Introduction: Detailed and specific including all aspects mentioned in guidelines. Detailed and specific, but missing one aspect mentioned. Detailed or Specific (not both) and/or missing 2 aspects mentioned Not detailed or specific and missing 1-2 aspects mentioned. Not detailed or specific and missing more than 3 aspects mentioned. History: PMH Treatments until admission Detailed and specific including all aspects mentioned in guidelines. Detailed and specific, but missing one aspect mentioned. Detailed or Specific (not both) and/or missing 2 aspects mentioned Not detailed or specific and missing 1-2 aspects mentioned. Not detailed or specific and missing more than 3 aspects mentioned. Pathophysiology Disease process, and manifestations. Extensive detail with causes and manifestations. Comparing your patient to the classic presentation. Detailed with causes and manifestations & comparison of patient to classic presentation. Detailed but without causes or manifestations OR comparisons Detailed but without causes or manifestations and comparisons Not detailed and without causes, manifestations, and comparisons. Assessment: Complete Head to Toe OR Mental assessment. Detailed and specific assessment includes all aspects mentioned in guidelines. Detailed and specific, but missing one aspect mentioned. Detailed or Specific (not both) and/or missing 2 aspects mentioned Not detailed or specific and missing 1-2 aspects mentioned. Not detailed or specific and missing more than 3 aspects mentioned. Related Treatment: Discuss treatments DURING your care that are specific to the diagnosis. Detailed treatments specific to diagnosis, as well as treatment/tests important to care. Detailed treatments specific to diagnosis. Detailed treatments not specific to the diagnosis. Could not identify relevant data Unable to identify treatment related to diagnosis or care. No related to treatment mentioned. Nursing Care: Nursing diagnoses with at least 3 interventions each. 3 or + with 3 interventions each and listed by prioritization. 3 or + either incorrectly prioritized, or with less than 3 interventions. 2 with 3 interventions each and listed by prioritization. 2 either incorrectly prioritized, or with less than 3 interventions. 1 or less diagnosis. Legal/Ethical: Legal/Ethical Issue. Actions (or should have been taken). Application of ANA Code of Detailed discussion of L/E Issue, actions taken (or should have been taken), and application of ANA Code of Detailed discussion of L/E Issue without either actions taken or application of ANA Code of Ethics Detailed discussion of L/E Issue without actions taken or application of ANA Code of Ethics Issue addressed that is neither legal or ethical. Statement that no ethical/legal issue existed.
Ethics. Ethics. Cultural/Ethnic: Culture of pt (socioeconomics and/or ethnicity). Discuss specific cultural care. Health/healing traditions influencing health care. Detail culture of pt with specific cultural considerations. Discuss actual or possible traditions influencing care. Detail culture of pt including either cultural considerations or traditions influencing care. Detail culture of pt with no cultural considerations or traditions influencing care. Incorrectly identify cultural/ethnic considerations there is no cultural/ethnic considerations for this patient. Teaching: Who to teach? What to teach (content and method)? How to teach? Why When to teach? Detailed teaching plan that answers all the questions. Detailed teaching plan that answers 4 of the questions. Detailed teaching plan that answers 3 of the questions. Detailed teaching plan that answers 2 of the questions. Detailed teaching plan that answers 1 of the questions. Or inappropriate teaching plan. Related Research: research articles related to the specific care of your patient 1 or more research articles summarized and applied to your patient. APA citation 1 research articles summarized and applied to your patient. No APA citation 1 research articles summarized and/or applied to your patient. APA citation 1 research articles summarized and/or applied to your patient. No APA citation 1 research articles not summarized or applied to your patient. Critical Thinking (presenter) Critical Thinking (audience) Add each score to find the total points earned ___________/(divide it by) 48 points possible) x 100 = __________ percentage earned Faculty comments and signature: Weekly Journal
EXAMPLE ONLY ARKANSAS TECH UNIVERSITY Department of Nursing Interpersonal Process Recording Example NURSE: VERBAL AND NONVERBAL PATIENT: VERBAL AND NONVERBAL PRINCIPLES THAT EXPLAIN BEHAVIOR AND INTERVENTION, FEELINGS AND OBSERVATIONS Date: Interaction Number 12 *Goal: Patient will identify situations arousing discomfort and how he handles them. Mr. E. had just returned from a home visit. He came over to me and said he had to check his clothes and would be right back. I said I would wait for him in the usual place. He returned ten minutes later at 8:10 a.m. How was your weekend? I was a little irritated that Mr. E. would be late; even though I knew it was ward policy that his clothes be checked at once. However, I waited in the usual place. Reinforcing trust by being on time and remaining there for patient. Maintaining terms of contract. Fine, and Focus conversation back to patient. Well, I was out on pass. I had a good time. I spent a lot of time straightening things up - putting summer clothes away and sorting out things. I could only work a few hours and then had to take a snooze. Fatigue may be emotional as well as physical. Sleep can be a defense against a trying situation. We had company too. My sister had just told people that I wasn't feeling well. She didn't tell them what was wrong and they expected to see me with casts or something. She left it to me to tell them what was wrong. Patient's anxiety rose here, by much moving around in his chair, embarrassed laughter, and lack of eye contact. Sister probably gave responsibility to patient because of her own feelings. How did you feel about telling them? Focusing to get pt to express feeling. Oh, I had no feelings about it at all. They're friends and they understand. They've seen me upset and angry. They understand. Denial of feelings as a protective mechanism. Hopes friends understand but not sure. What do you do when you get Exploring pt.’s usual coping strategies and helping patient to be aware of his behavior in reaction to stress.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current psychotrophic meds?(After PMH, put the medication number that correlates with that illness; This should also include hospital meds) PMH: Home and Hospital Meds: Pharm. Classification: Expected Outcome: Side Effects 1. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. 5. 6. 7. Nutrition Diet Height Weight BMI Snacks Nutritional Assessment (What are the nutritional for your patient based on his/her health status diagnoses; this may differ from the actual ordered diet)? Lab Results: (Complete for day before/most recent and then day of clinical) What lab results are RELEVANT that must be recognized as clinically significant to the nurse? Complete Blood Count (CBC:) Norms Mm/dd/yy Mm/dd/yy High/Low/WNL? WBC Hgb Platelets UDS TSH What lab results are that must be recognized clinically significant the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Misc. Labs: Norms Date: Date: High/Low/WNL? Tegretol Glucose Valproic Acid LiCo3 HCG ASO Titer Other: RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Liver Function Test (LFT:) Norms Date: Date: High/Low/WNL? Albumin Total Bilirubin Alkaline Phosphatase ALT AST RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
Therapy Sheet: Primary IV (peripheral, central line, PICC) Type of IV* Site of IV insertion Primary fluid infusing/rate of infusion Antibiotics Antibiotic Drug amount/total fluids cc/hr dose/hr Infusion and continuous drips Drug Ordered dose Drug amount/total fluids Drug amount/ ml cc/hr dose/min dose/hr IV Sedation Drug Ordered dose Drug amount/total fluids Drug amount/ml cc/hr dose/hr Heparin Dose Rate Dose/ml Dose/min Dose/hr PCA Drug Bolus Lockout