NR 446 week 2 Clinical Learning - Direct Patient Care Documentation

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. If any area within this packet was not performed, line out and place “N/A” in that section. • 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. • Patient Report: Utilized for receiving report. Students should deliver a hand-o! 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: Complete one Active Learning Template: Medication for each medication classification in which you have not previously completed a template. • Reflection Journal – Complete a reflection journal and submit to your faculty (or as directed) within 24 hours of completing your clinical learning experience. Reflective journaling provides a format to share your knowledge, skills, experiences and personal reflection related to concepts and strategies learned throughout your program. What could you or did you delegate and to whom? Include ways you plan to care for yourself 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. At least one time during the session, faculty will select one of the following questions for you to reflect on. 1. Describe how racial/health disparities, health equality/inequality, and social justice/injustice could apply to the clinical site/agency’s community. Consider the population and determine why this may be occurring. 2. Transportation and housing are drivers of health and equity. Describe the steps you would take as a nurse to evaluate transportation and housing for your identified community population and what actions you could perform to identify resources. 3. How can nurses be change agents and advocate for their community? Provide at least two specific examples.