Buchanan County Technology

BUCHANAN COUNTY TECHNOLOGY

AND

Higher Education Center

PRACTICAL NURSING Program

Clinical Handbook: Guidelines for Rotations in Specialty Areas

Adopted October 1983Revised February 1997Revised May 2005Revised 2012

Revised October 1986Revised August 2001Revised May 2007Revised 2016

Revised September 1988Revised August 2002Revised May 2009

TABLE OF CONTENTS

Guidelines for Rotation in Specialty Areas...... …2

Confidentiality in the Healthcare Setting...... 3

Clinical Guidelines...... 4

Student Worksheet...... 5-6

General Nursing Task Sheet/Questions...... 7-8

GENERAL ASSESSMENT GUIDELINE...... 9

aSSESSMENT AND cARE PLAN...... 10-27

In-service Form...... 28

Respiratory Observation...... 29-31

Evaluation and observation sheets…………………………………………………………………………………………..32-33

Emergency Department...... 34

Operating Room/PACU/Outpatient Surgery...... 35

Intensive Care Unit...... 36

Laboratory Department...... 37

Physician’s Office...... 38-42

Geriatric Objectives...... 43-44

MMSE...... 45-46

Medication List………………………………………………………………………………………………………………47-56

Medication Card……………………………………………………………………………………………………………..57

Medication Card example…………………………………………………………………………………………………...58

BUCHANAN COUNTY TECHNOLOGY & CAREER CENTER
PRACTICAL NURSING

GUIDELINES FOR ROTATION IN SPECIALTY AREAS

Students' rotation to specialty areas will utilize the following guidelines

Students rotating to specialty areas without assigned clinical faculty should use the attached guidelines. If necessary, you may contact either of the clinical instructors for clarification. Written assignments are required and submitted to the clinical instructor by the specified date.

Specialty areas without clinical faculty are Respiratory Therapy, PhysicalTherapy, EKG, Laboratory, Pharmacy, Radiology, Oncology, Rehabilitation, Emergency Room, OR, Outpatient Physician's Offices, Nuclear Medicine, Ultrasound, Outpatient Infusion, MRI, Utilization/Case Management/Discharge Planning, and Cumberland Mountain Community Health Services.

You may not leave the assigned clinical area without notifying the staff member that you are observing and/or the clinical instructor.

The clinical preparation assignments are due the day you begin the clinical assignment. The evaluation form is due one week after the clinical assignment is complete. Failure to complete these assignments may result in an unsatisfactory clinical grade.

When in doubt check it out with your instructor. If you do not feel comfortable with the assign task do not perform it. Always follow policy and procedure regardless of the instruction you are given by individual staff members, students or other personal.

Be professional. Be courteous. Be on time. Be accurate. Be ethical. Be honest.

Dress code for the clinical areas is white tennis shoes/rubber sole shoe, clean and wrinkle free, white clinical uniform/jacket; hair worn above the collar (no colors outside of the normal hair color spectrum). No artificial fingernails. If any student arrives to clinical inappropriately dressed will receive an unsatisfactory for the clinical and sent home to make-up the day on his or her own time.

MANAGING CONFIDENTIALITY IN THE
HEALTH CARE SETTING

The U.S. Department of Health and Human Services (“HHS”) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).1The Privacy Rule standards address the use and disclosure of individuals’ health information—called “protected health information” by organizations subject to the Privacy Rule — called “covered entities,” as well as standards for individuals' privacy rights to understand and control how their health information is used. Within HHS, the Office for Civil Rights (“OCR”) has responsibility for implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil money penalties. Violations can be one hundred to ten thousand dollars per article violated.

Confidentiality is becoming increasingly important in hospitals these days causing society as a whole to become very concerned. With so much private information being stored in computers, we wonder who has access to all this information. We hear often about someone breaking into these supposedly confidential computer records. It is no wonder that it is hard to keep a secret anymore.

Respecting a patient's right to privacy is now an essential element of guest relations, and it is the responsibility of every employee to promote good guest relations. Patients who feel that their privacy was violated at your institution will go elsewhere if they have a choice. Equally as important, maintaining confidentiality is a matter of respecting human dignity and patient rights. In addition, federally mandated via HIPPA laws, which are subject to criminal and civil penalties by law if violated.

Employees must learn to see themselves as advocates for patients. How should he/she want to be treated? The answer is by treating them in a manner that helps them retain their pride and dignity.

Most patients have a sense of loss of control while hospitalized. This is why anyone who encounters patients should be committed to doing everything possible to alleviate those feelings of helplessness. Respecting the right to privacy is one of the ways we can accomplish this.

Confidentiality affects not only patients but also everyone else connected with that institution. Staff at all levels, as well as patients' families, visitors, and medical personnel rely on confidentiality to protect individual privacy. It is very important for every member of the staff to realize this and practice this earnestly, keeping this thought in one's mind at all times.

The following helpful suggestions will help you become more aware of possible ways to maintain confidentiality

Discourage staff from discussing patients or their diagnosis on elevators, in halls, or at lunch in the cafeteria. You never know who will overhear your conversation, or what kind of damage could result. Often, people misunderstand what they overhear, and that can lead to trouble, too. Remember HIPPA!

Keep written information private. Admitting lists or report papers containing diagnoses, insurance papers, and medical logs should never be accessible to people in the area. These papers should be hidden or destroyed based upon the facility’s policy. As astudent, you should never disclose any information and should refer any information and or disclose to the clinical nursing supervisor.

Adopted October 1983Revised February 1997Revised May 2005Revised 2012

Revised October 1986Revised August 2001Revised May 2007Revised 2016

Revised September 1988Revised August 2002Revised May 2009

Clinical Guidelines

Each clinical day students are assigned patients for whom you will provide care that day as designated by your clinical instructor. You can perform routine AM care, bed linen changes and vital signs (once you have completed skills lab in the first year) without the clinical instructor. The Clinical Instructor must be present before you can perform any invasive procedure (Foley catheter, NG tube, removing heparin lock), etc. You cannot perform any procedure with just the floor nurses observing you; your Instructor must be present.

You will be responsible for completing and turning in to your Clinical Instructor the following assignments: Physical assessment (specific body system) and care plan for the day.

The major assignment included in this manual is a head-to-toe assessment. This should include definition, signs and symptoms, lab and/or x-ray procedures used to diagnose condition, and usual treatment according to your Medical-Surgical textbook. Also, include signs and symptoms you assessed your patient to have and compare the treatment he/she is receiving to the textbook treatment for that disease process. Compare any abnormal lab results with the normal lab values. For pediatric patients, compare assessment to growth and development charts. This assignment includes up to four plans of care related to the patient’s illnesses (at least 3 medical in nature and 1 psycho-social in nature)

While doing your medication administration rotation for two weeks,drugs that the assigned patient are prescribed are to be noted and investigated with findings documented on these medications sheets. (drug cards)Include any IV fluids, IVPB, PRN medications, TPN and lipids, and any nutritional supplements (Resource, Ensure), etc. your patient may be receiving. These drug sheets (cards) are to be turned in two weeks after the finish of your medication administration rotation.

A nursing care plan based on your assessment findings. Your nursing plan of care should be appropriate to patient needs and contain no less than four (4) nursing interventions. You will have a Medical Surgical Plan of Care and Psychological Plan of care due upon assignment.

Due dates for assignments each report and drug cards will be due on the Monday following the last clinical day of each week unless the clinical instructors assign another date. Nursing care plans will be assigned and scheduled per instructor.

Failure to turn in Assignments Failure to turn in required assignments will result in an unsatisfactory (U) clinical grade. If you receive three U’s--Conference with Faculty; five U’s--Conference with Faculty; six U’s Evaluation by Faculty with Possible termination. NO STUDENT WITH MORE THAN six U’s WILL BE ALLOWED TO CONTINUE PROGRAM.

Clinical Rotation (Specialty Area) assignment sheets Each clinical rotation (specialty area) assignment is to be turned in to your assigned Clinical Instructor within one week after your clinical experience in that area.

Each student must complete an observation sheet and evaluation sheet for each clinical area (page 32-33).

When performing an assessment make sure, you always include vital signs and pain assessment. If during your assessment you notice an abnormality document what you did to correct the abnormality.

Buchanan County Technology and Career Center Practical Nursing Student Worksheet (Daily sheets)

Name / Patient / Date of Care / MR#
Allergies / Age / DOB / DX
Diet / Isolation / DNR Status / VS
Fingersticks/SS / Respiratory / IV/SL / Precautions
Neuro / Gastro / Cardiac/Telemetry / GU
Everything Else
Nursing Diagnosis
Subjective and Objective Data
Short and Long Term Goals / Intervention / Rationale / Evaluation
Diagnosis
Clinical findings
Subjective
Objective
STG
LTG

Nurses Notes—Buchanan County Technology and Career Center Practical Nursing

Date / Time / Notes

GENERAL NURSING TASK SHEET

Date tasks as completed

OBJECTIVESASSISTEDCOMPLETED

Patient history.______

Positioning a patient.______

Turning a patient.______

Transferring a patient.______

Feeding a patient.______

Bed making.______

Vital signs.______

Intake and output.______

Height and weight.______

Isolation.______

Teaming with a professional.______

Personal Hygiene______

Additional objectives

Student evaluation for rotation improvement

GENERAL NURSING QUESTIONS

Contrast the difference between a registered nurse and a licensed practical/vocational nursing, including education and duties.

Describe the following positions supine, prone, Sims, and Fowler's.

Describe the following fluids 0.9% Normal Saline; 0.45 Half-normal Saline; D5LR Dextrose 5% Lactated Ringers; LR. Describe how each fluid works in the body; Name a type of condition that each fluid is given.

What is an SCD? Pulse Oximetry? What can cause inaccuracy in Pulse oximetry readings? What does it mean to spike an IV Bag?

Define reverse isolation.

What can cause inaccuracy in obtaining a Glucose reading?

Describe three methods for taking temperature. Identify the most frequently used, the most accurate, and the least accurate method.

Describe how to measure blood pressure. Identify the normal blood pressure range. Name the stages of Hypertension.

Fill in the blanks for common measurements used in intake and output

1 cc (mL) =______drops

1 ounce=______cc(ml)

1 teaspoon=______cc(ml)

1 tablespoon=______cc(ml)

1 cup=______cc(ml)

1 pint=______cc(ml)

1 quart=______cc(ml)

Patient A became disoriented and returned to the wrong bed B that was empty at the time. You are asked to turn patient B. You mistakenly turned patient A, not realizing that the patient was in the wrong bed. What should you do to prevent this mistake and what very serious mistakes could have happened?

Adopted October 1983Revised February 1997Revised May 2005Revised 2012

Revised October 1986Revised August 2001Revised May 2007Revised 2016

Revised September 1988Revised August 2002Revised May 2009

General Guidelines on Completion of Medical/Surgical Nursing Assessment Care plan

The introduction paper will precede the assessment in the packet to be turned in. The introduction paper will have the following components

APA formatting
Use of proper grammar and punctuation (spelling counts)
Explanations of each diagnosis that the patient has listed in the medical record
Testing results and the explanation of the impact of the result
Anything not included in the assessment packet/medication lists/plan of care

Useful resources

http//aspirations.english.cam.ac.uk/converse/essays/essaywriting/index.htm

A very good essay directive http//webster.commnet.edu/apa/index.htm

Other sources of reference are your text, drug book, care plan book, school library.

When planning care, please be careful to include the short-term goal, long-term goal that are measureable and timed. Also, evaluate these in the evaluation columns.

Medication sheets are completed the same as the medication cards that you do while in clinical setting.

Do not leave blank spaces. Answer each section. If a section does not apply to your patient, use N/A or explain why it does not apply.

Do the cover sheet in APA format. The introduction should be the patient’s story in narrative format. Always include vital signs pain assessment; teaching and safety assessment.

Care plans count as a test grade. If you are unsure how to complete the care plan, ask questions!

You may type the care plan but you must use the format provided. If you choose not to type the assessment and hand, write the assessment portion you must be very legible. Points are deducted for care plans that are difficult to read or that do not follow the outline. The narrative and cover sheet must be typed.

BUCHANAN COUNTY TECHNOLOGY & CAREER CENTER
PRACTICAL NURSING PROGRAM

Student ______Date of Care ______

Unit/Floor ______Age ______Diet ______

Primary Diagnosis ______

B/P ______P ______R ______T ______SPO2 ______

Intake for 24 hours / Output for 24 hours
PO / Urine
IV / BM
GT/NGT / Emesis
Irrigation / GT/NGT
Other / Other

TEACHING / LEARNING

Non-Prescription Drugs/OTC Medications/Supplements/Herbs/Vitamins
Name / Amount / Administered (x per day) / Reason / Route

Street drugs□ Yes□ NoSmokeless tobacco□ Yes□ No

Cigarettes□ Yes□ NoAmount used ______How long ______

Alcohol□ Yes□ NoAmount ______

Frequency ______Length of time used ______

Admitting diagnoses per provider

1. ______

2. ______

3. ______

4. ______

5. ______

Reason for hospitalization per patient ______

History of current complaint (what brought patient to hospital) ______

Patient expectations of this hospitalization

______

Previous illnesses

______

Previous hospitalizations

______

Previous surgeries______

Evidence of failure to improve

______

Last complete physical exam ______

HYGIENE

Activities of daily living

Mobility□ Independent □Assist□ DependantFeeding□ Independent □Assist□ Dependant

Bathing□ Independent □Assist□ DependantDressing□ Independent □Assist□ Dependant

Toileting□ Independent □Assist□ DependantDental □ Independent □Assist□ Dependant

Preferred time of bath ______

Equipment / prosthetic devices required Assistance provided by

Other

PAIN / DISCOMFORT

Location, intensity (0-10 with 10 most severe) ______

FrequencyQuality

DurationRadiation

Precipitating factorsRelieved by

Associated factors other

SAFETY

Allergies / sensitivity□ yes□ NoReaction

History of STD (date / type) □ Yes□NoHigh risk behavior□ Yes □No

Testing□ Yes□No

Blood transfusion□ Yes□NoWhen

Reaction □ Yes□NoDescribe

Seat belt/helmet use□ Yes□No

History of accidental injuries □ Yes□No

Describe ______

Fractures/dislocations □ Yes□No

Site

Cause

Arthritis/Unstable joints □ Yes□NoBack problems□ Yes □No

Surgical intervention□ Yes□No

Changes in warts / moles □ Yes□NoEnlarged nodes□ Yes □No

Delayed healing□ Yes□NoCognitive limitations□ Yes □No

Impaired vision□ Yes□NoHearing □ Yes □No

Prosthesis□ Yes□No

Location□ LUE□RUE□ LLE□RLE

Objective (Exhibits)

General appearance ______

Body odor□ Yes□No

Condition of hair / scalp ______

Presence of vermin□ Yes□No

Condition of fingernails toenails ______

Facial grimacing□ Yes□NoGuarding affected area □ Yes □No

Emotional response□ Flat□Cheerful□ anxious□Tearful

□ Depressed□Distracted□ Labile□Other______

Narrowed focus□ Yes□No

Temperature □ Warm□Cool□ Hot

General strength Right Arm□ +1 □ +2 □ +3□ +4

Left Arm□ +1 □ +2 □ +3□ +4

Right Leg□ +1 □ +2 □ +3□ +4

Left Leg□ +1 □ +2 □ +3□ +4

Muscle tone□ Good □ Fair □ Poor

Gait □ Steady □ Unsteady □ N/A

ROM □ Full □ Assist □ Passive

Paresthesia □ Yes □ No

Paralysis □ Yes □ No

FOOD / FLUID

Usual diet (type) ______

No. of meals daily ______

Loss of appetite □ Yes□No

N/V □ Yes □No

Heartburn/Indigestion□ Yes□NoRelated to ______

Relieved by ______

Allergy / food intolerance (list) ______

Dentures□ Upper□LowerWith Patient□ Yes □No

Mastication / swallowing problems□ Yes□No

Usual weight ______

Recent weight gain / loss□ Loss □Gain □N/A Amount ______

Skin Turgor ______

Pressure sore risk increases as the score decreases 15–16 = mild risk; 12–14 = moderate risk; 12 = serious risk.

RESPIRATORY

Dyspnea□ Yes □ NoRelated to ______

Cough/sputum□ Yes □NoDescribe ______

History of bronchitis□ Yes □ No

Asthma□ Yes □NoTB □ Yes □No

Emphysema □ Yes□No

Recurrent Pneumonia□ Yes□No

Exposure to environmental risks

Use of Oxygen□ Yes □NoUse of respiratory aids □ 02____L/minute

CPAP/BIPAP□ Yes □No

V-Mask□ Yes□NoVentilator □ Yes □No

Settings□ SIMV□AC□ IMV

FIO2______%TV ______Peak F. ______

Spontaneous Resp□ Yes □No

ETT______Level (cm)Position□ Rt □Lt

Cuff Pressure______mmHg

IPPB □ Yes □NoOther ______

Nebs□ Yes □NoMedication(s) ______

Rate ______Depth ______Symmetry ______

AP Diameter □ 2:1 □1:1

Use of acc. muscles □ Yes □NoNasal flaring□ Yes □No

Breath sounds Anterior ______Posterior ______

Cyanosis□ Yes □No

Clubbing□ Yes □No

Sputum characteristics ______Restlessness□ Yes □No

Tracheostomy□ Yes □NoCPT PD□ Yes □No

Current weight ______Height ______

Body build ______Mucous mem □ Dry □Moist

Edema General□ Yes □NoDependent □ Yes □No

Pitting □ Yes □NoPeriorbital □ Yes □No

Ascites □ Yes □ NoHalitosis□ Yes □No

Condition of teeth/gums ______

Appearance of tongue ______

Mucous membranes ______

Urine S/A or Chemstix ______

Serum Glucose (Glucometer) ______

IV Fluids□ Yes □NoType ______

Rate ______Force fluids □ Yes □No

NEUROSENSORY

Fainting/dizziness□ Yes □NoHeadaches □ Yes □No

Symptoms ______Intensity ______

Frequency ______Duration ______

How relieved ______

Tingling/numbness/weakness □ Yes □NoLocation ______

Stroke/brain injury (residual effects) □ Yes □No

Seizures□ Yes □NoType ______

Aura □ Yes □ NoFrequency ______

Postictal state □ Yes □ No

Vision loss □ Yes □ NoLast exam ______

Glaucoma □Yes □NoCataract□ Yes □No

Hearing loss □ Yes □NoLast exam ______

Epistaxis□ Yes □ NoSense of smell □Normal□Decreased

Other ______

MENTAL STATUS

Oriented / disoriented Time □Yes □No

Place□Yes □No

Person□Yes □No

Alert□Yes□NoDrowsy □Yes□No

Lethargic□Yes□NoComatose□Yes □No