left leg spasm, pain 8/10. E1: Able to demonstrate abdominal breathing. E2: Focused on breathing, but restless after about 45 seconds of controlled breathing. Requested pain medication for 10/10 pain level. -------------------------------------------L. Cleveland, SVN. #3 I3: Administered meperidine 50mg IM for severe left leg spasm. ---------------------------------------------------------------------- L. Cleveland, SVN. #3 E3 Stated pain reduced to 4/10. Pulse 82, B/P 126/82. Able to talk and assist with bath without c/o pain. I4: Encouraged to use radio with earphones during episodes of spasms, with imagery. E4: Stated she thought she would rather try the breathing exercises at this time.------------------------------------------------------------- L. Cleveland, SVN. #3 I3: Administered meperidine 50mg IM for left leg spasm, 7/10. Using breathing techniques during episode of spasm. E1: verbalized the breathing is helping her deal with the pain. ------------------------------- L. Cleveland, SVN. #3 I5: Reassessed pain relief. E5: Sleeping with shades closed and curtain drawn. ---------------------------------------------------------- L. Cleveland, SVN.
(#3 related care plan number located in residents chart)
COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 52 SAMPLE
BODY MECHANICS
CLINICAL/LAB SKILLS Upon completion of classroom assignment, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Maintain proper body alignment of all assigned patients. I N S T R L C 12/12/06-MCC-Rm 24-TR- Upon entry into room, observed pt sliding down in bed, with arm caught underneath body. Lowered head, repositioned with support under paralyzed Lt. arm, placed washcloth in palm to prevent contracture. Raised head and knees. Good job - based on your description you have a good understanding DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
Skills: 1. Gait belt use
8/7/06-MMCMS-Rm112-RC- Amb down hall w/belt 10/23/06-MMCMS-Rm 109-AL- Transferred w/belt bed to chair 11/11/06-FMC-Rm 8-MF-Assisted amb with walker 2x day both days using gait belt.
Please contact instructor to observe you using gait belt on patient one more time.
COMMUNICATION
CLINICAL/LAB SKILLS Upon completion of classroom assignment, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Verbally report observations immediately to both staff and instructor. DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
L C
4/23/06-FMC-Rm 15-JL-AM B/P 188/112, baseline 146/84 reported to RN who gave pen antihypertensive 4/24/06-FMC-Rm 18-TH-Confused and drowsy 30 min after prn pain med. Reported to RN, continued to assess VS.
Good reporting
2. Communicate with instructor, staff, and peers when requiring assistance. 3. Communicate with instructor and staff when patient refuses any aspect of care within 30 minutes. 5/27/06-MMCMS-Rm 118-KL-Refused all am care & bath. Reported to student sup-team leader & instructor.
L C
Prompt reporting prevented an incident. Great job.
ELIMINATION NEEDS
8. Demonstrate correct technique for applying a condom catheter. 9. Discuss & demonstrate correct technique & procedure while obtaining a residual urine. 2/11/06-FMC-Rm 22-DL-Voiding frequent small amts previous shift. MD ordered residual urine straight cath and keep in >350 residual. DL voided 125ml immediately after which I inserted 16f foleyw/ 875ml clear yellow urine returned. Balloon inflated, cath anchored. Pt tolerated well & verbalize relief. RN notified. L C Impressive! You reviewed the procedure and were very prepared. Also document asepsis objective.
College of the Siskiyous Vocational Nursing Satellite Rotation Clinical Evaluation Rotation: ____________________________ Student Name: ________________________________ Pre-Conference Date: __________ Time: ___________ Instructor Signature: ______________________
Under no circumstances is the student to remain in the satellite facility if the instructors signature is not present above. Please send the student home immediately and notify the assigned clinical instructor or the director.
ATTENDANCE: Staff, please sign and date each day, arrival and departure (Student cannot receive credit if signatures are omitted). Date: ___________Arrival time:___________Departure time:___________Signature:_________________________________ Date: ___________Arrival time:___________Departure time:___________Signature:_________________________________ Date: ___________Arrival time:___________Departure time:___________Signature:_________________________________ Date: ___________Arrival time:___________Departure time:___________Signature:_________________________________ STAFF EVALUATION: 1 = Not consistent in meeting expectations 3 = Exceeds expectations Objectives
1. Knowledge a. Focused on objectives b. Prepared for assignments c. Able to identify norms & deviations d. Transfers theory-demonstrates understanding e. Demonstrates ability to think critically 2. Nursing Diagnosis: a. Assesses both subjective & objective data b. Focuses on goals c. Implements appropriate intervention 3. Skills: a. Good organization/meets time frames b. uses universal precautions and asepsis c. Consciously exhibits concern for safety of clients d. Demonstrates competency in skill performance 4. Documentation: a. Uses correct spelling, terms, etc. b. Uses correct format c. Comments/notes are complete/clearly written 5. Communication: a. Communicates clearly to clients/staff/public b. Communicates professionally to clients/staff/public c. Demonstrates active listening skills 6. Attitude: a. Calm, quiet, respectful to peers, staff, client, public b. Assumes responsibility for assignments-comes prepared c. Willing to assist with various tasks/actively participates d. Demonstrates a cheerful, caring attitude e. takes initiative/self-directed/actively participates 7. Discipline: a. Arrives on time/completes required hours b. Neat appearance in compliance with school dress code c. Maintains confidentiality/privacy d. Cooperative e. Able to accept criticism and suggestion f. Adheres to school rules - does not need reminders 8. Ethics/Legal Issues: a. Maintains confidentiality/Privacy b. Reports omissions or errors ASAP c. Behaves with honesty and integrity 9. Role Concept: a. Describe your goals/progress/strengths or areas needing improvement
2 = Meets expectations N/A = Not applicable to this assignment Day 2/Date Postconference Comments
Preconferenc e
Day 1/Date
Post-conference Date: _________ Time:___________ Instructor Signature: ________________________
College of the Siskiyous Vocational Nursing Nursing 53 Objectives Table of Contents Section Asepsis & Infection Control Basic Physical Assessment Communication Diabetes Mellitus Endocrine Disorders Fluid, Electrolyte, & Acid Base Balance Functioning in Groups Home Health/Contemporary Health Care Intensive Care Unit/Special Care Unit Leadership Student Supervision Leadership Satellite Experience Medication Administration Nursing Process Obstetrics & Newborn Nursery Outpatient Surgery Recording & Reporting Respiratory Disorders Stress Adaptations Teaching & Learning Urologic Disorders Values & Ethics Public Health/Maternal Child Health Write Up # #, ## #, ## #, ## # Objective Count 10 15 8 13 5 15 10 25 18 14 35 6 15 45 25 5 14 11 26 27 7 37 Page # 2 3 4 5 7 8 10 11 17 23 24 34 35 36 48 56 57 59 61 63 66 67
## #, ##
# #, ##
Skills moved from Nursing 52: Respiratory skill #16: Pediatric NaCl installation and bulb suction (1) Reproductive skill # 10: Application of cold compress (1) Ostomy Care: All objectives (11) Total Nursing 53: 362 Total with Public Health: 399 Total Objectives Nursing 51, 52, 53: 1243 90%: 1119 95%: 1172 # Written Objectives # # If no opportunity by the end of Nursing 53, may write out @ Terminal objectives * Licensed staff may sign off
COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53
ASEPSIS AND INFECTION CONTROL

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: MEDICAL ASEPSIS 1. Demonstrate competency in medical asepsis. One omission & this objective cannot be achieved. @ 2. Correctly and consistently employs precautions in appropriate patient care activities (emesis, urine, fecal material, chemsticks, etc.). One omission & this objective cannot be achieved. @ 3. Correctly and consistently employs isolation techniques to protect himself/herself and others when caring for a patient in an isolation unit. (Must have a patient in isolation) 4. Assume responsibility for implementation of isolation precautions based on diagnosis or diagnostic workup. 5. Explain MRSA & describe at least five nursing interventions to prevent the spread of this organism. # * I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
SURGICAL ASEPSIS Successful completion of these objectives shall be recognized when the student accomplishes them with no cross-contamination between clean and unclean items. 6. Correctly perform & document at least five different sterile procedures (dressing changes, catheters, etc.). (5 objectives) 1. 2. 3. 4. 5.
Total (10): ______
BASIC PHYSICAL ASSESSMENT

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: OBJECTIVE: 1. Perform a physical assessment including all body systems and physiologic needs of assigned patients. SKILLS: Demonstrate third semester (N53) level assessment including all body systems and physiologic needs of assigned patients: (Each objective is to be completed on separate patients) 2. Neurological 3. Sensory-perceptual 4. Musculoskeletal 5. Skin 6. Respiratory 7. Cardiorespiratory. 8. Gastrointestinal 9. Genito-urinary In addition, correctly assesses & documents the following: 10. Pain level, location, description, etc. 11. Focused assessments I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
12. Neurovascular checks
13. Tubes/drains
14. Oxygen levels 15. Labs, etc.
Total (15): ______ COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53
COMMUNICATION
CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Verbally report observations in a manner demonstrating an understanding of underlying theory. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Communicate observations and assessments that are complete and relevant. @
3. Communicate with instructor, staff and peers when requiring assistance. Document at least three situations in order to achieve objective.
1.
2.
3.
4. Communicate with instructor and staff when patient refuses any aspect of care within 30 minutes. Any one omission & this objective cannot be achieved. (Must have at least 1 situation in which care was refused.) SKILLS: 5. Prepare and present a critical thinking exercise. (4 objectives)
Total (8): ______
DIABETES MELLITUS
CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. List interventions you provided which are specific to the patients diagnosis of diabetes mellitus and your rationale. * I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Provide patient teaching to an assigned patient including the type(s) of insulin ordered, onset of action and when to expect a reaction.
3. Provide proper skin care to a diabetic patient, including the feet, and explain to the patient the importance of such care.
4. Describe typical ineffective coping behaviors related to the diagnosis of diabetes. #
5. List five ways a nurse could provide emotional support and encouragement to a diabetic patient. #
1. 2. 3. 4. 5.
PAGE 2: DIABETES MELLITUS

CLINICAL/LAB SKILLS SKILLS: 6. Assess, intervene, report and document symptoms of diabetic acidosis and insulin shock. ## 7. Assess, intervene, report, and document symptoms of insulin shock. ## 8. State normal fasting glucose levels. # DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
9. Describe normal post-prandial glucose ranges. #
10. Assess lab values for a diabetic patient noting blood sugar, electrolytes, and A1C hemoglobin glycosolated values. List normal values and your patients values and what any abnormal values might indicate. 11. Instruct a diabetic patient in preparation and administration of insulin. *
12. Instruct a diabetic patient in performing chemsticks/accuchecks.
13. Instruct a diabetic patient in diet modifications.
Total (13): ______
ENDOCRINE DISORDERS
CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
1. Provide basic nursing care to patients experiencing various disorders of the endocrine glands.
Describe the disorder.
2. Identify patient with hypothyroidism and describe patient teaching. ##
3. Describe the post-operative nursing care of a patient who had a thyroidectomy or parathyroidectomy. #
State the surgery.
4. Describe the patient teaching to someone receiving corticosteroid therapy. #
5. Explain the electrolyte profile of an individual with an endocrine disorder. #
Total (5): ______
FLUID, ELECTROLYTE, AND ACID-BASE BALANCE

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Recognize signs and symptoms of fluid and electrolyte imbalances and report them accurately. * I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Discuss appropriate nursing interventions to prevent fluid imbalance. #
3. Discuss appropriate nursing interventions to prevent electrolyte imbalance. #
4. Demonstrate appropriate monitoring techniques in patients at risk for fluid imbalance.
5. Demonstrate appropriate monitoring techniques in patients at risk for electrolyte imbalance.
6. Review an assigned patients laboratory values for sodium, chloride and potassium levels and state abnormal results.
7. Provide patient teaching regarding signs and symptoms of both sodium and potassium deficits.
8. Assess a patient prior to, during, and immediately after a blood transfusion for signs of a reaction. ##
PAGE 2, FLUID, ELECTROLYTE, AND ACID-BASE BALANCE

CLINICAL/LAB SKILLS 9. Prepare and observe a patient undergoing therapeutic phlebotomy. Explain the rationale. # I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
10. Assess a patient for fluid overload. (Strict I&Os, correct daily weights, girth measurement). Must be documented.
SKILLS: 11. Correctly assess, report and document pedal edema.
12. Accurately calculate the drop rate of a patients prescribed intravenous infusion.
13. Correctly complete charting required during a blood transfusion.
14. Correctly discontinue an IV with appropriate documentation.
15. Correctly discontinue a saline lock with appropriate documentation.
Total (15): ______
FUNCTIONING IN GROUPS
CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Demonstrate active participation within the work group. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Demonstrate courtesy & respect toward instructors, peers, staff and others. List five examples. @
1. 2. 3. 4. 5.
3. During pre- and post-ward, contribute in a positive and constructive manner at all times. @
4. Demonstrate active listening during pre- and post-ward. @
5. Problem solve in a professional manner. List five examples.
1. 2. 3. 4. 5.
6. Particpates in the Yreka Health Fair; taking blood pressures and supporting the College of the Siskiyous nursing program. (5 objectives)
Total (10): ______
10
HOME HEALTH THE CONTEMPORARY HEALTH CARE SYSTEM

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Completion of patient worksheet (5 objectives) 2. Completion of pre-assignment prep sheet (3 objectives) 3. Verbalize entry level scope of practice for vocational nurses or registered nurses, working in community health care settings. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS STAFF INT.
4. Describe various job opportunities for VNs within community settings. (Not limited to Home Health)
5. Describe some major problems confronting health care today as it relates to patient care.
6. Discuss the role of utilization review/discharge planner in regard to patient care and home health nursing.
7. Assist in providing basic nursing care to a patient in a home care environment reflecting the philosophies and purposes of home health care nursing. Complete attached worksheet in order to receive credit for objectives. 8. Explain how a patient is referred to the Home Care nurse and how patient services are paid. (To be typed and turned in at post-conference) # 9. Participate in confirming and following physicians orders communicated to a home health agency and communicate your evaluation of patient care to the physician.
N/A
10. Give two examples of how patients benefit from Home Nursing care and state in what manner. (To be typed and turned in at post-conference) # 11. Discuss how the Home Care nurse can decrease the length of patients hospitalization and prevent further hospitalizations. (To be typed and turned in at post-conference) #
N/A
N/A
11
PAGE 2: HOME HEALTH/THE CONEMPORARY HEALTH CARE SYSTEM

CLINICAL/LAB SKILLS 12. Appropriately assist in referral of a patient to a social service agency. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR COMMENTS STAFF INT.
13. Explain the Home Care nurses role in the discharge planning of a hospitalized patient who will be requiring home health care nursing.
14. Observe the role of the RN in the home setting and compare with the responsibilities of the LVN.
15. Assist the Home Care nurse in meeting and documenting the patients physiological needs during a home care visit. 16. Assist the Home Care nurse in meeting and documenting the patients psychosocial needs during a home care visit. 17. With the assistance and supervision of the Home Care nurse, adapt equipment within the home environment to meet the needs of the patient. Complete worksheet in order to receive objective credit.
18. Adapt communication and teaching skills to meet the home care patients needs. Complete worksheet in order to receive credit for objectives.
19. Identify different home situations regarding the caregivers methods of coping with stress associated with caring for a patient in his/her home. Complete worksheet in order to receive credit for objective. (To be typed and turned in at post-conference) # 20. Describe how this experience will affect your care of patients in the future, specifically related to discharge planning activities. (To be typed and turned in at postconference)
N/A
N/A
Total (25): ______ Worksheet (5): ______ Prep Sheet (3): ______
12
HOME HEALTH ROTATION Fall 2008 North County pm 1833 S. Oregon Yreka 842-7325 Kelly Dewey, RN Secretary: Paulette 317 Deetz Rd. Mt. Shasta 926-4142 Coy Welborn, RN Secretary: Vickie South County 8:00 am 4:30
DATES August 27-28 September 3-4 September 10-11 September 17-18 September 24-25 October 1-2 October 8-9 October 15-16 October 22-23 October 29-30 November 5-6 November 12-13 November 19-20 December 3-4 December 10-11
STUDENT North County Aura Richert (541) 488-1480 Marion Stephens (530) 598-0052 Chelsie Burt (503) 475-1752 Susan LaGrange (530) 842-2984 Erica Droscher (541) 778-9536 Nicole Suter (530) 340-3839 Jenny Oliver (503) 951-8184 Marlo Shipman (541) 295-0635 Melissa Halvorseth (530) 905-0679 Raquel Ferguson (530) 598-5537 Natalie Schurwanz (530) 520-3207
STUDENT South County Vanessa Berg (916) 524-8753 Sonia Williams (530) 859-2357 Rhonda Holmes (612) 730-2086 Kristie Fowler (541) 301-0258 Jay Mais (530) 926-3688 Megan Horner (530) 938-4587 Richelle Deveraux (530) 859-0558 Lesli Sellman (530) 926-6680 Chelsey Faria (530) 859-0289 Alexis Najera (530) 926-1258 Mylissa Peck (530) 918-9350 Jen Krock (530) 918-9398 Jeff Wagner (541) 890-7944
13
Patient Worksheet Home Health Care After assisting and observing home health care patients, describe the following. (One objective each for a maximum of 5 objectives).
RN/ LVN Initials Date Chief reason for home health referral Modifications of home environment, in order to accomplish home care Describe patient teaching or learning needs Who in the home provides the care? (Spouse, daughter, etc.) Assess caregivers ability to cope. Describe how much help or time out the caregiver receives.
14
PRE-ASSIGNMENT PREPARATION SHEET (3 objectives) HOME HEALTH ROTATION Student Name: _______________________________________ Rotation Dates: ____________________
PLEASE READ THE FOLLOWING AND INDICATE THAT YOU UNDERSTAND WHAT IS EXPECTED OF YOU PRIOR TO YOUR HOME HEALTH ROTATION: 1. Students are to dress in professional and conservative attire. This includes slacks, blouse, school vest or jacket, and name tag. No jeans, low neck blouses, mid-drift shirts, or sandals are allowed. Jewelry and hair are the same as clinical dress code. Students may wear their whites if desired. 2. Lunches are often eaten in the car between home visits. You are to prepare and bring your own lunch every day. 3. You are under the direct supervision of the staff in the home care agency, you are expected to follow their directives. 4. Please leave all personal problems at home and maintain a professional decorum. 5. If you are ill, you are expected to call the agency by 7 a.m. and your clinical instructor. You are expected to attend the entire time or you will receive no credit for the day. If you are not making home visits, utilize the time doing your post assignment written questions. 6. Call the home health agency the day before to find out which patients you will be working with.
I have read and clearly understand the above requirements: Student Signature: _________________________________________________ BRING THIS FORM AND ANY ADDITIONAL DOCUMENTATION REQUIRED TO YOUR PREROTATION CONFERENCE: 1. Copies of patient consent forms: _____________________________________
PLEASE ANSWER THE FOLLOWING QUESTIONS: 2. Briefly explain the rules and regulations you will be expected to observe during your home health rotation.
15
3.
Briefly review job titles and responsibilities of the various nursing personnel in most home health agencies.
4.
Please indicate whether the following responsibilities: I: can be performed by you independently (without supervision) A: can be performed by you with assistance due to limited student experience, or S: can be performed by you only under the direct supervision of a licensed nurse. 1. Hygiene - including special skin care and shaving 2. Positioning, turning, ROM 3. Bedmaking 4. Feeding, assisting with meals 5. Ambulation, transfers from bed to chair, etc. 6. Vital signs 7. Weighing 8. Bandages, binders & TED stocking application 9. Soaks, compresses, simple dressings 10. Catheter care 11. Intake and output 12. Enemas, Harris flush 13. Specimen collection (urine, sputum, stool, wound drainage) 14. Blood Glucose Testing 15. Maintaining medical and surgical asepsis 16. Using universal precautions as appropriate 17. Sterile dressings 18. Catheterizations 19. Catheter irrigations 20. Suppositories 21. Cast care Traction 23. Colostomy care, ileostomy care Colostomy irrigation 25. Ventilator patients 26. Administer oral or injectable medications 27. Anything else not on this list!
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 22. _____ _____ 24. _____ _____ _____ 5.
Prepare the following written objectives; neatly typed and in detail. In order to receive credit for these objectives, they must be turned in on the day of your post-conference. #8, #10, #11, #19
16
INTENSIVE CARE UNIT/SPECIAL CARE UNIT

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment in the ICU will be able to: INTENSIVE CARE UNIT The student shall demonstrate initiative and accountability while working under the direct supervision of the staff and instructor in a special care assignment by: 1. Verbalizing understanding of commonly used medications in the special care unit. (5 objectives, see drug prep sheet) 2. Completion of Clinical Specialty Worksheet based on policy and procedures. (4 objectives) 3. Completion of ICU patient prep sheet on each patient cared for during rotation. (2 objective for each day) 4. Performing head to toe assessment with ICU nurse at beginning of the shift. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS STAFF INT.
N/A N/A
N/A
5. Demonstrating ability to follow ICU procedures in nursing care and assessment (i.e., vital signs and I&O at least q1h). Documents care given.
6. Demonstrating responsibility for assuming patient care within the VN scope of practice.
7. Verbalizing understanding of patients diagnosis and need for ICU admission.
SKILLS: 8. Accurately monitoring vital signs and promptly reporting changes.
Total count (18): ______ ICU Clinical Specialty Worksheet (4): ______ ICU Clinical Preparation Sheet (4): ______ ICU Drug Preparation Sheet (5): ______
17
NAME ______________________________________ CLINICAL SPECIALTY WORKSHEET INTENSIVE CARE UNIT Prior to your clinical rotation you are expected to complete the following objectives (4 objectives): 1. Review and discuss facility P & P regarding standard physiological monitoring routines.
2. Define the definitive care or flex patient.
3. List major procedures that may be done in the ICU. Discuss the rationale for doing in this environment.
4. Discuss nursing responsibilities for the patient on mechanical ventilation.
18
Name _____________________________________ CLINICAL PREPARATION SHEET INTENSIVE CARE UNIT 5. List types of ICU patients you are caring for during rotation (Review with instructor daily). (4 objectives) PATIENT INITIALS, DIAGNOSIS 1. FOCUSED ASSESSMENT POSSIBLE NURSING INTERVENTIONS PATIENT TEACHING
2.
3.
4.
5.
19
6.
7.
8.
20
Name: __________________________ DRUG PREPARATION SHEET INTENSIVE CARE UNIT/SPECIAL CARE UNIT
PLEASE NOTE: All drug information must be completed to the test in order to receive credit. Partial credit cannot be
given. Omission of even one drug will result in ZERO objective credit for drug preparation. If you are unable to locate the medication in your drug book, research other sources. (5 objectives)
You will be given a written quiz before your rotation. You will be expected to pass this quiz with at least 75%. If you do not pass, you may be allowed 2 additional retakes, provided you can pass prior to your assigned rotation. If you do not pass, you will loose objectives for the drug prep. In addition, you may loose objectives for that rotation. A key may be checked out prior to the quiz after showing this completed form to your instructor.
Trade name, generic name, class

1. Dobutamine
Reason For Use
Special Considerations
2. Adenosine
3. Dopamine and Regative
4. Calcium Chloride
5. Atropine
6. Dextrose 50%
7. Epinephrine drip
8. Procanimide
9. Magnesium Sulfate
21
10. Narcan
11. Propofol
12. Nipride drip
13. Nitroglycerin drip
14. Procainamide drip
15. Zantac drip
16. Digoxin
17. Lasix
18. Potassium Chloride
22
LEADERSHIP - STUDENT SUPERVISION

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Provide all SVNs with daily forms, designate absent students.. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Counsel students who are tardy, not prepared for assignments, or do not meet dress code requirements. (Must resolve a problem in order to receive the objective) 3. Assign lunch and breaks. Assess break book for signatures and counsel SVNs who do not sign prior appropriately. 4. Perform daily chart checks and document on worksheet. (2 objectives each worksheet) 8 total objectives. 5. Follow up with students whose charts are incomplete to gain compliance in a timely manner.
Give specific examples.
Give specific examples. 1. 2. 3.
Give specific examples. 1. 2. 3. Give specific examples. 1. 2. 3. Give specific examples. 1. 2. 3.
6. Collect daily forms at appropriate time and make written comments regarding performance.
7. Replace forms before running out so that all is prepared for next week.
Total (14): ______
23
LEADERSHIP AND SUPERVISION (Satellite Rotation)

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Completion of Drug Preparation Sheet (5 objectives) 2. Demonstrate the ability to make effective decisions in the best interests of the patient and within your scope of practice. 3. Communicate duties and assignments clearly to staff and peers. 4. Demonstrate effective communication by following the proper chain of command. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS STAFF INT.
5. Provide encouraging and supportive nursing care while demonstrating awareness of the emotional needs of the long-term care patient. 6. Provide encouraging and supportive nursing care while demonstrating awareness of the physical needs of the long-term care patient. 7. Assist in updating and evaluation of nursing care plans.
8. Make patient rounds for the purpose of evaluating the patients condition and the effectiveness of patient care. 9. Assist in the extensive admit assessment, history and orientation of the long-term care patient. 10. Assist staff in performing standard and sterile nursing procedures. Give 3 different examples. 1. 2. 3.
24
PAGE 2: LEADERSHIP AND SUPERVISION SATELLITE ROTATION

CLINICAL LAB SKILLS 11. Assist in coordinating patient discharge or transfers. Describe coordination efforts of those discharged. 12. Develop both a teaching plan and a tool to use while providing discharge instructions to a patient on multiple medications. (Include with objective for instructor to sign off.) 13. Observe the charge nurse in the delegation of nursing duties to various nursing personnel. Critique the tasks delegated by the charge nurse. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS STAFF INT.
14. Assist the charge nurse in charting responsibilities. Describe various charting responsibilities you completed. 15. Attend a patient care conference. 16. Conduct a teaching session on a topic related to basic care, to a small groups of CNAs. (5 objectives) 17. Observe & describe the correct procedure for controlled substance count.
SKILLS: 18. Phone or fax various lab reports to a physicians office. Describe those reports.
19. Note and update the resuscitation station of all patients. Identify where this information is located.
25
PAGE 3: LEADERSHIP & SUPERVISION SATELLITE ROTATION

CLINICAL LAB SKILLS 20. Transcribe admit orders and/or assist in taking new orders. 21. Perform initial admission assessment and chart correctly. 22. Initiate a care plan entry on a new problem developed by a patient. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS STAFF INT.
23. Communicate to pharmacy any new orders and/or changes in orders.
24. Administer all medications to a team of patients. Includes drug prep/cards and follow-up documentation. 25. Communicate changes in a patient condition to a physician.
26. Administer treatments.
27. Perform weekly skin assessment.
28. Draw blood for lab work (if already completed venipuncture section if IV therapy course).
Total (35) _____ Teaching (5) _____ Drug Prep Sheet (5) _____
26
Leadership And Supervision (Satellite Experience) VOCATIONAL NURSING 53

PLEASE NOTE: All drug information must be completed prior to the test in order to receive credit. Partial credit cannot be given. Omission of even one drug will result in ZERO objective credit for drug preparation. If you are unable to locate the medication in your drug book, research other sources. (5 objectives) You will be given a written quiz before your rotation. You will be expected to pass this quiz with at least 75%. If you do not pass, you may be allowed 2 additional retakes, provided you can pass prior to your assigned rotation. If you do not pass, you will loose objectives for the drug prep. In addition, you may loose objectives for that rotation. A key may be checked out prior to the quiz after showing this completed form to your instructor. Generic Name/Trade Name Drug Class 1. fluticasone & salmetrol / Advair Diskus 2. atenolol / Tenormin Dose Reason for Use Special Considerations
3. diltiazem / Cardizem
4. warfarin / Coumadin
5. lanoxin / Digoxin
6. phenytoin / Dilantin
7. metformin / Glucophage
8. isosorbide mononitrate / Imdur
Generic Name/Trade Name
Dose
Reason for Use
27
Drug Class 9.Insulin: Humulin 70/30, Regular, NPH
10. K+ / K-Dur
11. furosemide / Lasix
12. escitalopram / Lexapro
13. atorvastatin / Lipitor
14. benazepril / Lotensin
15. lovastatin / Mevacor
16. gabapentin / Neurontin
17. Nitroglycerin Patch
18. paroxetine / Paxil
19. clopidogrel / Plavix
20. Prednisone
Generic Name/Trade Name Drug Class
Dose
Reason for Use
28
21. lansoprazole / Prevacid
23 risperidone / Risperdal
22. carbidopalevodopa / Sinemet:
24. levothyroxine / Synthroid 25. hydrocodone and acetaminophen / Vicodin
29
Planned Teaching Schedule Shasta View

Name Date of presentation Pre-Conference Date
1. 2. 3. 4. 5. 6. 7.
Using a mechanical lift Caring for a colostomy Positioning the resident Range of motion exercises Ambulating the resident/assisted fall Measuring I & O Measuring height & weight (standing-bedridden-wheelchair) 8. Coughing & deep breathing & use of splint 9. Applying elastic stockings & use of thromboguards 10.Giving a cool water bath 11.Use of inspirometer/nasal cannula/O2 12. Condom catheter 13. Feeding residents 14. Stool/Urine collection 15. Heat/Ice application 16. Communication w/residents & staff 17. Grooming 18. Basic emergency care 19. Infection control 20. Non pharmacologic Comfort Measures 21. Caused of Mental Confusion 22. Accident Prevention in Long Term Care 23. Elder abuse 24. Confidentiality/ HIPPA 25. Sleep Pattern of the Elderly 26. Sensory Alterations 27. Fire Safety (RACE)
Each third semester vocational nursing student is required to do a 20-30 minute teaching segment to CNAs in a skilled nursing facility. The teaching segment will be scheduled on a day the student is scheduled to be in clinical rotation.
Prior to the presentation, complete the attached In-service Education forms. These include a lesson plan, brief description of the course, behavioral objectives, method of instruction and a post-test. The post-test should consist of 10 questions. The In-service Education form should be completed prior to, and reviewed with instructor, at pre-conference appointment. Teaching content must be consistent with the CNA text. A copy of this text will be kept in the classroom for your reference.
Questions used for the post-test should be based on the behavioral objectives. The Director of Staff Development will complete an evaluation of the students teaching skills in order to give feedback to the student and the instructor. This is a great opportunity to practice teaching skills in a controlled environment with a supportive individual. Do the best you can and enjoy!
Objectives (5): _____
30
INSERVICE EDUCATION FORM 1. Lesson Plan Subject: Estimated time: 2. Brief Description of Course:
3.
Behavioral Objectives: Upon completion of the course, the participant will be able to:
4.
Method of Instruction:
31
Emp. # _____________ Name: ________________________ Post Test Name: ____________________________________________ Date: ___________________________
32
EVALUATION MICRO TEACHING PRESENTATION THIRD SEMESTER VN STUDENTS COLLEGE OF THE SISKIYOUS STUDENT NAME: _____________________________________________________ DATE: ________________________________ LENGTH OF TIME OF PRESENTATION: _____ 10 mins. _____ 15 mins. _____ 20 mins.
EXCELLENT GOOD
_____ 25 mins.
FAIR
_____ 30 mins.
NOT DONE OR NOT APPLICABLE N N N N N N
1 2 3 4 5 6 7
Knowledge of subject Demonstration of skill Organization of material presented Ability to answer questions from group Professional presentation Usefulness of material presented Other:
3 3 3 3 3 3
2 2 2 2 2 2
1 1 1 1 1 1
Comments: How will this information improve your patient care? _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Signature (Optional): _______________________________________________
33
MEDICATION ADMINISTRATION 53
CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Administer all medications correctly. (No occurrence reports) All meds all patients. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Demonstrate ability to correctly calculate dosage administration. List 3 examples.
1. 2. 3.
3. Assess, document and provide patient teaching needs relevant to their medication regimen. List 3 examples.
1. 2. 3.
4. Demonstrate responsibility and accountability should a medication error occur. # #
5. Adhere to time frame constraints for medication administration. All meds should be given within 30 minutes before or after on med-surg & 60 minutes before or after on SNF. SKILLS: Patient teaching to include: 1. Relevant information about the medication, written material, & thorough documentation. List 3 examples. 1. 2. 3.
Total (6): ______
34
NURSING PROCESS
CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will demonstrate understanding of the nursing process by successful completion of three of the following care plans: * 1. An assigned simple medical patient. Instructor approval: _____________ I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. An assigned at risk surgical patient, including nursing interventions to prevent or mitigate problems. Instructor approval: _____________ 3. An assigned pediatric patient (6 weeks - 14 years). OR Instructor approval: _____________
4. An assigned complex medical or surgical patient. Instructor approval: _____________
*Patient selections must be obtained from medical-surgical rotations with prior approval from instructor. Student should have provided handson care for two consecutive days. (These care plans are worth 15% of N53 theory grade.) (Each care plan worth up to 5 clinical objectives.)
Clinical Objectives for Care Plans A = 91% - 5 objectives B = 82% - 4 objectives C = 75% - 3 objectives D = 65% - 2 objectives F = under 65% - 1 objective
Total: (15) _______
35
OBSTETRICS AND NEWBORN NURSERY

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Preparation sheet accurately and completely prepared prior to OB rotation. (20 objectives) 2. Verbalizes understanding of commonly used medications in OB and newborn nursery. (5 objectives) I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
3. Demonstrates ability to follow admitting procedures according to hospital policy & physician orders.
4. Observes, assists, and supports a woman in labor. # # (If no patient in labor by the end of NUR 53, may write up how you, as an LVN, would achieve this objective.)
5. Assists with the nursing care during the delivery of a newborn, including assessment, evaluation, ID, VSs, medications, bath. # # (If no patient in labor by the end of NUR 53, may write up how you, as an LVN, would achieve this objective.) 6. Provides nursing care during the post-partum recovery stage (4th stage of labor). 7. Assumes the teaching role to the post-partum family. 8. Observes and/or provides nursing care to the cesarean mother. 9. Observes and assists physician with circumcision. Provide patient teaching for post-circumcision assessment and care. ##
36
OB & Newborn Nursery Page 2

CLINICAL/LAB SKILLS 10. Explain precautions to prevent newborn abduction while describing technique. # 11. Accurately charts newborn and post-partum care on appropriate charts. 12. Demonstrates ability to assess and meet physical needs of the laboring and post partum patient. 13. Demonstrates ability to assess and meet psychological needs of the laboring and post partum patient. SKILLS: 1. Complete OB check/admit record DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Correctly attach fetal monitor. ##
3. Explain the difference between early, late and variable deceleration. # 4. Perform fundal massage. ## 5. Assist with first ambulation postpartum. 6. Assess post-partum patient for urinary elimination. 7. Apgar scoring. Describe results on an assigned NB. ## 8. Observe neonatal resuscitation. Explain the interventions used. ## 9. Assist & describe procedure for identification of mother & newborn. 10. With assigned OB staff, assist in performing the Dubowitz evaluation.
Total (45) _____ Rotation Objectives (20): _____ OB Drug Prep Sheet (5): _____ Speciality Worksheet (20): _____
37
PLEASE NOTE: All drug information must be completed prior to the test in order to receive credit. Partial credit cannot be given. Omission of even one drug will result in ZERO objective credit for drug preparation. If you are unable to locate the medication in your drug book, research other sources. (5 objectives) You will be given a written quiz before your rotation. You will be expected to pass this quiz with at least 75%. If you do not pass, you may be allowed 2 additional retakes, provided you can pass prior to your assigned rotation. If you do not pass, you will loose objectives for the drug prep. In addition, you may loose objectives for that rotation. A key may be checked out prior to the quiz after showing this completed form to your instructor. (73 possible)
DRUG PREPARATION SHEET OB
Generic Name/Trade Name Drug Class

Methylergonovine/ Methergine
Dose
Reason for Use
MgSO4:
Emgel/ Erythromycin Opth . Rubella
Docusate/ Colace
Butorphanol/ Stadol
Ibuprofen/ Motrin, Advil
Acetaminophen c Codeine/ Tylelol with Codeine
Rh immune globulin/ RhoGam
38
Phytonadione/ Vit K
Terbutaline/ Bricanyl, Brethaire
Oxytocin/ Pitocin
Naloxone (neonatal)/ Narcan
Ca Gluconate/ Kalcinate
Misoprostol/ Cytotec Fentanyl transdermal/ Duragesic
1% Lidocaine/ Xylocaine
24% Sucrose
1% Lidocaine without Epinephrine/ Xylocaine
39
NAME: _________________________ CLINICAL SPECIALTY WORKSHEET MATERNAL CHILD OBSTETRICS AND NEWBORN NURSERY (20 objectives possible) 1. Prior to your rotation, review videos and/or textbooks to find the information to complete the following: (1) Describe how to time contractions
Briefly describe early decelerations
Briefly describe variable decelerations
Briefly describe late decelerations
Describe characteristics of normal, healthy FHTs
2. Describe the focused assessment for labor admission. (1)
3. Discuss the following warning signs of complications and antipartum nursing interventions. (1) S.S hemorrhage Nursing interventions S/S eclampsia Nursing interventions
40
S/S urinary retention Nursing interventions
S/S prolapsed cord Nursing interventions
S/S fetal distress Nursing interventions
S/S placental abruptus Nursing interventions
S/S placental previa Nursing interventions
4. Define the stages of labor (include contraction characteristics, expected cervical changes, physical S/Ss. (1) First stage of labor
Second stage of labor
Third stage of labor
41
5. Define the fourth stage of labor. (2) A. Frequency of V/Ss B. Size and position of fundus 1) Describe evaluation of fundus
2) Describe how to document fundal height
3) Describe correct technique to massage fundus
4) Describe how to assess vaginal bleeding
5) Describe the normal number of peripads during the fourth stage and subsequent hours following delivery
6) Describe Post-Partum vaginal bleeding a) Correct terminology b) Progressive changes 7) Describe normal progressive involution of uterus
8) Describe what you should do prior to first ambulation
42
9) Describe observations of first voiding. Explain rationale for this.
10) Describe post partum perineal care.
11) Describe patient teaching regarding asepsis (handwashing) before receiving infant or feeding or nursing infant.
6. Regional anesthesia (1) A. Discuss three types of regional anesthesia and describe nursing interventions in the use of these: 1) ________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 2) ________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 3) ________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ B. Describe proper positioning for a woman post anesthesia. C. Explain the rationale and need for monitoring. D. Describe the technique to assess for urinary retention
43
7. Describe patient teaching and instruction to nursing mothers stressing the importance of diet, fluid intake, beast care and prevention of complications. (1) Diet: ____________________________________________________________________________ ________________________________________________________________________________ Fluid: ___________________________________________________________________________ ________________________________________________________________________________ Breast Care: ______________________________________________________________________ ________________________________________________________________________________ Prevention: _______________________________________________________________________ ________________________________________________________________________________ 8. Cesarean birth patient: (1) A. Describe the care given to a pre-Cesarean birth patient.
B. Describe the care given to an emergency C-birth patient.
C. Describe the care given to a post-Cesarean birth patient.
9. Nursing care of the newborn: (1) In the Delivery Room: A. Describe how and when Apgar scoring is done.
B. Describe when neonatal resuscitation is begun.
C. Describe the methods used to provide warmth for the newborn.
D. Describe the identification process.
44
E. Prophylactic agent to prevent ophthalmia neonatorum. Describe agents used.
F. Describe the correct procedure for instillation.
Immediate Care of the Newborn (1 objective) 1. Describe normal height, weight, head circumference for each sex.
2. Describe normal temperature expected initially. Describe environmental factors that influence newborn temperature.
3.
Describe the procedure for inspecting the cord for signs of hemorrhage.
4.
Describe policy to bathe and dress the infant.
5.
Describe methods of maintaining a clear airway as necessary.
6.
Describe and state rationale for positioning infant appropriately to prevent complications.
45
Routine Nursery Care (1 objective) 1. Describe the hospital policy regarding the correct technique for scrubbing and gowning prior to handling the infant.
2.
Describe daily inspection of infant during bath.
3.
Describe instruction of the mother in performing a newborn bath.
4.
Describe patient teaching to mother in these techniques: Bathing:
Lifting: Holding:
Feeding:
Positioning: Temperature taking:
10. Describe the policy for correct procedure for transporting infant to the mother. (1)
11. Circumcision (1)
46
1.
Describe post circumcision assessment
2. 3.
Describe post circumcision care Describe what to teach the mother
12. Describe the procedure to prevent newborn abduction. (1)
13. Discuss the procedure to assist in the discharge of infant and mother. (1)
14. Observe and care for the premature (preterm) infant. (1) A. Gavage feeding: Describe when you would gavage an infant.
B. Describe the policy for gavage feedings.
15. Assess and meet not only the physical, but also the psychological needs of the laboring woman and the post partum patient. Describe how you met these objectives. (3) (This objective to be completed during the rotation)
47
OUTPATIENT SURGERY
CLINICAL/LAB SKILLS Upon completion of classroom assignments, lecture and discussion, the successful student, during a clinical assignment, will be able to: 1. Complete OPS Rotation P&P completely during rotation. (5 objectives maximum) 2. Verbalize understanding of commonly used medications in outpatient surgery. (5 objectives) 3. Verbalize understanding of types of surgeries during the OPS rotation (2 objectives per day). 4. Document that required forms and diagnostic testing has been completed and appropriately included in the patients chart prior to surgery. 5. Observe and describe the procedure for signing appropriate consents. I N S T R DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
6. Confirm and document the completion of all pre-operative orders.
7. Assess patient allergies and follow correct protocol for documentation.
8. Observe patient teaching and psychological preparation for surgery during pre-op interview.
9. Prepare the patient for surgery. (Clothing removal and storage, patient gown and cap and identification band, use of restroom, completion of surgical checklist and pre-op medications.)
10. Observe initiation IV therapy, observation of IV site, fluids and equipment and describe nursing responsibilities after initiation of IV. 11. Perform post-operative assessment and observe for complications (monitor and document vital signs and a focused assessment).
48
12. Complete charting requirements.
13. Provide discharge teaching (dressings, medications, follow-up visits, complications to report).
14. Perform nursing procedures required on non-student assigned patients with instructor approval.
Total count (25): _______ OPS clinical specialty worksheet (5) _______ OPS clinical preparation sheet (4) _______ OPS drug preparation worksheet (5) _______ Total count: _______
49
DRUG PREPARATION SHEET OPS All drug information must be completed prior to the test in order to receive credit. Partial credit will not be given. Omission of even one drug will result in ZERO objective credit for drug preparation. If you are unable to locate the medication in your drug book, research other sources. (5 objectives). You will be given a written quiz before your rotation. You will be expected to pass this quiz with at least 75%. If you do not pass, you may be allowed to retake provided you can pass prior to your assigned rotation. If you do not pass you may be excused from the rotation. A key may be checked out prior to the quiz after showing this completed form to your instructor.
Generic/Trade name Class

Lidocaine PF
Dose/Route
Reason for use
Special Consideration
cyclopentolate/ Cyclogyl
phenylephrine/ Mydfrin
ciprofloxacin/ Ciloxin meperidine HCl/ Demerol morphine sulfate
midazolam/Versed
diazepam/Valium
ketorolac/Toradol

hydromorphone/Dilaudid
Dose/Route
Reason for use
50
oxycodone/Oxycontin
hydrocodone & acetaminophen/Norco
fentanyl/Sublimazae
dorperidol/Inapsine
Scopolamine
alprazolam/Xanax
ondansetron/Zofran
diphenhyramine/Benadryl
labetolol/Trandate
cephalexin/Keflex
Heparin

promethazine/Phenergan
Dose/Route
Reason for use
51
hydroxyzine/Visteril
famotidine/Pepcid
metoclopramide/Reglan
ranitidine/Zantac
52
Name: ___________________________________ CLINICAL SPECIALTY WORKSHEET OUTPATIENT SURGERY (5 objectives) Prior to your clinical rotation, complete the following: 1. Discuss facility requirements for preoperative screening: A. Lab and other diagnostic tests:
B. Procedure to follow when ordered tests not available.
2.
Discuss facility requirements for obtaining consents.
3.
Discuss facility policy regarding immediate pre-op preparation.
4.
Describe history and physical requirements.
53
CLINICAL PREPARATION SHEET OPS 5. List types of outpatient surgeries scheduled during your rotation (review each day before the rotation) (2 objective per day). SCHEDULED SURGERY
Dates:
FOCUSED ASSESSMENT
PATIENT TEACHING
Dates:
Dates:
Dates:
Dates:
Dates:
Dates:
Dates:
Dates:
54
CLINICAL PREPARATION SHEET OPS (Continued) SCHEDULED SURGERY

Dates:
FOCUSED ASSESSMENT
PATIENT TEACHING
Dates:
Dates:
Dates:
Dates:
Dates:
Dates:
Dates:
Dates:
Dates:
55
RECORDING AND REPORTING

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Report off on all assigned patients to the appropriate staff member in a complete, concise, inclusive and relevant manner. (Staff member must initial each time) 1. 2. 3. 4. 5. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Chart all pertinent information on assigned patient (legibly, neatly, completely). @ 3. Chart procedures using correct language and terminology. @ SKILLS: 4. Signs/initials chart forms in correct format. @ 5. Records all care given on flow sheets in correct format and on all forms. @
Total (5): ______
56
RESPIRATORY DISORDERS
CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Recognize signs of respiratory distress such as dyspnea, cyanosis, Cheyne-Stoke respirations or hemoptysis, while responding quickly and appropriately. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Demonstrate correct nursing skills in the care of the post-operative patient to prevent hypostatic pneumonia.
3. Provide nursing care to the patient with respiratory tract secretions.
SKILLS: 4. Instruct in deep breathing
5. Instruct in coughing
57
Respiratory Disorders Page 2

CLINICAL/LAB SKILLS 6. Instruct in frequent turning I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
7. Position to facilitate easier breathing
8. Demonstrate effective use of medical asepsis
9. Provide patient teaching in preventing the spread of infection. (Teaching card required)
10. Provide patient teaching regarding the importance of increased fluids and good nutrition. (Teaching card required) 11. Provide patient teaching regarding prevention of abdominal distentions. (Teaching card required) 12. Provide care of the patient with a tracheotomy using aseptic technique.
13. Aseptically collect a sputum specimen (explain procedure).
14. Obtain a throat swab specimen for a C/S. (Explain the procedure)
Total (14): ______
58
STRESS AND ADAPTATION

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Demonstrate appropriate nursing care to an assigned patient and/or family member, experiencing ineffective coping during hospitalization. 2. Describe appropriate coping behaviors a patient might utilize in a stressful situation. # 3. Describe appropriate coping techniques a student could use in a stressful situation during a clinical assignment. # 4. State five methods the student could utilize to prevent stress during a clinical assignment. # 1. 2. 3. 4. 5. * I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
SKILLS: Give an example ofyoure your demonstrate effective coping during a clinical assignment by: 5. Remaining outwardly calm.
* *
6. Accept criticism and change behavior accordingly.
7. Demonstrate confidence in nursing abilities.
8. Ask appropriate person for help.
59
9. Not allowing personal problems to affect performance.
10. Performing consistently at best level. @
11. Responding appropriately in a crisis situation.
Total (11): ______
60
TEACHING AND LEARNING

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Identify the overt learning needs of an assigned patient. 2. Instruct patients in technical aspects of health care needs. 3. Thoroughly and yet concisely document both teaching and learning that has occurred. (Give 3 specific examples) 1. 2. 3. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
4. Identifies the overt learning needs of an assigned patient and demonstrates ability to provide accurate patient information of various health education needs. (Document up to 16 different topics. Include teaching cards.) (16 possible) SKILLS: Teach a patient regarding the following: 5. Insulin 6. Special diet
7. Community resources
8. Discharge instructions
9. Life-style changes
Total (26): _____
61
TEACHING AND LEARNING (Record 1 Objective Each)
Week # 1 __________ (date) 2 __________ (date) 3 __________ (date) 4 __________ (date) 5 __________ (date) 6 __________ (date) 7 _________ (date) 8 _________ (date) 9 _________ (date) 10 ________ (date) 11 ________ (date) 12 ________ (date) 13 ________ (date) 14 ________ (date) 15 ________ (date) 16 _________ (date) 17 ________ (date)
Room # 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1________ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______ 1 _______ 2 _______ 3 _______
Pts. Initials __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
LEARNING NEED
INSTRUCTIONS GIVEN
UROLOGIC DISORDERS
CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to: 1. Provide appropriate nursing care to a patient with a urologic disorder. I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
2. Provide nursing care to a patient with a urinary catheter with proper positioning of tubing and maintaining drainage bag below the level of the bladder at all times. 3. Accurately describe rationale for collecting serial urines. #
4. Describe rationale for restricting fluids and for forcing fluids as ordered (urologic patient). #
5. Appropriately assess a patient with renal failure.
6. Provide appropriate nursing care to a patient experiencing renal failure.
7. While caring for a patient experiencing renal failure, provide a quiet environment conducive to rest and explain the rationale.
8. Describe nursing interventions for a patient in renal failure. #
9. Describe the purpose of the following labs and tests in relation to renal failure patients. (3 objectives) A. BUN B. Creatinine C. 24o urine for creatinine clearance #
Urological Disorders Page 2

CLINICAL/LAB SKILLS 10. Provide appropriate nursing care to a patient experiencing renal calculi. # # DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR COMMENTS
11. Assess and document pain and/or bleeding while caring for a patient diagnosed with a renal calculi. ##
12. Summarize the nursing care specific to a patient having peritoneal dialysis. # 13. Assess and document pain and/or bleeding while caring for a patient with a urological infection (cystitis, urethritis, nephritis, pyelonephritis.)
14. Explain rationale for nursing interventions provided to a patient with a nephrostomy tube. # 15. Provide nursing care to a patient with a supra pubic catheter while maintaining sterility and providing instruction for care and clamping upon discharge. Explain rationale. ## SKILLS: 16. Correctly prepare a urologic patient for diagnostic tests and examinations. 17. Accurately measure and record urinary output and/or total shift output. 18. Correctly irrigate a bladder and/or instill medications as ordered, using aseptic technique, with appropriate and accurate documentations. ## 19. On a patient with a 3-way bladder irrigation, accurately observe and document; color of urine, size and number of clots, patency of catheter. 20. Correctly maintain output for a 3-way bladder irrigation. *
Urological Disorders Page 3

CLINICAL /LAB SKILLS 21. Remove a retention catheter, observing for voiding, bleeding, retention, incontinence. Explain teaching given to patient. 22. While caring for a patient with a urologic disorder or infection of the urinary tract, accurately assess, report and document quantity voided, abnormal flow of urine, characteristics of urine (color, odor, clouding), change in pattern of voiding, pain and discomfort, frequency, urgency, incontinence, burning, bleeding, quantity retained. 23. Carefully strain all urine as ordered, with prompt reporting and recording for a patient with renal calculi. # # 24. Provide accurate post-surgical nursing care to a urologic patient, including proper positioning, reinforcement of dressing, correct interpretation of vital sign monitoring, careful measurement of urinary output. 25. Irrigate a nephrostomy or pyelostomy tube. ## DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR COMMENTS
Total (27): ______
VALUES AND ETHICS 53

CLINICAL/LAB SKILLS Upon completion of classroom assignments, lectures and discussion, the successful student, during a clinical assignment, will be able to 1. Maintain a professional standard of ethics. @ 2. Maintain professional behaviors. @ I DESCRIBE HOW YOU COMPLETED THIS OBJECTIVE INSTRUCTOR/STAFF COMMENTS
3. Maintain patient confidentiality at all times. @
4. Demonstrate an understanding & acceptance of the Nursing 53 student vocational nursing role in the clinical setting. @
SKILLS: 5. Maintain appropriate dress code for community rotation. If one violation occurs in this area, this objective cannot be achieved.
6. Assume responsibility for professional conduct during community rotations.
7. Assume responsibility for preparation prior to community rotations. If one violation occurs in this area, this objective cannot be achieved.
Total (7): ______
PUBLIC HEALTH MATERNAL CHILD HEALTH VOCATIONAL NURSING 53 During a scheduled conference with your instructor, complete the following objectives. Develop charts or teaching cards for each of the following: 1. Discuss causative agents, transmissions, signs and symptoms, treatment, prevention, and long-term effects of untreated sexually transmitted diseases, dangers to mother and fetus. (See pp. 255-257 in your textbook and next page of this objective book.) (5 objectives) 2. Contraceptives - Describe common contraceptives and advantages and disadvantages of each. (Include how each prevents formation or early development of a fertilized ovum. Compare the advantages and disadvantages of each method and discuss the most reliable methods of contraception.) (See next page.) (5 objectives) 3. Discuss patient teaching for a client starting on birth control pills. (1 objective) 4. Develop comparison chart between cows milk and breast milk (e.g., fat, protein, CHO, trace elements, calories, etc.). (3 objectives) 5. Develop mini-lesson plan for breast feeding mother. (Include five advantages of breast feeding, dietary modifications a nursing-mother may need to make for herself and her baby, the differences in content of calories, protein, carbohydrates, fat and minerals between breast milk and cows milk, techniques for taking the baby off the breast, and techniques for holding the breast feeding infant.) (5 objectives) 6. Develop mini-lesson plan for bottle feeding mother. (Include methods of bottle preparation and safety factors.) (5 objectives) 7. Describe five critical factors to assess hydration of the infant. (2 objectives) 8. Describe four criteria to assess nutritional status of infant. (2 objectives) 9. Compare the food pyramid to the normal diet of a child. Identify potential problem areas and how you would provide client teaching aimed at correcting deficiencies. (2 objectives) 10. Discuss immunization recommendations for new parents. (Prepare drug cards for each agent on the current immunization schedule.) (5 objectives) 11. Identify injection sites, needle size and gauge for the following: infant, one year, three years, six years. (2 objectives) Total (37) ________
During any Nur 53 Tuesday prep conference meeting with your clinical instructor, be able to recite from memory the following methods of contraception, advantages and disadvantages, failure rate and protection from STDs/HIV. (5 objectives) Contraceptive methods preventing fertilization. Contraceptive Advantages Disadvantages Failure STD/HIV Technique Rate Protection 1. Abstinence No appliances, preparation, or expense At times difficult to maintain 0 Yes 2. Coitus No appliances, preparation, or expense Sperm often escape prior to withdrawal 19% No interruptus 3. Periodic All forms a-d. Requires period of abstinence. Planning and 20% No abstinence (natural No appliance or immediate preparation. records necessary. family planning) Relatively inexpensive. May be acceptable to groups objecting to other forms of contraception. Can be used to plan pregnancy as well as to avoid. a. Calendar Simple Requires period of abstinence, planning. Not 20% No method (rhythm) useful when cycles quite variable. b. Basal body Relatively simple Requires period of abstinence, planning. Body 20% No temperature temperature may vary widely if ill, etc. c. Changes in Once learned, relatively simple. Useful for women Requires period of abstinence. More difficult to 20% No cervical mucus. who do not ovulate regularly. learn to evaluate, more record keeping. Billings or ovulation method d. Symptotherma Women using these methods learn more about Requires period of abstinence, more complex 20% No (employs a-c their bodies. Useful when cervical mucus is record keeping. above & atypical evaluation of other signs & symptoms) 4. Male condom For femal, protection is responsibility of the male. Must be carefully applied after erection and 20% Yes (best fairly inexpensive. Readily available. carefully removed after coitus. Interrupts protection) foreplay. 5. Female condom Female able to protect self. Can be inserted hours Must learn application 7 removal technique. 12% Yes before coitus. Less likely to tear than male condom. Safe alternative if sensitive to latex. 6. Diaphragm or Fairly inexpensive. Highly effective. Can be Must be fitted by health care provider, carefully Diaphragm 18%. Yes cervical cap with inserted hours before coitus positioned by woman. Diaphragm use associated Cervical cap (limited) spermicide with bladder infections; caps with abnormal used by women changes in Pap smears. never pregnant 18%. Cervical cap used by women who have given birth vaginally 36%. 7. Spermacides Easy to apply. Relatively inexpensive. Readily Must be applied within 1 hour of intercourse and 21% Yes available. Provides vaginal lubrication. left in place for 8 hours afterward. Some find it (limited) messy, irritating, or failing to melt or foam correctly. Contraceptive methods preventing ovulation. 1. Combination oral Use not directly associated with sexual activities. Several contraindications exist. Possible 3% No contraceptives (the Easy to use. Ability to stop and conceive. complications include: heart attack, deep vein pill) Protective effect against ovarian and endometrial thrombosis, stroke. Careful follow-up necessary. cancer, pelvic inflammatory disease, and benign Must remember to take daily. Backup method if breast disease. more than one pill is missed. Questionable use during lactation. 2. Progestin-only All of the above advantages, plus does not have Must remember to take at the same time each day. 1.1 to 13.2% No oral contraceptives negative effect on lactation. Less risk of Backup contraception needed if pill is taken 3 or (mini-pill) complications. more hours late. Common side effects: irregular menses, weight gain. 3. Injectable No internal appliance. Not directly associated Contraindications: unexplained vaginal bleeding, 0.3% No. progestin (Depo with sexual activity. Injection lasts 3 months. acute liver disease, breast cancer or blood clots. Provera) Other advantages similar to oral progestin except Requires injections every 3 months. Common side not immediately reversible. effects: irregular menses, weight gain. Progestin implants All of the above advantages except duration of Requires sub-dermal plant with risk of infection, 0.09% No. (Norplant effect is 5 years. Immediately reversible with bleeding, and prominent appearance of rod under removal of rods. skin. Contraindications and side effects similar to those of injectable progestin.
During a scheduled conference with your instructor, be able to recite from memory the following commonly sexually-transmitted diseases including s/s, medical treatment, prevention and effects on the fetus or newborn. Complete effects on fetus or newborn. Use this chart as your guidelines for completing Maternal Child Health Objective #1. Common Sexually Transmitted Diseases
STDs Gonorrhea Signs/Symptoms Male: dysuria, penile discharge of whitish fluid or yellowish purulent matter, eventual sterility. Female: often asymptomatic, but may have vaginal discharge, pain in lower abdomen, burning during urination Primary: Chancre, headache, enlarged lymph glands. Secondary: usually asymptomatic, but may experience rash, loss of hair, sore throat, arthritis. Tertiary: damage to blood vessels, heart, nerves, eyes. Male: lesions on glans penis shaft, scrotal sac, inner thighs. Female: lesions on vulva, vaginal surface, cervix, and buttocks. Female: none or vaginal discharge, urinary frequency, soreness, itching, fishy odor. Male: Dysuria, urinary frequency, whitish, watery penile discharge. Appearance of warts, raised, flat or cauliflower-like growths on genitalia, vagina or cervix. Medical Treatment Ceftriaxone (Rocephin) injection or other antibacterial and doxycycline PO Nursing Interventions & Teaching Teach that health followup is necessary because reinfection is possible. Encourage reporting of sexual partners so they can be treated. Protect self by following standard precautions during care. Teach return for periodic check-ups. Encourage cooperation with public health officials to locate and treat infected partners. Refer to herpes resource center for support. Protect self by wearing gloves during direct care. Assessment for signs of PID in women; education on modes of transmission. Education about transmission, prevention by use of condoms and monogamous relationships and treatment. Symptomatic psychologic support, education on prevention of transmission. Effects on Fetus or Newborn
Syphilis
Penicillin or other antibacterial in primary stage. Symptomatic relief measures.
Genital herpes (herpes simplex virus type II) Chlamydia
Acyclovir or valacyclovir HCI alleviates symptoms. Doxycycline Azithromycin, Erythromycin base (pregnancy) Freezing, laser therapy, surgical removal, topical chemotherapy, podophyllum resin. Build up immune system; treat symptoms; ZDV, didanosine, lamivudine, stavudine, zalcitabine, zidovudine.
Condyloma
HIV/AIDS
Test positive for HIV, weight loss, malaise, frequent infections, opportunistic infections.

Med Sheet

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Med Sheet

Diunggah oleh

Hak Cipta:

Format Tersedia

MEDICATION WORKSHEET Student Name___________________________________ Pt. Initials_________ RM#__________ Dr.

____________________________ Diagnosis: ____________________________________ Allergies: _____________________________________________Last BM: ___________

LAB NORMS WBC 5.0-10.0 x 10 3rd No bacteria

DO'S AND DON'TS OF DOCUMENTATION

Make sure your documentation

Write legibly Chart the time you gave a

Record each phone call to a

Chart a patients refusal to allow

Chart patient care at the time you

PRACTICE NURSES NOTES

(#3 related care plan number located in residents chart)

COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 52 SAMPLE

Skills: 1. Gait belt use

Prompt reporting prevented an incident. Great job.

Post-conference Date: _________ Time:___________ Instructor Signature: ________________________

COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53

ASEPSIS AND INFECTION CONTROL

Total (10): ______

COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53

BASIC PHYSICAL ASSESSMENT

12. Neurovascular checks

14. Oxygen levels 15. Labs, etc.

Total (15): ______ COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53

2. Communicate observations and assessments that are complete and relevant. @

Total (8): ______

COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53

4. Describe typical ineffective coping behaviors related to the diagnosis of diabetes. #

PAGE 2: DIABETES MELLITUS

9. Describe normal post-prandial glucose ranges. #

12. Instruct a diabetic patient in performing chemsticks/accuchecks.

13. Instruct a diabetic patient in diet modifications.

Total (13): ______

COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53

Describe the disorder.

2. Identify patient with hypothyroidism and describe patient teaching. ##

State the surgery.

4. Describe the patient teaching to someone receiving corticosteroid therapy. #

5. Explain the electrolyte profile of an individual with an endocrine disorder. #

Total (5): ______

COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53

FLUID, ELECTROLYTE, AND ACID-BASE BALANCE

2. Discuss appropriate nursing interventions to prevent fluid imbalance. #

3. Discuss appropriate nursing interventions to prevent electrolyte imbalance. #

4. Demonstrate appropriate monitoring techniques in patients at risk for fluid imbalance.

5. Demonstrate appropriate monitoring techniques in patients at risk for electrolyte imbalance.

PAGE 2, FLUID, ELECTROLYTE, AND ACID-BASE BALANCE

SKILLS: 11. Correctly assess, report and document pedal edema.

13. Correctly complete charting required during a blood transfusion.

14. Correctly discontinue an IV with appropriate documentation.

15. Correctly discontinue a saline lock with appropriate documentation.

Total (15): ______

COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53

4. Demonstrate active listening during pre- and post-ward. @

5. Problem solve in a professional manner. List five examples.

Total (10): ______

COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53

HOME HEALTH THE CONTEMPORARY HEALTH CARE SYSTEM

PAGE 2: HOME HEALTH/THE CONEMPORARY HEALTH CARE SYSTEM

COLLEGE OF THE SISKIYOUS VOCATIONAL NURSING 53

INTENSIVE CARE UNIT/SPECIAL CARE UNIT

7. Verbalizing understanding of patients diagnosis and need for ICU admission.

SKILLS: 8. Accurately monitoring vital signs and promptly reporting changes.

2. Define the definitive care or flex patient.

MEDICATION WORKSHEET Student Name_______________________________ Pt. Initials_ RM#______ Dr.

Diagnosis: Allergies: _______Last BM: _

Post-conference Date: ___ Time:_ Instructor Signature: ____________________