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Nursing care is dependent upon caregivers
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Nursing care is dependent upon caregivers? assessment, prioritization of care needs, and evaluation of patient and family responses. Growth into a new role is enhanced by reflection._x000D_
Please select one patient from your patient assignment in collaboration with your clinical instructor between clinical weeks 3 and 7. This patient must have multiple acute and chronic health conditions. The summation is to be completed following your clinical experience with the patient. Complete the following:_x000D_
1. A brief overview of the patient?s reason(s) for hospitalization, treatments received/scheduled, and progress to date._x000D_
2. Narrative head to toe (or by systems) assessment.
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a. You may use the facility?s documentation system as a guide. The narrative physical assessment history may follow the template outlined in the health assessment textbook – ?normal? or ?within normal limits? are not to be used as descriptors._x000D_
3. Select a minimum of 3 priority NANDA approved diagnoses for your patient. Remember to think priority!_x000D_
4. Focused progress note of your clinical shift with the patient_x000D_
a. Document your plan of care, interventions performed, and patient/family responses noted during your clinical shift with the patient in the form of a narrative progress note. Accurate documentation of time is vital in a medical record._x000D_
The progress note should include accurate times (written in military time). Remember, the progress note should (at minimum) address the 3 priority nursing diagnoses.
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5. Reflection of the clinical day_x000D_
a. Describe your clinical performance for the day. Include positive experiences and areas for growth. Discuss the interactions encountered or observed on the unit (ancillary staff, nursing staff, physician/nurse practitioner/physician assistant staff, family members). Discuss strategies for change. The reflection should be about one page in length (typed, double-spaced)._x000D_
Section Expected Criteria Points Awarded/Points Possible_x000D_
Overview of Pt. Hospitalization Accurately and concisely provides brief overview of the patient?s reason(s) for hospitalization, treatments received/scheduled, and progress to date._x000D_
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