CHAMBERLAIN UNIVERSITY
National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 |
chamberlain.edu
Please visit chamberlain.edu/locations for location specific address, phone and faX information.
CLINICAL LEARNING – DIRECT
PATIENT CARE
LEVEL 3 CLINICAL COURSES
DOCUMENTATION
PAGE 1 OF 10
Student Name:
D#: Date:
Course: NR341: Complex Adult
Health Session and Year:
Directions
This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning setting.
All information within this packet must be handwritten, (with the exception of the reflection journal) reviewed with your faculty on your assigned clinical
day and submitted within 24 hours (or as directed by course coordinator). If additional space is needed, please use the back of each page.
• Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the Clinical Learning Evaluation. Satisfactory rating meets the following:
– Clinical Learning Competency: Completes all clinical learning experiences and requirements successfully (PO 5).
• Performance Descriptor: Completes all assignments related to the clinical learning experience within established guidelines.
• I-SBAR: Utilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been received. Students
should deliver a hand-off report at the end of their shift to the bedside nurse.
• Assessment Findings, Labs and Healthcare Provider Orders: Document your initial and ongoing assessment findings, lab results with why they were
drawn specifically for your patient and healthcare provider orders with why they were specifically ordered for your patient.
• ATI® Active Learning Templates Required:
– Diagnostic Procedure: Select one diagnostic procedure from the healthcare orders table and complete one Active Learning Template: Diagnostic Procedure.
The selected diagnostic procedure should be one in which you have not previously completed a template for this session.
– Therapeutic Procedure: Select one therapeutic procedure from the healthcare orders table and complete one Active Learning Template: Therapeutic
Procedure. The selected therapeutic procedure should be one in which you have not previously completed a template for this session.
– Nursing Skill: Select one nursing skill from the healthcare orders table and complete one Active Learning Template: Nursing Skill. The selected
nursing skill should be one in which you have not previously completed a template for this session.
– Medications: List medications below and complete one Active Learning Template: Medication for each medication classification in which you
have not previously completed a template.
Time Due Drug/Classification Clinical Significance
0930 Tramadol (Opioid Analgesic) Provides reliefe from severe acute pain
0930 Furosemide (Loop Diuretic) Reduces hypertension and fluid retention
0930 Oxygen (Medical gas) Helps combats SOB and increases O2 sat
0930 Ondansetron (5-HT3 antagonist) Helps with patients nausea and vomiting
0930 Metoprolol (Beta Blocker) Reduces blood pressure and decreases heart rate
0930 Penicillin (Antibiotic) Helps to treat possible present infecion
• Nursing Diagnosis:
Identify three nursing diagnoses for your patient and list them by priority below. Complete one concept map for your top nursing diagnosis listed below.
1. Ineffective airway clearance related to fatigue as evidence 2. Acute pain related to obstuction of bilary ducts as
by severe evidence b
3. Imbalanced nutrition related to decreased oral intake as
evidenc by p
• Reflection Journal:
Complete a reflection journal and submit to your faculty within 24 hours of completing your clinical learning experience. Reflective journaling provides a format
1-180405 ©2019 Chamberlain University LLC. All rights 0119pflcpeADA
reserved.
, CHAMBERLAIN UNIVERSITY
to share your knowledge, skills, experiences and personal reflection related to concepts and strategies learned throughout your program. The reflection journal
is required to be typed, Word document, Times New Roman 12-point font. Minimum of one page and no more than three pages.
1-180405 ©2019 Chamberlain University LLC. All rights 0119pflcpeADA
reserved.
National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 |
chamberlain.edu
Please visit chamberlain.edu/locations for location specific address, phone and faX information.
CLINICAL LEARNING – DIRECT
PATIENT CARE
LEVEL 3 CLINICAL COURSES
DOCUMENTATION
PAGE 1 OF 10
Student Name:
D#: Date:
Course: NR341: Complex Adult
Health Session and Year:
Directions
This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning setting.
All information within this packet must be handwritten, (with the exception of the reflection journal) reviewed with your faculty on your assigned clinical
day and submitted within 24 hours (or as directed by course coordinator). If additional space is needed, please use the back of each page.
• Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the Clinical Learning Evaluation. Satisfactory rating meets the following:
– Clinical Learning Competency: Completes all clinical learning experiences and requirements successfully (PO 5).
• Performance Descriptor: Completes all assignments related to the clinical learning experience within established guidelines.
• I-SBAR: Utilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been received. Students
should deliver a hand-off report at the end of their shift to the bedside nurse.
• Assessment Findings, Labs and Healthcare Provider Orders: Document your initial and ongoing assessment findings, lab results with why they were
drawn specifically for your patient and healthcare provider orders with why they were specifically ordered for your patient.
• ATI® Active Learning Templates Required:
– Diagnostic Procedure: Select one diagnostic procedure from the healthcare orders table and complete one Active Learning Template: Diagnostic Procedure.
The selected diagnostic procedure should be one in which you have not previously completed a template for this session.
– Therapeutic Procedure: Select one therapeutic procedure from the healthcare orders table and complete one Active Learning Template: Therapeutic
Procedure. The selected therapeutic procedure should be one in which you have not previously completed a template for this session.
– Nursing Skill: Select one nursing skill from the healthcare orders table and complete one Active Learning Template: Nursing Skill. The selected
nursing skill should be one in which you have not previously completed a template for this session.
– Medications: List medications below and complete one Active Learning Template: Medication for each medication classification in which you
have not previously completed a template.
Time Due Drug/Classification Clinical Significance
0930 Tramadol (Opioid Analgesic) Provides reliefe from severe acute pain
0930 Furosemide (Loop Diuretic) Reduces hypertension and fluid retention
0930 Oxygen (Medical gas) Helps combats SOB and increases O2 sat
0930 Ondansetron (5-HT3 antagonist) Helps with patients nausea and vomiting
0930 Metoprolol (Beta Blocker) Reduces blood pressure and decreases heart rate
0930 Penicillin (Antibiotic) Helps to treat possible present infecion
• Nursing Diagnosis:
Identify three nursing diagnoses for your patient and list them by priority below. Complete one concept map for your top nursing diagnosis listed below.
1. Ineffective airway clearance related to fatigue as evidence 2. Acute pain related to obstuction of bilary ducts as
by severe evidence b
3. Imbalanced nutrition related to decreased oral intake as
evidenc by p
• Reflection Journal:
Complete a reflection journal and submit to your faculty within 24 hours of completing your clinical learning experience. Reflective journaling provides a format
1-180405 ©2019 Chamberlain University LLC. All rights 0119pflcpeADA
reserved.
, CHAMBERLAIN UNIVERSITY
to share your knowledge, skills, experiences and personal reflection related to concepts and strategies learned throughout your program. The reflection journal
is required to be typed, Word document, Times New Roman 12-point font. Minimum of one page and no more than three pages.
1-180405 ©2019 Chamberlain University LLC. All rights 0119pflcpeADA
reserved.
