clinical package
Description
- Mobility or Safety
- Elimination
- Oxygenation: Gas Exchange
- Thermoregulation or fluid and electrolytes
- Inflammation/infection
- Tissue Integrity
- Pain
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Date: |
7/19/2019 |
Student name: |
Clinical Site/Unit: |
TCU |
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Clinical Site Instructor: |
Clinical Site Mentor: |
George |
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Overweight/underweight: |
Allergies: |
No known |
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Marital Status: |
divorce |
Religion: |
lutheran |
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Cultural Background: |
white |
Primary Language: |
English |
Code status: |
1 |
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Diet/Nutrition: |
Activity: |
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Treatments: |
IV/Tubes/Ostomies: |
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Interdisciplinary Cares (OT/PT/RT): |
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Dressings/Wounds: (type & location) |
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Oxygen: (delivery method & amount) |
Dialysis: |
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Admitting Medical Diagnosis(s): |
Multiple sclerosis |
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Primary (if different than Admitting) |
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Secondary (Do not include History Of): |
Localize edema |
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Medication Data Sheet
Scheduled Medications that your patient is currently taking.
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Drug Name and Classification |
Expected action & indication for use |
Side Effects/ Adverse Reactions |
Medication/Food Interactions |
Nursing Administration Special Instructions & Assessments |
Client Education & Evaluation of Medication Effectiveness e.g. Pain Scale |
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Metoprolol 25mg |
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MiraLAX |
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Multi vitamins |
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Omega 3 fatty acid 1000mg |
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Aquaphor ointment |
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Vitamin d 500mg |
. |
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Magnesium 400mg |
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Bisacodyl suppository 10mg |
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Camphor menthol lotion |
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Acetaminophen 650mg |
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Daily Brains, to be completed during clinical day.Begin your day with a plan and change/make notes as needed.You may print and use this template or create your own.
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Room #:18 |
Diet: |
Ambulation: wheel chair |
IV fluids: |
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Medications |
Treatments |
Nursing care/interventions |
Vital Signs |
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0700 |
Remove hand splint |
Check vital signs Check for constipation |
138/70 |
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0800 |
Calcium Metoprolol Multivitamins Mega 3 |
Apply oitment |
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0900 |
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1000 |
Ensure |
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1100 |
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1200 |
Tizzadine 4mg |
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1300 |
ASSESSMENT SUMMARY: Complete in narrative form based on the form filled out during clinical day.
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Body System |
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Vital Signs and Pain Level: |
138/70 pain level is zero |
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References:
Nursing Standards
Nursing and Midwifery Board of Australia. (2018). Code of conduct for midwives. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
Clinical Guidelines
Guideline Adaption Committee. (2016). Clinical practice guidelines and principles of care for people with dementia. NHMRC Partnership Centre for Dealing with Cognitive and Related Function Decline in Older People. https://cdpc.sydney.edu.au/wp-content/uploads/2019/06/CDPC-Dementia-Guidelines_WEB.pdf
Living Guideline
Stroke Foundation. (2022). Australian and New Zealand living clinical guidelines for stroke management – chapter 1 of 8: Pre-hospital care. https://app.magicapp.org/#/guideline/NnV76E
Evidence-based practice
BMJ Best Practice
Goldfarb, S., & Josephson, M. (2020). Cystic fibrosis. BMJ Best Practice. https://bestpractice.bmj.com/
Schub, T., & Cabrera, G. (2018). Bites: Head lice [Evidence-based care sheet]. Cinahl Information Systems. https://www.ebscohost.com
Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation. http://www.hcmarketplace.com/supplemental/3737_browse.pdf
JBI: Evidence summary
Swe, K. K. (2022). Blood glucose levels: Self-monitoring [Evidence summary]. JBI EBP Database. https://jbi.global
JBI: Best practice information sheet
Bellman, S. (2022). Experiences of living with juvenile idiopathic arthritis [Best practice information sheet]. JBI EBP Database, 24(1), 1-4.
Cochrane Database of Systematic Reviews
Srijithesh, P. R., Aghoram, R., Goel, A., & Dhanya, J. (2019). Positional therapy for obstructive sleep apnoea. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010990.pub2
Drug Information
Codeine. (2023, January). In Australian medicines handbook. Retrieved February 2, 2023, from https://amhonline.amh.net.au
Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm
Dartmouth Writing Program. (2005). Writing in the social sciences. http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing, 13(1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html
Wagner, D. (n.d.). Why writing matters in nursing. https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/
Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html
Perth Children’s Hospital. (2022, April). Appendicitis [Emergency Department Guidelines]. Child and Adolescent Health Service. https://www.pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Appendicitis
Department of Health. (n.d.). Who is being active in Western Australia? https://ww2.health.wa.gov.au/Articles/U_Z/Who-is-being-active-in-Western-Australia
Donaldson, L. (Ed.). (2017, May 1). Healthier, fairer, safer: The global health journey 2007-2017. World Health Organisation. https://www.who.int/publications/i/item/9789241512367
NCBI Bookshelf
Rodriguez Ziccardi, M., Goyal, G., & Maani, C. V. (2020, August 10). Atrial flutter. In Statpearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540985/
Royal Perth Hospital. (2016). Procedural management: Pre and post (24-48 hours) NPS. Canvas. https://courses.ecu.edu.au
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