Clinical Worksheet Plan Of Care Concept Map Worksheet: 1 Per Medication ISBAR Worksheet

Clinical Worksheet Plan

Clinical Worksheet             Plan of Care Concept Map             Pharm4Fun Worksheet: 1 per medication             ISBAR Worksheet

1) Patient Introduction

Olivia Jones is a 23-year-old African-American female, G1P0 at 36 weeks of gestation. She has been diagnosed with severe preeclampsia and is admitted to the labor and delivery unit for assessment and surveillance.

Pregnancy has been unremarkable until routine prenatal visit at 30 weeks with elevated blood pressure at 146/92 mm Hg, proteinuria, and developing mild preeclampsia. She has been on bed rest at home until prenatal visit today with increasing symptoms, resulting in admission.

She has gained 3 pounds since prenatal visit 1 week ago. Protein dipstick is +4, negative ketones, negative glucose, +2 dependent edema, and facial puffiness.

Ms. Jones is complaining of a headache that is not resolved with acetaminophen. She presents with nausea and fatigue and complaining of epigastric pain, visual changes, and chest tightness. The fetus is active; however, patient states that it is a bit quieter than normal. There is a possibility of premature rupture of membranes. An IV with lactated Ringer’s is running at 125 mL/hr. Labs were obtained.

Medication: Magnesium sulfate (injection)

2 Patient Introduction

Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor assessment.

The patient states that her water may have broken earlier this morning and she thinks she is in labor. AmniSure was positive. Vaginal exam reveals 50% effacement of cervix, cervical dilation 4 cm, and fetus at -2 station.

The patient’s boyfriend is present, and she has phoned her mother to inform her of her admission. The provider has been notified, and prenatal records have been pulled.

The lab report indicates that the patient’s group B strep vaginorectal culture taken at 36 weeks was positive. The patient wishes to have a natural birth without medication. Admission intrapartum orders have been initiated, initial labs have been drawn, and a saline lock has been placed in her forearm.

Medication: Promethazine hydrochloride

3 Patient Introduction

Amelia Sung is a 36-year-old Filipino female, G2P1 (L1) at 39 weeks of gestation, who was admitted 24 hours ago for induction of labor.

First-born male delivered vaginally 3 years and 3 months ago. Weight: 3,345 g (7 lb 6 oz). Length 55 cm (22 in).

She was started on oxytocin at 1 mL/1 mU, and the infusion was increased throughout the day per protocol. A mainline IV of lactated Ringer’s is running at 125 mL/hr, and oxytocin (30 units in 500 mL normal saline) is running at 20 mU/min (20 mL/hr).

Her cervical exam at admission was 2 cm dilation, 80% effaced, at -1 station, with fetus in vertex position. At 0100 hours, dilation was 4 cm, 100% effaced, still at -1 station and fetus in vertex position. She received an epidural shortly after that, and 1 hour later, her membranes ruptured; the fluid was clear.

Three hours ago, she was fully dilated and started pushing. The fetal heart rate has been stable with a baseline of 120/min, moderate variability, and early decelerations since she started pushing. She is getting tired from pushing, and the descent of the fetal head has been slow.

During the past few contractions, the baby has started to crown. The provider has been called and has arrived, so Amelia may continue pushing.

Medication: Oxytocin

4 Patient Introduction

Carla Hernandez is a 32-year-old Hispanic female, G2P1 (L1), at 39 5/7 weeks of gestation. She was admitted to labor and delivery in active labor at 0600 hours today, accompanied by her husband Earl.

To progress the delivery, artificial rupture of membranes was performed by the provider a few minutes ago. The provider has just left the room to make rounds.

Suddenly, the fetal heart rate drops dramatically, and you discover that the umbilical cord is prolapsed. You are ready to handle this situation with another nurse who is also present in the room.

Medication: Terbutaline sulfate

5 Patient Introduction

Fatime Sanogo is a 23-year-old primiparous female from Mali in her first hour after vaginal delivery. The patient was admitted yesterday at 0600 hours for oxytocin induction of labor secondary to postdates (41 4/7 weeks). She declined all pain medication during labor.

Following a prolonged second stage, she delivered a vigorous female infant at 0605 hours with Apgar scores of 9 and 9 and weight of 4,082 g (9 lb 0 oz). The patient contracted a second-degree perineal laceration during delivery; this has been repaired.

Placenta was delivered manually at 0635 hours via Dr. Schultz. Bleeding was controlled by fundal massage and infusion of remaining oxytocin induction bag, which is still running at 20 mL/hr (20 mU/min); approximately 100 mL left in the bag.

The patient was just up to the bathroom and couldn’t void. She is now dozing, and the father of the baby is at the bedside, holding the baby and sending text messages from the phone. Fatime does not speak English fluently, as she has only been in the country for 7 months. You enter the room to assume care of the patient and to perform the second of four assessments every 15 minutes.

Medication: Misoprostol

STUDENT

CLINICAL REPLACEMENT PACKET

Student Resources

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vSim CLINICAL REPLACEMENT PACKET for STUDENTS

STUDENT INSTRUCTIONS FOR VIRTUAL CLINICAL REPLACEMENT

This activity packet is intended to be used with your assigned virtual patient found in vSim. The Six Step learn flow in vSim is to be followed as instructed below. Once you have completed the Six Steps, in additon to this Clinical Replacement Activity Packet, submit for grading as instructed in your syllabus.

LEARN FLOW – STEP ONE

 Finish the Suggested Readings, then complete the following four activities: o Clinical Worksheet o Plan of Care Concept Map o Pharm4Fun Worksheet (one per medication) o ISBAR Worksheet

EST. TIME: 4 – 6 HOURS

LEARN FLOW – STEP TWO

 Take the Pre-Simulation Quiz o Student may take several times using the answer key to provide immediate

remediation prior to the virtual simulation. Quiz is recorded as complete.

LEARN FLOW – STEP THREE

 Launch the virtual simulation o Suggest student complete the vSim Tutorial prior to launching Step Three. o Each clinical experience in the simulation lasts a maximum of 30 minutes. o Student is to complete the simulation as many times as it takes to meet an 80% benchmark.

LEARN FLOW – STEP FOUR

 Complete the Post-Quiz o The answer key is not visible to the student until after they have submitted the quiz. o The quiz grade is recorded as a percentage

LEARN FLOW – STEP FIVE

 Document o The student documents the clinical events that occurred during the simulation

using the information contained in step five. o If using DocuCare, the instructor assigns the same vSim patient which can be

found in DocuCare cases.

LEARN FLOW – STEP SIX

 Reflection Questions o Students are to complete the reflection questions and submit to instructor post

clinical replacement (see syllabus for details). o The quiz grade is recorded as a percentage

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STUDENT LEARNING OUTCOMES

ASSIGNMENT

This ac�vity creates an opportunity for you to organize the nursing care required for the pa�ent care presented in your assigned vSim.

At the end of this ac�vity, student will be able to:

1. Describe pathological events associated with the pa�ent’s disease process or condi�on.

2. Create a plan of care and priori�zed nursing interven�ons based on pa�ent care needs.

3. Iden�fy an�cipated diagnos�c and physical assessment findings related to the iden�fied condition or disease process.

1. Log into thePoint and launch the assigned vSim, following all instruc�ons posted on your learning management system (LMS).

2. Review the informa�on contained in the pa�ent informa�on.

3. Review the smart sense links associated with Nursing Care, Diagnos�cs, and Pharmacology found in the suggested reading area.

4. Create the following “concept map”. List the pathophysiology associated with the pa�ent’s disease process or condi�on, the an�cipated physical assessment findings, vital signs, diagnos�cs, specific nursing interven�ons, and other pa�ent informa�on associated with the pa�ent situa�on.

5. U�lize the smart sense links throughout the vSim to complete the worksheet.

6. Submit your concept map for review.

CONCEPT MAP/ PLAN OF CARE EST. TIME: 30 MINUTES

DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

CONCEPT MAP WORKSHEET

DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)

PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS

ANTICIPATED NURSING INTERVENTIONS

IS AR EST TIME MIN

This SBAR ac�vity assists you in building the skill of communica�ng per�nent informa�on when caring for a pa�ent. Appropriate ac�ons you should do to complete this ac�vity include finding appropriate data to provide a thorough SBAR report.

STUDENT LEARNING OUTCOMES

At the end of this ac�vity, student will be able to: 1. Iden�fy per�nent data from the pa�ent informa�on area of the vSim suggested reading sec�on. 2. Communicate per�nent informa�on for a pa�ent using ISBAR.

ASSIGNMENT

1. Log into thePoint and launch the assigned vSim, following all instruc�ons posted on your learning management system (LMS).

2. Review the informa�on contained in the pa�ent informa�on area of the suggested reading sec�on. 3. Review the smart sense links found within the Nursing Care, Diagnos�cs and Pharmacology areas of the

suggested reading. 4. Navigate and fill out the data in the following document using the pa�ent informa�on provided in the

suggested reading area. 5. Submit for review.

INTRODUCTION

vSim ISBAR ACTIVITY

Your name, posi�on (RN), unit you are working on

SITUATION

Pa�ent’s name, age, specific reason for visit

BACKGROUND

Pa�ent’s primary diagnosis, date of admission, current orders for pa�ent

ASSESSMENT

Current per�nent assessment data using head to toe approach, per�nent diagnos�cs, vital signs

RECOMMENDATION

Any orders or recommenda�ons you may have for this pa�ent

STUDENT WORKSHEET

PHARM-4-FUN EST. TIME: 30 MIN (PER MEDICATION)

This ac�vity provides you with the opportunity to create per�nent pa�ent educa�on on the pharmacological agents associated with the vSim ac�vity. You will u�lize this worksheet for each drug listed under the pharmacology are of the suggested reading sec�on.

STUDENT LEARNING OUTCOMES

At the end of this ac�vity, student will be able to:

1. Explain purpose for taking the iden�fied pharmacological agents. 2. Discuss per�nent pa�ent educa�on related to all the listed pharmacological agent.

ASSIGNMENT

1. Log into thePoint and launch the assigned vSim, following all instruc�ons posted on your learning management system (LMS).

2. Review the informa�on contained in the pa�ent informa�on. 3. Review the smart sense links associated with the Pharmacological agents found in the suggested

reading area. 4. Use the smart sense link to complete the following “pa�ent educa�on” worksheet for each

pharmacological agent listed in the Pharmacology are of the suggested reading sec�on. 5. Submit for review.

PATIENT EDUCATION WORKSHEET

NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION:

CLASSIFICATION:

PROTOTYPE:

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

PURPOSE FOR TAKING THIS MEDICATION

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

STUDENT LEARNING OUTCOMES

ASSIGNMENT

This activity creates an opportunity for you to prepare for a virtual clinical experience. This activity provides you with the opportunity to manage patient care, prioritize interventions, and identify aspects of care that could be delegated.

At the end of this ac�vity, student will be able to:

1. Describe pathological events associated with the patient’s disease process or condition.

2. Create a plan of care that is prioritized and is based on the patient’s care needs.

3. Identifies path to healing or health and path to death or injury.

4. Describes aspects of care that can be delegated and appropriate personnel to complete delegated tasks.

1. Log into thePoint and launch the assigned vSim, following all instructions posted on your learning management system (LMS).

2. Review the information contained in the patient information.

3. Review the smart sense links associated with the Nursing Care, Diagnostics, and Pharmacology, found in the suggested reading area.

4. Complete all areas of the attached clinical worksheet.

5. Submit the completed worksheet.

CLINICAL WORKSHEET

vSim Worksheets Grading Rubric

Criteria 5 Points 4 Points 3 Points 2 Points 1 point Total Points

Content Knowledge

-Follows all requirements for the assignment. -Conveys well-rounded knowledge of the topic. -Content well organized, logical. -Easy to read and understand throughout all of worksheet.

-Follows all requirements for the assignment. -Major points of topic are mostly covered in the required assignment areas. -Content organized, logical flow. -Easy to read and understand through most of worksheet.

-Knowledge of topic is par�ally covered. -Key informa�on is missing from 2 or more assignment areas. -Worksheet difficult to follow in two or more areas. -Informa�on is incomplete in two or more areas.

– Knowledge of topic is general in more than three areas of the worksheet. – 1 or more areas of worksheet le� blank. -Content unorganized throughout worksheet. -Difficult to understand content of paper.

-Knowledge of topic is general throughout en�re worksheet, and/or does not cover all the required assignment areas. -Two or more areas le� blank on worksheet. -Unable to follow flow of worksheet.

Cri�cal Thinking

-Concisely explains each content area. -Analyzes informa�on, connects data points to provide accurate, concise informa�on. -Scholarly work.

-Explains each content area. -Presents informa�on about the topic. -Some analysis, insight present, some data points threaded together. -Scholarly work. -Major aspects of the

content areas are presented, but content lacks insight and analysis. -Few data points connected to provide informa�on.

-Few aspects of the content areas presented. Few insights presented, lacking analysis. -Data points not connected to informa�on provided. -Li�le understanding gained from informa�on presented.

-Informa�on is basic. -No aspects of the content present in the worksheet. -Lacks insight, analysis, and conclusions. -No understanding from the content presented.

Wri�ng Composi�on (Spelling, Grammar, Sentence Structure)

-An occasional spelling error present. -Grammar, readability, and sentence structure is error free.

-Some minor errors (1-3 errors) with spelling, grammar and/or sentence structure, not consistent throughout worksheet. -Errors do not interfere with the readability or comprehension of informa�on.

-Frequent errors (4-5 errors) with spelling, grammar and/or sentence structure. -Errors effect ability to comprehend informa�on present on worksheet and readability.

-Numerous errors (5-6 errors) with spelling, grammar and/or sentence structure throughout worksheet. -Difficult to understand informa�on presented due to numerous errors.

-Excessive errors (>6 errors) occur with spelling, grammar and/or sentence structure, throughout worksheet. -Unable to understand informa�on presented in the worksheet.

Total Points:_________

Clinical Worksheet Date: ________________________ Student Name: _____________________________ Assigned vSim: ___________________________

Initials:

Age:

M/F:

Code Status:

Diagnosis:

Length of Stay:

Allergies:

HCP:

Consults:

Isolation:

Fall Risk:

Transfer:

IV Type: Location:

Fluid/Rate:

Critical Labs: Other Services:

Consults Needed:

Why is your patient in the hospital (Answer in your own words and include the History of present Illness):

Health History/Comorbities (that relate to this hospitalization):

Shift Goals/ Patient Education Needs: 1.

2.

3.

4.

Path to Discharge:

Path to Death or Injury:

Clinical Worksheet Alerts: What are you on alert for with this patient? (Signs & Symptoms)

1.

2.

3.

What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)

1.

2.

3.

List Complications may occur related to dx, procedure, comorbidities:

1.

2.

3.

What nursing or medical interventions may prevent the above Alert or complications?

1.

2.

3.

4.

Management of Care: What needs to be done for this Patient Today?

1.

2.

3.

4.

5.

6.

Priorities for Managing the Patient’s Care Today

1.

2.

3.

4.

What aspects of the patient care can be Delegated and who can do it?

Purpose: This rubric analyzes the components of the electronic health record that students would utilize when

documenting the care of a patient during a simulated event.

Components: Each criterion contains performance criteria to demonstrate the critical thinking and clinical reasoning

utilized during a simulated patient care encounter. The performance criteria describe the traits that are linked to a level of

performance. There are four levels of performance as well as a “not applicable” column. The levels of performance

indicate the degree to which the student documented the events of the simulated patient care situation.

Using the Rubric:

• Students: Prior to the simulation experience, the students can use the rubric to prepare for the documentation

requirements associated with a simulated experience. The emphasis on thorough, systematic documentation of the

nursing care provided during the simulation will facilitate clinical reasoning and critical thinking development. The

student can utilize the rubric to perform a self-assessment of their documentation of the simulated events prior to

submitting their DocuCare assignment. The rubric provides transparency related to the expectations for

documentation and the grading of the student’s submitted work.

• Faculty: The simulation documentation is only graded in whole numbers. The minimum accepted score is an 80%.

The student will need to resubmit the simulation documentation if the total percentage is less than 80%. The

student receives one attempt to remediate and edit their documentation.

Grading Rubric for DocuCare Entry: vSim

Rubric for Grading vSim Clinical Worksheet

5 3 1 0 Patient Information:

Demographics, Diagnosis, Allergies, Provider, Consults, Isolation, Fall Risk, Intravenous Therapy, Critical Labs, Services and Needed Consults

All documented areas 100% complete and provide thorough information.

Three listed areas completed OR documented areas 75% complete.

Less than three listed areas completed OR documented areas less than 50% completed.

Patient information area blank.

Medical History:

Why patient is in the hospital, History of present Illness, Past Medical/Surgical History, Comorbidity Factors

100% of HPI, Past Medical/Surgical History and Comorbidity Factors completed with thorough, relevant information.

75% of HPI, Past Medical/Surgical History and Comorbidity Factors completed. Information relevant to scenario.

50% of HPI, Past Medical/Surgical History and Comorbidity Factors completed. Information basic and lacks relevancy.

25% of HPI, Past Medical/Surgical History and Comorbidity Factors completed. Information not relevant, or content areas left blank,

Patient Education/Goals:

Shift Goals, Patient Education Needs

Thorough and detailed patient education. Patient shift. goals are SMART, relevant, and detailed goals. 100% of worksheet area is complete.

Provides patient education but lacks thoroughness or details. Patient shift goals missing 1-2 components of SMART goals. 75% of information needed for worksheet area present.

Patient education lacks thoroughness and details. Patient shift goals missing 3 – 4 components of SMART goals. 50% of the information needed for worksheet area present.

Missing patient education and/or patient shift goals. Patient shift goals lack all components of SMART goals. 25% of the information needed for worksheet area present.

Disease Progression:

Pathway to Death or Injury Pathway to Health

Pathway to death and health is identified with detail. Information is concise, relevant, accurate and portraits appropriate timeframe for occurrence. 100% of the information needed for worksheet present.

Pathway to death and health is identified. Information is relevant and accurate. Missing timeframe for occurrence. 75% of information needed for worksheet area present.

Missing over 50% of needed information for worksheet area present. Pathway to death and health identified but content either not relevant or accurate for situation present in scenario.

Pathway to death and health contains information not relevant or accurate to the scenario or section left blank.

AACIP:

Alerts, Assessments, Complications, Interventions and Prevention

Alerts, Assessments, Complications and Interventions/Preventions identified thoroughly. Answers relevant to scenario. 100% of the information needed is present.

Alerts, Assessments, Complications and Interventions/Preventions identified. Most answers relevant to scenario. 75% of the information needed for worksheet area present.

Missing 2 – 3 areas on worksheet. Answers not relevant to scenario. 50% of the information needed is present.

Missing 4 or more areas on worksheet. Answers not relevant to scenario. 25% of the information needed for worksheet area is present.

Nursing Care Plan:

Management of Care, Priorities for Patient Care, Delegation

Management of Care relevant to case scenario and detailed. Priorities for scenario identified. Identifies all aspects of care that can be delegated and identifies appropriate personnel to delegate activities to. Answers detailed, Critical thinking evident.

Management of Care, Priorities or delegation sections relevant to scenario. Answers generic to situation. Some evidence of critical thinking present.

Missing relevant data in one or more categories (management of care, prioritization, delegation). Answers basic without detail. Little to no evidence of critical thinking present.

Information provided not relevant to scenario. Answers are basic without detail. No evidence of critical thinking. Missing answers in one or more area.

TOTAL POINTS