Data tool and concept map
Note from Student. Home work data tool and concept Map

Patient IntroductionLocation: Orthopedic unit 1555SBAR report from day shift nurse:Situation: Mrs. Jacobson is an 85-year-old white female who was admitted last evening after falling and fracturing her hip. X-rays have been taken and show left intertrochanteric hip fracture. Mrs. Jacobson is scheduled for surgery tomorrow.

Background: Mrs. Jacobson has a 10-year history of osteoporosis, and her daughter reports that recently Mrs. Jacobson has been having dizzy spells.

Assessment: Mrs. Jacobson’s vital signs are stable. Her pain is under control with morphine every 4 hours, and I medicated her at 1400. Her pain level was 2 after the morphine. The skin is intact; color and sensation around the hip area are within normal limits. A Morse Fall Scale assessment was completed on admission, and her score was 45. Fall precautions were implemented.

Recommendation: You will need to reposition Mrs. Jacobson as she needs to be turned every 2 hours. You should perform a focused musculoskeletal assessment, reinforce safety, and provide patient education on fall risk. Assess her pain level and medicate for pain if needed.Fundamentals of Nursing CareLynn, P. (2019). Taylor’s Clinical Nursing Skills: A Nursing Process Approach, 5th Edition.Medical-Surgical Nursing CareAssessing the Musculoskeletal System, Chapter 3, pp. 130-136Medical-Surgical Nursing CareComponents of a Neurovascular Assessment, Chapter 3, pp. 130-136Medical-Surgical Nursing CarePreventing Falls, Chapter 4, pp. 146-154Medical-Surgical Nursing CareWound Healing, Chapter 8, pp. 418-421Medical-Surgical Nursing CarePressure Injuries, Chapter 8, pp. 419-421Medical-Surgical Nursing CarePreventing Pressure Injuries, Chapter 8, 416-417Medical-Surgical Nursing CareEnsuring Safe Patient Handling and Movement, Chapter 9, pp. 504-509Medical-Surgical Nursing CarePositioning Patients in Bed, Chapter 9, pp. 503-593Diseases and ConditionsExpert Clinical Content from Lippincott AdvisorPharmacologyHip fracturePharmacologyOsteoporosisPharmacologyExpert Clinical Content from Lippincott AdvisorPharmacologymorphine sulfate-naltrexone hydrochloridePharmacologyraloxifene hydrochlorideProceduresExpert Clinical Content from Lippincott ProceduresPharmacologyPassive range of motion exercisesPharmacologyAntiembolism stocking application, knee-lengthPharmacologyFall managementPharmacologyFall preventionPharmacologyBody mechanicsAssessment ToolsHartford Institute for Geriatric Nursing, New York University College of NursingSPICES: An Overall Assessment Tool for Older Adult, available at: https://consultgeri.org/try-this/general-assessment/issue-1.pdfs

DATA TOOL INSTRUCTIONS

Use this as a guide when completing data tools for each clinical assignment. Following the guidelines for each category will help to assure you have all the pertinent information and data needed on your data tool.

To be completed prior to start of clinical time!!!

Clinical paper work-Data Tool and Concept Map

All clinical paperwork is to be completed by the student assigned to the designated patient/resident/client on designated form. Collaborative work or copying another student’s work is not acceptable and will result in a failing grade and student code disciplinary action. The objectives of this course include but are not limited to

· Demonstrate accountability for own competence, performance, and behavior when working with the adult/geriatric patient.

· Collect health data in an organized manner of the adult/geriatric patient at the beginning level.

· Begin to identify educational needs, risk for complications and environmental factors that could impact on the health of the adult/geriatric patient.

· Perform basic psychomotor skills based on current best practices.

· Utilize the nursing process to identify patient needs, prioritize care and compare findings with expected standards in caring for the adult/geriatric patient.

In order to meet the stated objectives all clinical paperwork is to be completed solely by the student that work was assigned to.

· DAILY PLAN:

Include what you plan to do each hour of the day; bath/am care, vital signs, assessment,

treatments, medications, etc.

· VITAL SIGNS:

State the frequency of vital signs. List a set of base line vital signs for you to compare your results with during the day. **Record vital signs as taken. State shift and day of week due.

· **INTAKE AND OUTPUT:

Calculate intake and output totals . If fluids are restricted or encouraged, specify the amount. Indicate any drains that need to be included in output and their individual amounts to be added to output.

· SITUATION:

This the area of the data tool where basic demographic information about your assigned client will be included which is acceptable under HIPPA restrictions.

· BACKGROUND:

· Weight, Height and BMI : State most recent weight from chart and identify month obtained, review weight history. State height and calculate BMI.

· Allergies: note all allergies, including medications, food, and environmental substances.

· Code Status : State the client’s code status.

· Primary Language : Spoken and written if different.

· Physical Handicaps: Include any physical restrictions the client is documented as having.

· Precautions: Circle the ones that apply and use the OTHER line to include those that may not be listed on this sheet.

· Miscellaneous Data: This section is for any date you may find in the chart which will not really fit into any of the other categories but may still impact your client’s care.

· Past Medical History: This section is used for you to document all medical diagnoses which could impact you care during your day with this client.

· **ASSESSMENT (Patient Data Gathering Worksheet): This whole page will be used to document not only the required treatments and orders of the physician in the appropriate place but, to document your observations while doing your head to toe evaluation of your assigned client.

· Cellular Regulation: This section will include what type of restrictions you will have to be careful of during you day of care, any specific labs that may be involved in this and their tested values, and any restrictions on the amounts or consistencies of these fluids.

· List Labs::These are the most common labs you may encounter, but, you will also notice there is space available for other lab data and diagnostic test that have been performed on this patient and will be pertinent to your client’s care. You will need to include these in this space. Space is provided later in this data tool for a more in-depth look at the lab/diagnostic tests.

· Cognition: This is where you will document your neurological assessment of your client.

· Oxygenation: Again, this will include your assessment data you obtain on your client.

· Perfusion: This section will include all your cardiovascular, circulatory and neurovascular data you obtain during your day of care.

· Elimination: The data included here will be based on your assessment as well as the client’s known routine patterns. Routine patterns will be included as part of your required documentation here. Also include status of continence of client.

· Nutrition: This section will include the prescribed diet and how the client tolerated this diet and/or any difficulties they may be having with their current diet.

· Sensation : Pain scores, which pain scale was used to evaluate the pain was used, method of main management used, what the response to the method was, and any other sensory impairment the client may be known to have or be experiencing during your assessment will all be included here. Also any corrective devices used to improve the client’s response these deficits.

· Mobility :You will provide the information which is indicted on this section as well as address the client’s balance and gait and any changes observed. If PT or OT are involved indicate how often and client’s response to these.

· Protection :Make sure when documenting here you pay close attention to any deviations from what is considered normal for your particular client’s group and document them all here. Be very descriptive and paint a verbal picture.

· Psychosocial: Emotional state will include client’s affect at the time of assessment, any new stressors they may be encountering and any chronic difficulties which may be involved in their care.

· Sexuality : You may include any aspects that may influence you client in this area. REMEMBER: Sexuality does not only refer sexual contact, but also involves gender identification and the life changes which can influence the client’s definition of them self.

· ABNORMAL LABORATORY VALUES& RADIOLOGY/DIAGNOSTIC TESTS

This page will be used for further data collection and discussion of any abnormal lab values or any radiological or diagnostic test that have been performed lately on your client. REMEMBER: Pay close attention to the blocks titled “Explanation of abnormal value, Nursing responsibility and Impression, Reason Ordered”. These blocks are to help you think through the client’s current status and why the practitioner is going in a particular direction with their treatment.

· MEDICATION WORK SHEET

This sheet is required on each client you will be taking care of each week. Feel free to print out extra pages when needed (and you will need them). Make sure NO information is left blank on this page. If there are any blanks here, it will impact your chance to pass medications on that day of care. Include life threatening and common side effects of medication in the ‘Critical Assessments, Nursing Implications, and Patient /Family Teaching. Include if the medication is crushable if the patient had crushed medication. You will need to profile ALL medications that the client is currently taking. Utilize extra medication sheet as needed

If you are to give medications and you have not passed the dosage calculations test must write out the dosage calculation and safe dose for every medication on the medication sheet prior to 7am on day you are giving medication.

· MEDICAL/SURGICAL WORKUP PAGE

· Medical Condition #1. This condition will be identified to the student by the clinical instructor. It must be a complete working definition of the condition and include the complete reference notation.

· Patient signs and symptoms : These are the specific signs and symptoms the assigned client exhibits related to this condition. This information can be looked up in the patient chart and through past nursing assessments.

· Textbook/reference Signs & Symptoms : This information is derived from your medical surgical textbook and are the general signs & symptoms that MAY be observed in a client with this particular condition.

· Patient Surgical Procedures : If your client has had any surgical procedures during their admission, list them in this area and briefly define them.

· Erickson’s Developmental Stage: Look up the appropriate stage for your client based on their age and list how this may impact your care of them.

· Discuss patient’s past medical history… : Discuss completely, how the client’s past medical history may or could impact the care you will be providing them on your day of care.

RECOMMENDATION: Clinical Care Concept Map:

Primary Concept & Related Medical Diagnosis : You will have to include the nursing concept that you have been covering in class and any medical diagnoses your client has listed that relate to this nursing concept.(Primary Concept: See section VI) Medical Diagnosis . History or MD orders in patient’s medical record or case scenario.

Priority Nursing Assessments: Describe the ongoing, priority assessments you will be prepared to perform during you clinical day based on information gathered to this point. List 10. (Look up medical diagnosis in Medical Surgical Book or Lippincott Advisor)

Patient Presentation : This is a restatement of the medical condition that has been designated for your client for that week.. (Medical Diagnosis. History or MD orders in patient’s medical record or case scenario.

Assessment Data :These are the particular areas you will be paying attention to during your head to toe assessment of your client that are specifically related to your client’s condition; list at least 10 different assessment data (vital signs, ROM, etc. all count as ‘1’ each).(Patient specific data, from medical record or case scenario.)

Relevant Diagnostic Tests & Labs : List the tests here that have been performed which either reflect information about your client’s condition or may have an impact on your day of care.(Patient’s Medical record or case scenario)

Treatments & Medications : List in this section any and all treatment you will be performing during your day. These may include dressing changes, tube feedings, Foley care, breathing treatment… These are not the only treatments that may be listed here. Also, list the time medications are due and how many you will be giving during those times.(Patient’s Medical record or case scenario)

Patient problem/Nursing Diagnoses: Student will select two problems. At least on physical problem, 2nd problem may be a physical or psychosocial health problem. Place them in the proper priority order. The problem placed in the #1 spot will be considered the primary problem on which to focus. Label at least 10 items in Assessment data, lab & diagnostic test data, and treatments & medication data for supportive of each problem selected and list under problem. Must be specific findings, not what you are looking for, what is known to be. NO ‘risk for’ problems in NUR 134.(Nursing Diagnosis Book)

Worst Case Scenario/Potential Complications: Explain specific negative changes in your client’s condition you would anticipate and watch for based on information gathered to this point.(Look up in Medical Surgical Book or Lippincott Advisor)

· CARE PLAN

· Patient Problem/Nursing Diagnosis 1 : This information will be carried over from the previous page and written exactly the same way with no additional wording, explanations or clarification.1a. Select your nursing priority to support your nursing outcome. The priority will come verbatim from the textbook, Nursing Diagnosis priority section.

· Outcome: (The patient will): This is a statement you will develop which will be positive in nature and specific to your client and their limitations, if any. You will also have to include a specific time period in which it will be completed, and it will have to be specifically measurable and realistic. Keep in mind; this does not have to be an elaborate discussion only a simple, one-sentence statement that will be used to show/measure client’s progress.

· Nursing Interventions : This information will be derived from course text for care planning;copy verbatim. Next selectinterventions in your selected nursing priority sectionfrom your nursing diagnosis manualand copy verbatim. After copying verbatim you will personalize by putting individualized data in parenthesis (). Include page number only if using Nursing Diagnosis Manual; if using any other source include full reference in APA format.

Example-Demonstrate use of standing aids and mobility devices (walker) p. 511.

REMEMBER: These are things you will to, with or for your client with a goal in mind of moving them toward improvement with a focus on their primary health problem.

· Rationale: This information copied directly from you nursing diagnosis manual and explains why this would be appropriate for your client. REMEMBER: Follow same formatting as in interventions.

· **Patient Response to Intervention : This information is provided during or after your day of care and should be a statement of how your client physically, emotionally OR verbally responded to your direct intervention with them. This is not always a verbal response from the client, although on occasion that type of response may be appropriate.

· **Evaluation of Outcome: You will explain your stated outcome was met, partially met or not met. If there is any other response here besides met, you will go on to explain why it could not be met as written and what you could have done differently to have a positive outcome for your client. REMEMBER: If you put not met or partially met here, this does not mean you were not successful. It may mean the situation changed with your client that kept you from meeting this goal and you had to adjust your care to accommodate this change.

NOTE: It is strongly suggested you use these guidelines each time when completing your data tools to make sure you have the minimum required information included.

** = The items marked with the two asterisks may be left blank when you arrive for your clinical day. The must be completed prior to turning in the paperwork at the end of the day.

Applied Sciences
Architecture and Design
Biology
Business & Finance
Chemistry
Computer Science
Geography
Geology
Education
Engineering
English
Environmental science
Spanish
Government
History
Human Resource Management
Information Systems
Law
Literature
Mathematics
Nursing
Physics
Political Science
Psychology
Reading
Science
Social Science
Liberty University
New Hampshire University
Strayer University
University Of Phoenix
Walden University
Home
Homework Answers
Blog
Archive
Tags
Reviews
Contact
twitterfacebook
Copyright © 2022 SweetStudy.com