Nursing Care Plan Packagec

Medical History Student Name - Marchelle Minor Client’s Initials - mn

Room - 405

Date - 10-02-09 Client’s Diagnosis: Pancreatitis, New onset Diabetes Mellitus

________________________________________________________________________ * * Write out the findings of your physical assessment. Use proper narrative phrasing including the following data: 1. Admitting Medical Diagnosis:

Pancreatitis - new onset Diabetes mellitus II

Obese Hispanic female, age 28 is admitted to the hospital, communicates well in English. She expresses all over abdomen pain and is guarding. She is moaning with pain, upon palpation there is rebound activity with facial grimacing. Patient denies nausea or vomiting stated her last meal was yesterday morning and caused abdomen pain and bloating feeling. Last menstrual cycle was 4 days and regular every 2 weeks. Last bowel movement was 3 days ago. She acknowledges change in appetite and weight gain. She is without dizziness or night sweats. Her weight is 215lbs, Blood pressure is 138/86, pulse 100, respirations 22, 99.0 99% saturating on room air. No known allergies. Patient states this is her first time in the hospital and prior to moving here she lived with her mother and father in El Paso. Both are alive and healthy. Current surgery / surgical history; is denied. Past medical history

No history is available

Home medications. None Disease/preventive care. Patient denies; infectious History of Present Illness:

Drug use: Cannaboid user weekly past 8 years;

Support systems: Father and mother IMPRESSIONS:

Severe Pancreatitis, Severe Dehydration, Leukocytosis , Hyperglycemia, Cannaboid use, constipation

PHYSICAL EXAMINATION General overall condition: Awoke in semi- fowler position, has bilateral 22 gage wrist/hand IVs’ with 24 hours replacement time/ restart negative for signs or symptom of infiltrate. Right is capped – Left has 0.9ns infusing at 250cc. Robust female, alert x3 respirations are even non-labored. Skin warm dry and intact color is within normal limits. 1. Vital Signs T 97,

Bp, 121/76,

P 101,

R20

2. Head:

Normal symmetrically, scalp clean without lesion, no dandruff

3. Ears:

No earache, deafness, tinnitus, no vertigo or discharge

4. Eyes:

No diplopia, itching, dry eyes, eye pain or photophobia, orbits normal

5. Nose:

Normal membrane pink and moist.

6. Throat:

Flexible. Normal pulsations, no palpable thyromegaly, no palpable Lymph nodes, trachea

central, no JVD 7. Nails: 8. Skin: 9. Neuro

Normal, Good capillary refill Skin is warm dry and intact, color wnls. Sensation is intact, Cranial nerves II – XII intact

10.Musculoskeletal 11.Respiratory

WNLS No pedal edema Peripheral pulses normal negative joint swelling

Normal contour of the chest with symmetrical motion. Clear to auscultation bilaterally, No

dyspnea, No pleural rub. 12.Cardiovascular

Tachycardia. Normal S1, S2 No murmurs.

13.Gastrointestinal

No Scars, Hypoactive bowels sound, 4 quadrants. Pt is very tender in the right upper

quadrant and mid epigastrium, she is complaining of tenderness all over her back and abdomen. Murphy is negative. 14.Genitourinary

Urine positive for cannabis, Foley - Lab

15.Mouth

Normal lips, Buccal mucosa is dry, Normal looking teeth and gums

16.Nose Normal external, septum and turbinates (3) Use SCAR charting me NURSES NARRITIVE : Use correct documentation technique. Document subjective and objective data at least every two hours. Chart the care and responses of the client during your care. Please include an opening and ending statement. Sign after each entry. Preceptor and SN; and date of birth.

Initial observation: 08:30a.m.

NPO: The patient is alert and able to state her name

She is sitting in a semi- fowlers position with TV on. I introduced myself. as a Sn and stated I

would be working the her nurse: Noted bilaterally 22g peripheral IVs taped, secure and intact, no s/s of redness or infiltration Left hand heplocked, Right has 0.9ns infusing @ 125cc via pump. Foley to gravity with 300 cc of light urine. Q4 hr Finger sticks, 264; administered : 4 units of regular insulin per s/s, given sq in right upper arm. Pantoprazole 40mg IVP. Abdomen large taunt. Daily Vitals signs completed. Noted abdomen large taunt patient denies pain at this time. Observed patient guarding her stomach with facial expression of pain. I asked the patient if she would like to have some pain medication and from 1 to 10 what was her pain level? She stated it was at a 7. Administered Morphine 5 mg Ivp for pain. (alcohol wipe – ns flush before and after med administered______________________________________________________________________________________MMinor:sn SN:

09:00 Returned to observe patient; when asked about the pain she stated it was “much better and it

didn’t hurt anymore.” Ice chip at her bedside. Bed in low position- side- rails up x2 call-bell in reach _____________________________________________________________________________________________MMinor:sn Preceptor and SN;

09:15a.m. Assessment of patient reveals she is no longer in pain, talking on her phone

and rubbing her abdomen, I, with permission check her lower extremities, bilaterally warn to touch with full range of motion, no pedal edema, peripheral pulses normal. No joint swelling. Good capillary refill. No petechiae or ecchymosis noted._______________________ ________________________________________________________________________________________________MMinorsn SN: 11.15a.m Patent is in bed asleep – snoring; top side-rails up, remains in semi-fowlers position, respirations easy, non-labored, color within normal limits, resting on her left side. Call-bell remains in reach.________________________________ _____________________________________________________________________________________________MMinorsn SN:

12:00 Patients remains pain free as expressed. CBG 150, no sliding scale coverage, Respiration remain

easy non-labored, color within normal limits, as observed q2 hour checks, in no apparent distress at this time._________________ _____________________________________________________________________________________________MMinorsn Preceptor and SN;

1250; Report off to preceptor, condition of patient is stable she is pain free at this time.

____________________________________________________________________________________________Mminorsn (4) Pathophysiology 1. Disease Name, Definition, Changes in Body Tissues/Organs, Function/Structure: Pancreatitis: an inflammatory condition of the pancreas that may be acute or chronic. Acute pancreatitis is generally the result of damage to the biliary tract, as by alcohol, trauma, infection disease, or certain drugs. It is characterized b y severe abdominal pain (generally epigastic or upper left) radiating to the back, fever,

anorexia, nausea, and vomiting. There may be jaundice of the common bile duct is obstructed. The development of pseudocysts or abscesses in pancreatic tissue is a serious complication. The pancreas is an elongated grayish pink lobulated gland that stretches transversely across the posterior abdominal wall in the epigastric and hyochondriac regions of the body and secretes various substances, such as digestive enzymes, insulin, and glucagon. The chronic pancreatitis is similar to those of the acute form. 2.

Clients at Risk: A block in the ducts between the pancreas and the liver. This includes gallstones that force pancreatic fluids to back up, causing inflammation and permanent damage. Tumors, Chemicals in the digestive system, Inflammation of nearby organs antibiotics, such as sulfa drugs and tetracycline, high exposure to estrogen and some diuretics, binge drinking or regularly drinking large amounts of alcohol, abdominal surgery complications from a screening procedure called endoscopic retrograde cholangiopancreatography (ERCP), Infections (such as mumps or viral hepatitis), high levels of calcium or triglycerides in the blood. People at risk of gallstones are also at risk for acute pancreatitis. This includes pregnant women, women who have had many pregnancies and people who are overweight.

3. Effects on Client (signs & symptoms): area. The abdomen is rigid and tender.

Symptoms of the acute form include pain upper part the stomach

SIGNS: nausea, vomiting, bloating, belching, hiccups and/or collapse. The patient may have steady which radiate to the back, side or lower stomach area. The patient may also have a fever, shortness of breath or kidney problems if the symptoms are severe. The patient may also be constipated, have a slow pulse and show signs of and show signs of jaundice. 3.

How diagnosed (X-rays, lab test, etc.)

Diagnostic Test for Pancreatitis are: computed tomography (CT),

ultrasound of the gallbladder. Abdominal x-rays, 3 series, arterial blood gases, BMP, CBC, Urine Drug screen, lipase, Hemoglobin A1c How Treated: Treatment options offered for Pancreatic Diseases include: Noninvasive photo-dynamic therapy, a treatment for bilary strictures, Drug therapy for all pancreatic disorders, Noninvasive photo-dynamic therapy, a treatment for bilary strictures, Drug therapy for all pancreatic disorders, Endoscopic pancreatic therapy to help alleviate pain and improve pancreatic duct drainage in patients with chronic pancreatitis, Enzyme therapy, which can aid nutritional absorption of food and curb weight loss. Medications: Cotazym, Pancreatin, Pancrelipase, lipram-Cr20, Pancrease MT– Action- Inhibit pancreatic secretions

4. Expected Outcome (chronic, corrected with treatment, death, etc.): The expected outcomes the patient will be pain free (opioid analgesia The patient will understand the importance of nutritional planning. 5. Possible Complications: Acute pain relief is the first priority for patients with chronic pancreatitis Diabetes Mellitus, chronic steatorrhea ,high risk for biliary obstruction a serious and painful complication Disrupted skin integrity, after each stool use a soothing emollient such as Sween Cream, zinc oxide cream. 6.

Specific Nursing Actions: The focus of caring for the patient with chronic pancreatitis is pain management, assist in maintaining a nutritional intake and prevent reoccurrence. psychosocial adaptation to a chronic illness and alcoholic abstinence. (www.aa.org) Teach the patient to take the pancreatic enzyme before or at the beginning of the meal. Disrupted skin integrity, after each stool use a soothing emollient such as Sween Cream, zinc oxide cream. Surgical management is not a primary intervention for the treatment of chronic pancreatitis.

7. References (must give page number or exact web address) 1. Mosby’s Nursing Drug Reference by Darlene Como, page 767,768 2. Medical-Surgical Nursing 6th edition by Ignatavicius and Workman page 1378, 1386 3. http://www.cedars-sinai.edu/2204.html 8.

Individualize to your client care: This patient will have to make new life changes. She is scared because this is her first hospital admittance. She must focus on new medical problems. I am hoping social services will help direct her, she’ll need diabetic consultation, glucometer, supplies, and on-going teaching for her new onset diseases. A referral to Al-Anon (www.al-anon.org) self help groups, are available to her drug problem. Education is the key to change for developing a different live style.

STUDENT: M Minor MIDLAND COLLEGE PRIMARY: Cameron Name: m.n MR#00000 DR. Bighook DIET: NPO P86 R20 BP138/86 O2 Sat 99% Pain Assessment 7

Clinical Worksheet Room:405 DX: ALLERGY:NKA 8:00VS:T99.0 3

12:00VS:T98.8 P R Tolerable level: 3

BP121/86

O2 Sat

97%

Tolerable level:

Pain Assessment 0

ASSESSMENT:Neuro, Skin, Musculo/Skeletel, Resp, Cardio, GI, Gu, Surgical wounds/Dressings, Mental IV:Sol.

D5ns

Amount:1000cc

TUBING CHANGE DATE:10/4/09

saline lock

rate 250cc

IV Site: Left wrist

IVPB: Potassium chloride 40 mg in isotonic 100ml; 25ml per hour CBG: 7:00 Intake

264

4 units regular

1550

11:30140 Output 700

TED Hose: no

SCDS: no

Dressing: Type none

Location: 0

Observation: IS:

Pulls:

Times per

hr.

Coverage: 0

Drain# 1: none

Drain #2: none

Bath: cna

Oral Care: self

Foley NG

yes

Removed no

no

Patent/ Placement no

Drain none

Charged/Drainage none

IV / Restart none

Site

MEDS: bag

D5w potassium chloride,

Removed

morphine 5mg IVP , pantoprazole 40 100 ml isotonic Banana

Nursing Diagnosis:Comfort, alteration in related to disease process as evidenced by complaints of pain Goal(SMART):

Patient will be pain free as verbalized at in of nursing assignment

Diagnostic Procedures: Labs, EKG, X-Rays, etc List labs, x-rays or other diagnostic tests not listed elsewhere. List dates, normal values, and correlate findings to your client’s history and current medical problems. Also note any special nursing considerations. DATE TEST NORMAL PATIENT VALUE/ INTERPRETATIONS NAME RANGE Diabetic: Potassium loss with 10/02/0 polyuria. 9 Potassiu 3.5 – 5.0 *3.3 Blood test m Poor potassium intake, increased excretion of potassium, especially coupled with poor intake, is the most common cause of hypokalemia, diuretics, digitalis, vomiting, wounds, diarrhea, renal disease. Nothing by mouth cushing disease potassium, especially coupled with poor intake, is the most common cause of hypokalemia. shift from extracellular to intracellular space is another cause. 10/28/0 9

RBC

4.2. 5.4

10/02/0 9

amylase

23 to 85 units per liter (U/L).

*3.652L Blood test Low RBC values are caused by many cause; Hemorrhage, gastric bleed or trauma Hemolysis as in glucose 6 phosphate dehydrogenase dedficiency, hyperocytosis Chronic illness, tumor or sepsis *42.22 Blood Test use to diagnose; Amylase is within normal values. use to diagnose Pancreatitis use to

diagnose (elevated amylase) Hepatitis (inflammation of liver leads to elevated amylase) Gallblader disease (here, the gallbladder causes secondary pancreatitis, IV dextrose can cause of false negative reading;

10/02/0 9

Glucose

70 - 110

10/02/0 9

BUN

10 - 20

*250 Blood Test Patient has Diabetes Mellitus Elevated Blood sugar are caused by many factors;Too little insulin either as a food or correction bolus, or basal (background) insulin Poorly time insulin injection or pump bolus Stress (even seeing and being attracted to someone can elevate blood glucose!) Illness Inactivity (being sedentary)Too much food High fat food meals The Somogyi Effect High altitude Insulin resistance or not rotating injection sites often enough, Insulin resistance or not rotating injection site, certain medications steroids,eExercising without sufficient water, insulin or snacks Blood Test * 7 Commom causes increased protein catabolism or an excessive protein load. imply prerenal azotemia blood urea nitrogen and serum creatinine usually rise in tandem;

the normal BUN: Cr ratio is 10-15: Disproportionate rises in BUN: Cr (> 20: 1) 10/02/0 9

lipase

12-70 U/L

Blood Test *12,365 Normal Common causes: Pancreatitis, Pancreatic cancer, Cholycystitis, Gastroenteritis

Medication Sheet Drug Name (brand & Generic): Morphine, Roxanol Drug Classification: opioid analgesic Narcotic Schedule II Desired Effect (Use): Severe pain, Depresses pain impulse transmission at the spinal cord level by interactiong with opioid Side Effects(s) (5 Common): respiratory suppression, sedation, headache, constipation, confusion. Side Effect(s) (ALL LIFE threatening): addiction-forming, decrease respirations, coma, death Nursing Implications (5 Major Ones-Include teaching): • • • • •

Pain: location, type, character; give dose before pain becomes severe: Bowel status; constipation common I&O ratio; Check for decreasing output B/P, pulse, respirations, (character, depth, rate) CNS changes: dizziness, drowsiness’, hallucinations, euphoria, LOC, pupil reaction.

Teach patient/ family: • To change position slowly, orthostatic hypotension may occur • To report any symptoms of CNS changes, allergic reactions • To avoid use of alcohol, CNS depressants • Withdrawal symptoms may occur, nausea, vomiting, crams fever, fainting anorexia Compatible with other medications? If no, what medications are non-compatible Yes, Syringe compatibilities: atropine, benzquinamide, bupicacaine, butorhpanol, cimetidine, fentanyl ranitidine. scopolamine Compatible with IV solution? If no, what solution is medication compatible with? Yes: D5w, D10w, 0.0ns, 0.45nacl, Ringers sol Amount of solution needed for dilution and rate of administration: After diluting with 5 ml or more sterile H2O or NS; give 15 mg or less over 4-5 minutes Reference Book and Page Numbers Mosby’s Nursing Drug Reference 2007 Pge 694-5 Client dose, Route & /Reason….. 5mg, IVP, Pain Management PRN Q2 hours .

Medication Sheet Drug Name (brand & Generic): Pantoprazole, Protonix Drug Classification: Benzimidazole, Protein pump Inhibitor Desired Effect (Use): production

Suppresse gastric secretions, blocks final step of acid

Side Effects(s) (5 Common): • Headache, Insomnia • Diarrhea, • Abdominal pain • Rash • Hyperglycemia Side Effect(s) (ALL LIFE threatening): None Nursing Implications (5 Major Ones-Include teaching): • GI system: bowel sounds, q8h, • abdomen for pain, • swelling. • Anorexia • Hepatic studies: AST, ALT, alk phosphatase during treatment Teaching patient/family: • report severe diarrhea • Diabetic patient should know hypoglycemia may occur • Avoid hazardous activities; Avoid alcohol, salicylates, ibuprofen Compatible with other medications? If no, what medications are non-compatible Yes: Plavix, Macrodantin, Inderal Compatible with IV solution? If no, what solution is medication compatible with? Yes: 0.9 NaCl, D5, LR. Amount of solution needed for dilution and rate of administration: Reconstitute with 10 ml 0.9 NaCl Reconstitute with 10 ml 0.9 NaCl Reference Book and Page Numbers Mosby’s Nursing Drug Reference 2007 page770 -771 Client’s Dose, Route & Reason: 40mg, IVP, Pancreatitis

Medication Sheet Drug Name (brand & Generic): sodium Chloride 0.9% (Normal Saline) Drug Classification: Isotonic fluids Desired Effect (Use): Same osmolality of plasma Side Effects(s) (5 Common): Fluid overload Side Effect(s) (ALL LIFE threatening): None Nursing Implications (5 Major Ones-Include teaching): Compatible with other medications? If no, what medications are non-compatible Yes, morphine, protonix, Compatible with IV solution? If no, what solution is medication compatible with? Yes, Compatible with Blood Amount of solution needed for dilution and rate of administration: 1000cc per bag Reference Book and Page Numbers http://www.rxlist.com/normal-saline-drug.htm Client’s Dose, Route & Reason: 0.9 sodium chloride, 250cc hour, IV, continously Isotonic saline fluids such as 0.9% sodium chloride solution can temporarily expand the extracellular compartment during times of circulatory insufficiency, replenish sodium and chloride losses, treat diabetic ketoacidosis, and replenish fluids in the early treatment of burns and adrenal insufficiency. Because their osmolality is similar to that of blood, they're also the standard flush solutions used with blood transfusions. 0.9% Sodium Chloride Injection, USP contains 9 g/L Sodium Chloride, USP (NaCl) with an osmolarity of 308 mOsmol/L (calc). It contains 154 mEq/L sodium and 154 mEq/L chloride. The flexible container is made with non-latex plastic materials specially designed for a wide range of parenteral drugs including those requiring delivery in containers made of polyolefins or polypropylene. For example, the AVIVA container system is compatible with and appropriate for use in the admixture and administration of paclitaxel. In addition, the AVIVA container system is compatible with and appropriate for use in the admixture and administration of all drugs deemed compatible with existing polyvinyl chloride container systems. The solution contact materials do not contain PVC, DEHP, or other plasticizers. The suitability of the container materials has been established through biological

evaluations, which have shown the container passes Class VI U.S. Pharmacopeia (USP) testing for plastic containers. These tests confirm the biological safety of the container system. The flexible container is a closed system, and air is prefilled in the container to facilitate drainage. The container does not require entry of external air during administration. The container has two ports: one is the administration outlet port for attachment of an intravenous administration set and the other port has a medication site for addition of supplemental The primary function of the overwrap is to protect the container from the physical environment.

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CARE PLAN FORM #______ Student Name_M Minor_____________________Date______ Patient Initials__mn_____________Page ____of_____ ASSESSME NURSING PATIENT INTERVENTIONS RATIONALE EVALUATIO NT DX SHORT N (PES TERM * (5) Format) GOAL (SMART) Pt guarding Alteration Pt denies 1. Medicated 1. Avoid Relief left upper of comfort pain at patient to reduce extended obtained, quadrant of related to this time abdomen pain and periods Resp, easy abdomen disease will relieve stress for without non labored, has pain and process, continue comfort measures. medications per patient tenderness evidence to *Q2-4hrs as by observe pt has less documented expression q2hrs 2. Keep Hob in 2. Decreases anxiety pain scale 8 of pain until end Semi-fowlers pain on lower Breathing 1 - 10 of shift position and upper easier& *PRN & daily organs better communicati on Remain 3. Support pain/ 3. Encourage pt to and stabilize goal stress, used pillow to abdominal meet.decrea free splint abdomen area se in (moving at all To help grimacing, times ) * Daily decrease less stress pain observed

Steatorrhea

Alterations

4. Assist with ADLs And repositioning q2 hours and prn

4. Less movement equals less pain.

pt smiling as being assisted repositioning and ADls

5. Massage back prn and *tid 10–

5. Help relieve

Decrease in pain relaxing

and foul smelling stools that may increase in volume as pancreatic insufficiency increases

of stool related to Diarrhea,; decreased peristalsis, immobility ,

Pt has blank facial expression during CBG

knowledge Deficient

Prioritized according to what level from Maslow: (circle choice) 1. 1. Physiol ogical 2. 2. Safety & securit y 3. 3. Love & Belongi ng

15 min Pt will have minimal discomfor t from gas and liquidy stool 4-8 hours

Complete Understan d ing of the disease and the CBG before shift ends.

6. Identify pts normal bowel status and whether she requires antidiarrhea med on a routine bases. Q 4hr

7. Implement teaching began glucometer q am & pm.

discomfort anxiety/stres s pt assess and identifies if diarrhea is playing a role in PTl, it’s normal symptom in this disease process. Early implementati on to familiarize pt disease

Brushing her hair

sween cream or zinc oxide to area, after each bm : Relief noted immediately

Pt verbalized ability to use the glucometer

4. 4. Selfesteem 5. (5). Self -actuali zation Lac 08-2009

Discharge Planning Activity = Activities as tolerated. Medications= Patient will be discharged home on anti-diabetic, anti-inflammatory, and pain medications. Equipment = glucometer and diabetic supplies, Treatments or Therapy = follow-up with diabetic in-depth teaching, management and nutritional consult to be scheduled with Certified diabetic educator (CDE). Help needed = Social service consultation, Rehab: Drug use Al-Anon, www.alanon.org. and diabetic consult will be scheduled. Office visits (follow up) = patient should follow up with primary care Doctor upon discharge. Diet = low fat, diabetic 1500 cal. Safety = Patient should have a responsible family member to help her focus and manage her new life style.

Grading NAME:______________________ Objectives 3 Documentati Does not on completely follow correct narrative technique Assessment data

8 Systems are reviewed and complete with objective and subjective data

Medications

List meds given

Criteria for Nursing Care Plan 5 Follows correct charting technique and up dates Q 2 hours 10 Systems are reviewed and complete with objective and subjective data Lists med name with general uses, but uses do not necessarily apply to pt

7 Follows correct charting tech focused/assessm ent complete and updates Q 2 hours

10 Follows correct charting Head to Toe assessment complete and updates q 2 hours Discharge planning

12 Systems are reviewed and complete with objective and subjective data

Both objective and subjective data incorporated all 14 systems are reviewed and complete

Lists med with uses and all life threatening side effects

Lists all meds and how it applies to pt’s assessment data. Lists applicable nursing interventions such as teaching, monitoring &/or assessment with each Lab relevant, complete, & shows progression of healing/disease Dx applies to pt’s assessment data

Lab Data

Incomplete

Lab not relevant to Medical Dx

Relevant Lab test are not current

Nursing Diagnosis Choice

Not supported by documentati on None listed

Not correct PES form

Dx could apply to pt, but not the obvious choice

Omits relevant data

Some info is absent for selected Dx

Not SMART

Not documente d as done

Goal SMART and partially completed

Data clustering (AEB)

Goal

Critical thinking and understanding of Pathophysiology applied. Reason for Dx selection clear Goal SMART and documented as completed even if evaluation is not

Interventions

Pt-centered, and timed

Pt-centered, time frame, and specific

Patient-centered, actions appropriate to meet outcomes, 4 interventions listed per outcome.

Rationale for the interventions

Incomplete list

Provides reason for interventions

Maslow

None listed

Does not apply to intervention s Illogical

Partially correct

accomplished. Patient-centered, specific, and appropriate for dx & outcomes. Time frame stated. 5 or more interventions listed per outcome. Includes teaching and monitoring nursing interventions necessary to achieve pt outcomes Demonstrates critical thinking in applying reasoning Valid

____________Below 70 Make corrections and print copy. Make an appoint. with your clinical instructor for assistance ____________70 -100 Make corrections and print copy for instructor to discuss suggestions. INSTRUCTOR: _____________________ SCORE:__________________________________

Midland College / A.D.N. Program RNSG 1462 Clinical Evaluation Name___________________________________________________Date____________________ Document Satisfactory or Unsatisfactory Comments: Name Date Faculty Builds performance on previously learned skills Performanc e 1. Theoretical knowledge: Bath, Bed, AM Care, Treatments (IS), Theory: Mobility and Safety. 2. Critical Thinking: Disease Process, Education, Medication Thinking: Rationale and Adm. 3. Communication: Report, Therapeutic and Interdisciplinary Com: Communication. 4. Caring: Nurse Advocate, Empathy and Rapport. Caring: 5. Management: Completion of Skills and Documentation. Manage: 6. Professional Behaviors: Confidentiality, Punctual, and Behaviors: Respectful. Student Comments: Faculty Comments: Faculty Comments: _____Medication Administration: _____Treatments: _____Med Adm: _____Professionalism: ____Accepts responsibility for nursing care: ____Seeks learning opportunities

_____Treatme nts: _____Professi onalism: ____Accepts resp:

Strategies for improving:

Recommendations:

____Seeks learning opportunities Recommend ations:

_____Clinical Incident Report _____Attend Skills Lab for mandatory 4 hour Remediation due by_______________________ _____ Incident Report _____Mandat ory Skills Lab for 4 hour due by__________ Faculty Date

Faculty Signature_______________________ Date___ My signature indicates that I have read the above statements and am aware of my clinical performance. Signature Date