Preparing for clinical day

First, as nursing students who will be exposed to the clinical area, you need to formulate your general and specific objectives. Bring with you all the paraphernalia and you should also know what are your expected activities applying the nursing process.

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Assume you may end up having to write a care plan on the patient. After your clinical is over and the patient has been discharged, the information is no longer going to be easily available to you, so it is up to you to get the important facts. Getting information about a patient is part of the Assessment process (data collection). The more you know, the more you'll understand about what is going on with the patient and the better you are able to make decisions about their care. No one can ever know the entire patient's medical history, even if you think you do. Sometimes even the patient can't remember everything.

According to one author (Pamela Schuster, Concept Mapping: A Critical-Thinking Approach to Care Planning), 99% of assessment data comes from documentation that is in the medical record and obtaining it can be time-consuming. The other 1% is obtained when you are face-to-face with the patient and perform your own interview and physical assessment. Now, I've known that for years, but this was the first author that I've found who actually wrote it down in a book. That said, here's where to look and what data you might need:

The Patient's Chart

Face Sheet (typically one of the first pages in the chart)

patient's age (you need to know the normal growth and developmental tasks for the patient's age and how illness may/may not have affected that) gender marital status occupation admission date reason for admission (may be called the admission diagnosis, may include any planned surgical procedures) past medical diagnoses

Doctor's Order Sheets/Physician's Orders

any DNR (do not resuscitate) order diet activity allowed orders for lab and diagnostic procedures medication orders IV orders other treatments (i.e., oxygen, catheters, NG tubes, dressing changes) support services (i.e., physical therapy, occupational therapy, speech therapy, respiratory therapy, social worker) consultations by other physicians, usually specialists

Physician's Progress Notes

the patient's progress and response to medical treatment changes in the patient's condition

medical and surgical procedures that have been performed and findings results of tests and procedures

Doctor's History and Physical Exam Physician Consultations

the patients H&P by the admitting physician that includes a review of systems and past medical, family and social history any consultation reports that may also have some review of systems and past medical history the consultation section may contain consults by other ancillary services that don't have their own section in the chart

Surgical Consents

the name of the exact procedure(s) the patient has had or is to undergo (a surgical consent must have the complete name of the surgical procedure written out with no abbreviations)

Operative Report Pathology Report

date and name of surgical procedures done by physicians medical diagnoses findings full description of the procedure and any materials/prostheses placed in the patient's body report on any tissue biopsied or removed during a surgical procedure

Laboratory and Diagnostic Procedures

date and time of collection and analysis/examination of blood, urine, stool and other body substances blood bank records (if the patient has had blood/blood products transfusions) x-ray reports EKG tracings and reports EEG tracings and reports

Nursing Admission Assessment

past medical diagnoses past illnesses, injuries and surgeries if the patient has an advanced directive (living will, healthcare power of attorney) height and weight allergies medications taken at home home caregiver a nursing review of systems a nursing assessment of the patient's ability to perform ADLs

Nurses Notes/flow sheets/Graphic sheet

graphic information (vital signs) I&O information (may indicate IVs and catheters) BM monitoring activity performed

Other resources on the Nursing Unit

Medication cart

Medication Sheet/Record IV Therapy Record o allergies o drugs/dosages/routes/times o IV solutions to be infused and rates double check the generic and/or brand names of the drugs listed on the Medication Sheet/Record by looking at the labels on the drugs in the patient's bin.

The nurses station

Kardex allergies (food and drug) age, gender, admission date diet activity allowed IV orders surgical procedures DNR orders diagnostic tests to be done ordered treatments (i.e., oxygen, catheters, NG tubes, dressing changes) support services (i.e., physical therapy, occupational therapy, speech therapy, respiratory therapy, social worker, discharge planning) o consultations by other physician specialists blank copies of forms you are going to have to document on the next day to become familiar with what information goes on them and where. These forms can include: o assessment forms o fall risk assessment form o standardized pre-written care plans/clinical pathways o printed copies of standing orders o educational materials that might apply to your patient

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The nurses who work on the unit, preferably the one assigned to your patient

anything you can't find on your own

To help you organize your clinical day, print out a copy of the Student Clinical Report Sheet for one patient to help you. This was developed to help students organize their clinical day. The Critical Thinking Flow Sheet for Nursing Students was developed to help include all the elements needed in writing a care plan, but there are some items on it that may help you determine the assessment data you want to collect. Once you get this information THEN start looking up information about the medical diagnoses, procedures, lab tests, drugs and their side effects.