Help Preparing for Clinical Day!

[lpnhell]

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]

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]

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]

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]

Excellent question! i've been working on creating a list for you. first,

• 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 Potes

• 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)

Perative 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
  • allergies
  • drugs/dosages/routes/times
  • 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)
  • 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:

  • assessment forms
  • fall risk assessment form
  • standardized pre-written care plans/clinical pathways
  • printed copies of standing orders
  • educational materials that might apply to your patient

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 (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!)

[lpnhell]

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.!!!!!!!

[Daytonite, BSN, RN]

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]

Thank you very much Daytonite, this is going to be useful when I start my clinicals.

[Acosmo27]

Daytonite, wow, those references you have as links at the bottom of your posts are awesome.. thank you so much!

[Jaxs]

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]

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.