choose your client from the clinical experience and prepare a concept map and make a powerpoint
Weekly Concept Focus
- Mobility or Safety
- Elimination
- Oxygenation: Gas Exchange
- Thermoregulation or fluid and electrolytes
- Inflammation/infection
- Tissue Integrity
- Pain
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Date: |
Student name: |
Clinical Site/Unit: |
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Clinical Site Instructor: |
Clinical Site Mentor: |
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Overweight/underweight: |
Allergies: |
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Marital Status: |
Religion: |
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Cultural Background: |
Primary Language: |
Code status: |
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Diet/Nutrition: |
Activity: |
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Treatments: |
IV/Tubes/Ostomies: |
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Interdisciplinary Cares (OT/PT/RT): |
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Dressings/Wounds: (type & location) |
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Oxygen: (delivery method & amount) |
Dialysis: |
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Admitting Medical Diagnosis(s): |
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Primary (if different than Admitting) |
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Secondary (Do not include History Of): |
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Medication Data Sheet
Scheduled Medications that your patient is currently taking.
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Drug Name and Classification |
Expected action & indication for use |
Side Effects/ Adverse Reactions |
Medication/Food Interactions |
Nursing Administration Special Instructions & Assessments |
Client Education & Evaluation of Medication Effectiveness e.g. Pain Scale |
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Daily “Brainsâ€, to be completed during clinical day.Begin your day with a plan and change/make notes as needed.You may print and use this template or create your own.
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Room #: |
Diet: |
Ambulation: |
IV fluids: |
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Medications |
Treatments |
Nursing care/interventions |
Vital Signs |
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0700 |
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0800 |
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0900 |
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1000 |
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1100 |
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1200 |
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1300 |
ASSESSMENT SUMMARY: Complete in narrative form based on the form filled out during clinical day.
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Body System |
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Vital Signs and Pain Level: |
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Sensory: |
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Neurological: |
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Respiratory: |
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Cardiac: |
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Integument: |
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Gastrointestinal: |
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Musculoskeletal: |
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Renal: |
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Endocrine: |
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Immune and Hematologic: |
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Psychosocial/ Sociocultural / Spiritual: |
Patient education: (e.g. medication, possible complications associated with the patient, nutrition, activity)Complete in a narrative format exactly how you would educate the patient.Include 7 narrated sentences.
Outcome: Critical Thinking: Self assessment:
Self reflect on how your clinical experience correlates with what you learned in this week’s module.Objectives are located in the course under each module and are helpful in completing this section.
Outcome: Caring
Identify one example from your clinical day in which you observed, participated in, or provided some aspect of caring for the provision of psychosocial and/or cultural diversity needs. How did you inspire or make a difference in your patients life today?
References (at least 3 in APA format)
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