How to do good in clinical? Please help!

Daytonite, BSN, RN · Jan 30, 2009

a care plan is based on assessment information that you gather about the patient. that is why you take a report and look at kardex information on patients before starting to work on them. for care plan assignments in school you can get all the information you need to begin a care plan from the patient chart. you can also add information that you collect from questioning the patient and doing a physical examination on them. you are looking for data that is abnormal (anything that is not normal). when you learned about doing a physical exam in school you learned what normal vital signs were. remember? when people become ill and have disease, their physiology and vital signs change and some of these things become abnormal. that is how the doctors (and we nurses) know something is wrong with the patient. part of our job is to find those things. that abnormal data are called symptoms. we can group certain symptoms together to give us nursing diagnoses that describe nursing problems. we develop nursing interventions to treat them. we hope to achieve goals. do you see the rationale from very simply knowing the person's illness and assessment information? you may not see your patient, but as long as you know their medical diagnosis you can begin to develop some kind of care plan for them by merely breaking the medical diagnosis down into its signs and symptoms. you constantly add data and re-evaluate what you will do for the patient in your head all the time. sometimes one little piece of information can change everything you will be doing for the patient. this is no different than the way things happen in your own life. [i got a notification yesterday that i have to appear for jury duty the same week i had planned to go out of town. do i sit and cry about it? after my hissy fit i fixed the problem. re-evaluated, new interventions, changed the goal. that's what you do. and life goes on.] you are also problem solving when you are care planning.

example: i will have a patient tomorrow with pneumonia. knowing nothing else, i look up pneumonia and find that these patients have these signs and symptoms:

signs and symptoms
- fever
- thick purulent sputum production
- crackles, wheezes or rhonchi heard in lung fields
- using accessory muscles to breathe
- pleuritic chest pain
- cough

with that information you can assume these nursing problems will be present

ineffective airway clearance (thick purulent sputum production, crackles, wheezes or rhonchi heard in lung fields, cough)
ineffective breathing pattern (using accessory muscles to breathe)
hyperthermia (fever)
acute pain (pleuritic chest pain)

i would develop some general and standard nursing interventions and goals for each of those diagnoses for my clinical the next day.

when i actually see the patient the next day and have a chance to do my own physical exam on the patient, talk with them and review their chart more closely i can change any of the above and customize it. when i am in clinicals the next day i will take a lot of notes from the chart. see https://allnurses.com/nursing-student-assistance/help-preparing-clinical-227507.html (help preparing for clinical day!!!!!!!!!!!!!) to find out what is important information to copy from a chart.

dragon1407 · Jan 31, 2009

thanks for fast respond!

i understand what you said. but let say that i might not see the pt on the second day, i still evaluate all of my nis.

what i try to understand is that i have to come up with a nx and eos (in my head) that is related to the pt's clinical picture. i have to do know all the nis for each eos so that i can care for the pt and have the evaluations and write them up later at night. that means i need to know a lot nis. that is challenging to me since i will be doing many nis in the care. some may be applicable to careplan and some not. and i am student, i might not remember all the nis. my instructor said that i can still have evaluation for careplan for one care since i could have done many things for the pt.

please be patient with me and explain more!

thanks sincerely,

Daytonite, BSN, RN · Jan 31, 2009

You won't be doing the EO in clinical on paper. You will do that when you get home. In clinical all you will need to be concerned with are the NIs. So, if you know the patient's medical diagnosis and the medical orders you will know much of the NI that will need to be done. Before nursing diagnoses, we treated the symptoms (what NANDA calls defining characteristics). If a patient was vomiting, we wrote "vomiting" on the care plan where you would put the nursing diagnosis today. What do you do for vomiting? Those are nursing interventions (NIs). You will not always have time to write them down, you just do them because the patient has to come first. It will be the same with "diarrhea" or "edema of the lower extremities". You will get many patients with these same things. You will do the same NI for the first patient as you will do for the 10th patient you have with the same problem. By the time you have the 10th patient you will remember without looking at a piece of paper what you need to do for the patient. When you see your 200th patient you won't even think about where your piece of paper is.