Nursing Students Student Assist
Published May 31, 2007
lpnhell
34 Posts
Hey everyone! I need to know how to prepare for my clinical day, my teacher gives us the assignment at the hospital the night before. I know I need to research all meds, but what else? What should I write down from the chart at the hospital when I am reviewing it. Thanks for your help ... LPN wannabe
tookewlandy
727 Posts
Get all the biographical data,Write down the current diagnoses, History of present Illness,Past Medical/Surgical Histories,Family History of illness,Allergies,Activity allowed(i.e bed rest etc),Diet allowed,LAB/Diagnostic data,Meds,Treatments,Growth and development/Economical/Social data,
Also good to read surgical reports, and Nursing assessment forms in the chart(ER etc)
I always ask the nurse/cna/md that is with them when i go in for clin prep about the client they are usually very very helpful
Thats all i can think of now( the month off has set in, gotta get back in to SN mode myself)
santhony44, MSN, RN, NP
1,703 Posts
Admitting diagnosis, any chronic diagnoses, and I'd look at those disease processes. (The admitting H&P will usually give you the background information on the patient, in a pretty concise manner).
You'll need to know why the patient is on the meds he or she is on, what are possible side effects, possible interactions, and so forth.
What labs have been done and what those values are, particularly abnormals. The same for any diagnostic testing.
How the hospital course has run.
Vital signs ranges.
Any allergies.
Have I covered the whole chart yet???
RNrural
114 Posts
It would also be very helpful to know how the pre-existing conditions will affect the patients treatment of the existing condition. Knowing your Pathophisiology of each of the disorders or diseases will be very helpful.
Daytonite, BSN, RN
1 Article; 14,604 Posts
Excellent question! i've been working on creating a list for you. first,
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:
Face sheet (typically one of the first pages in the chart)...
Physician consultations
Surgical consents
Perative report
Pathology report
Other resources on the nursing unit
Medication cart
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
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:
The nurses who work on the unit, preferably the one assigned to your patient.
to help you organize your clinical day, print out a copy of the student clinical report sheet for one patient to help you (link is at the bottom of all my posts).
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.
P.S. I forgot to add that when you are looking at any of the physician history & physicals or consultation reports read through them and look for reference to any symptoms the patient might be having. These same symptoms can be helpful to you later in determining nursing diagnoses if you have to construct a care plan. Also, on some of these different chart documents you may find evidence that the patient has a tube, drain or other medical device in them that wasn't mentioned anywhere else in the record (some people are just real good at observation and documenting these things!)
Thank you daytonite for all your help, and thanks to everyone, it's great to know I have people in the same boat as me. thanks again.!!!!!!!
You are very welcome. This is information that should be posted on the forum for all students to see. I've gotten the impression that many students are not clear on exactly where assessment data can come from. I'll start working on a form that students can just take with them to fill out to guide them in the collection of this information. Good luck in your clinicals!
gaajr1, RN
148 Posts
Thank you very much Daytonite, this is going to be useful when I start my clinicals.
Acosmo27
302 Posts
Daytonite, wow, those references you have as links at the bottom of your posts are awesome.. thank you so much!
Jaxs
20 Posts
I can't find the link to the Clinical Report Sheet or the flow sheet. Can someone help me figure out how to view it?
jjjoy, LPN
2,801 Posts
Daytonite said:This is information that should be posted on the forum for all students to see. I've gotten the impression that many students are not clear on exactly where assessment data can come from.
I'd say that this is information schools should provide their students with and that the reason so many students are not clear on what information they need and where to get it is because the instructors/schools aren't giving them a list like that wonderful one you created. Why not? That's not "spoon-feeding" nor denying students the opportunity to develop problem-solving skills. That's structured education and that's what school is for. To help make one's time learning more effective and efficient. So you don't have to fumble along, figuring everything out as you go. Students get more than enough opportunities to problem solve without having to guess at what exactly they're expected to have prepared for clinical days/care plans/etc.