The Hashemite University

Faculty of Nursing

Adult Care Nursing II / Clinical Book

Semester

Course syllabus

Course Title: Adult Care Nursing II/ Clinical

Course Number: 0702244

CO-Requisites or Prerequisites: Adult Care Nursing I/ Theory

Credit Hours: 3 Credit Hours

Faculty members:

- office hours: with arrangement with your instructor

- Course coordinator :.

- Coordinator:

Course Description:

This practicum course is a continuation of Adult Care Nursing I/Practicum course

and is designed to help students utilize knowledge and skills learned from the Adult

Care Nursing II/Theory course and apply it to the care of patients in selected acute

and critical care settings. The course helps the student learn the nursing

management of patients requiring high-technology support, and adapt to the critical

care nurse role in coordinating patient care with other members of the health care

team in a complex and highly-demanding environment. The course includes

observation and performance of skills in different specialized-care clinical settings.

As such, students will have the opportunity to develop their communication skills,

critical thinking skills, time management skills, and critical care nursing skills as

they utilize the nursing process in the care of patients and their families in selected

critical care areas such as medical and surgical intensive care units, coronary care

units, hemodialysis, emergency rooms, burn units, cardiac catheterization, and post-

operative recovery rooms. The course consists of 3 credit hours (12 hours/ week).

Course Intended Learning Outcomes (ILOs):

Caring:

1. Demonstrate caring through theory- and evidence-based nursing interventions.

2. Integrate the concept of holistic care in dealing with adult clients in critical care

settings.

3. Recognize the need for client/family teaching for specific nursing interventions.

4. Demonstrate awareness of the rights of individuals to choose their own values,

practices, and life styles.

Communication:

1. Implement therapeutic communication skills as they relate to the nurse-client

relationship in the critical care setting.

2. Carry out proper nursing documentation and reporting of significant data to

other members of the health care team and instructors in a timely manner.

3. Exhibit effective professional verbal and nonverbal communication with patient,

family peers, instructor, members of the health care team and administration.

Critical Thinking 1.Utilize nursing science and diagnostic reasoning in theory-based nursing care of

individual adult clients in critical care settings.

2.Demonstrate critical thinking and problem solving abilities appropriate for the

care of adult clients in acute and critical care settings.

3.Explain scientific principles supporting basic nursing skills.

4.Assume responsibility for self-development and continued learning through

identification of personal learning goals.

Nursing therapeutic intervention:

1.Demonstrate the appropriate clinical and scientific skills in providing nursing care

for patients in acute and critical care settings.

2.Recognize the nurse’s role in providing nursing care within a multidisciplinary

approach to critically-ill patient management.

3.Implement the nursing process in order to assess the patient’s physical,

psychological, and spiritual needs prior to providing nursing care.

4.Present verbal and written clinical reports in regard to patient’s condition and

his/her responses to treatment.

5.Perform organized, simple, and theory-driven client/family teaching for specific

nursing interventions

6.Provide individualized updated therapeutic nursing interventions based on client

needs and current research.

7.Evaluate the outcomes of therapeutic nursing interventions.

8.Analyze physiological actions, side effects, rationale, and nursing implications of

pharmacological agents used in the care of clients with a life-threatening illness.

9.Integrate appropriate pharmacological interventions, nutritional measures, and

patient teaching in the care of the critically-ill patient.

10. Integrate elements of nursing process as it applies to the nursing care of

critically-ill patients.

11. Provide culturally-sensitive care to the critically-ill patient and his/her family.

12. Discuss ethical decision making related to care of patients with life-threatening

alterations in health.

13. Develop teaching/discharge/referral plans for clients and their families to

facilitate adaptation to a life-threatening health alteration.

14. Incorporate universal precautions in nursing care.

Specific objectives:

At the end of clinical rotations the student will be able to:

In the Critical Care Units:

1.Allocate unit resources.

2.Identify policies related to patient admission, & transfer.

3.Handle unit medications accurately & safely.

4.Describe the medical management of different disease states including desired

outcomes and associated risks.

5.Manage holistic & critical patient care with different life- threatening conditions.

6.Apply therapeutic communication skills with patient, family, & health team

members.

7.Identify ACLS (advanced cardiac life support) procedure, its team, and the role of

the nurse in the resuscitation process.

8.Document all aspects of care provided to a patient.

9.Demonstrate advanced nursing skills in providing care for critically ill patients.

10. Identify various disease processes commonly encountered in the critically ill

patients.

11. Interpret clinical and laboratory assessment data related to various disease

processes in critically ill patients.

In the Emergency Room (ER):

1.Allocate ER resources.

2.Provide safe & quick emergency nursing care to patient with an emergency life-

threatening situation

3.Prioritize nursing care according to nature &severity of patients' conditions.

4.Apply therapeutic communication skills with the patient, family & health team

members.

5.Document probably all Aspects of care provided to a patient.

6.Handle emergency medications accurately & safely.

7.Identify policies related to patient admission, & discharge.

8.Identify ACLS (advanced cardiac life support) procedure, its team, and the role of

the nurse in the resuscitation process.

In the Day Case Unit:

1.Allocate unit resources.

2.Identify pre, & postoperative nursing care.

3.Document all aspects of care provided to a patient.

4.Apply therapeutic communication skills with patient, family, and health team

members.

5.Identify the information needed by the postoperative patient for discharge.

In the Operating Room (OR):

1.Allocate unit resources.

2.Describe the physical environment of the OR.

3.Describe basic principles of aseptic technique used in the OR.

4.Differentiate between general and regional or local anesthesia, including

advantages, disadvantages, and rational for the choice of the anesthetic technique.

5.Describe the functions of the members of the surgical team.

In the Recovery Room:

1.Allocate unit resources.

2.Apply therapeutic communication skills with patient, family, and health team

members.

3.Document probably all aspects of care provided to a patient.

4.Identify the components of an initial post-anesthesia assessment.

5.Explain the etiology and nursing assessment and management of potential

problems encountered during the postoperative period.

6.Identify policies related to the transfer of a patient from recovery room.

In the Cardiac Catheterization Lab:

1.Allocate laboratory resources.

2.Identify preparation process for patient scheduled for catheterization.

3.Provide proper nursing care before, during, &after catheterization process.

4.Apply therapeutic communication skills with patient, family, and health team

members.

5.Handle commonly used medication in Catheterization. Lab accurately & safely.

6.Identify policies related to the transfer of a patient from Catheterization. Lab.

In the Hemodialysis Unit:

1.Allocate unit resources.

2.Provide proper nursing care before, during, and after hemodialysis process.

3.Apply therapeutic communication skills with patient, family, and health team

members.

4.Document probably all aspects of care provided to a patient.

5.Compare common vascular access sites used for hemodialysis.

6.Identify the necessary techniques required to initiate and terminate the procedure

of hemodialysis.

7.Apply universal precautions.

In the Floors:

1.Allocate floor resources.

2.Identify policies regarding admission, transfer, and discharge of a patient.

3.Prepare and administer medication accurately and safely.

4.Manage holistic patient care with different diseases.

5.Apply therapeutic communication skills with patients, families, and health team

members.

6.Document all aspects of care provided to a patient.

Teaching Methods:

Interactive discussion

Audio-visual aids

Critical thinking exercises and scenarios

Clinical practice in the critical care settings at different teaching hospitals

Teaching rounds

Seminar

Research-based written assignments

Case studies

Required Textbooks:

Smeltzer, S., & Bare, B. (2010). Handbook for Brunner and Suddarth's Textbook

of Medical-Surgical Nursing (12th Edition). Philadelphia: J.B. Lippincott.

Smeltzer, S., & Bare, B. (2010). Brunner and Suddarth’s Textbook of Medical

Surgical Nursing (12th Edition). Philadelphia: J.B. Lippincott.

Recommended Textbooks:

Lewis, S., Heitkemper, M., & Direksen, S. (2000). Medical Surgical Nursing:

Assessment and Management of Clinical Problems. St. Louis: Mosby

Phipps, W., Sands, J., & Marek, J. (1999). Medical Surgical Nursing:

Concepts and Clinical Practice. St. Louis, Mosby

Monhan, F., & Neighbors, M. (1998). Medical Surgical Nursing:

Foundations for Clinical Practice. Philadelphia. Saunders

Timby, B., and Smith, N. (2003). Introductory Medical-Surgical Nursing (8th

Edition). Lippincott Williams & Wilkins. Philadelphia.

Course Policies:

1. Attendance: students are expected to attend all class sessions. If a student

cannot attend a class session, the instructor must be notified prior to that. Per the

Hashemite University’s rules and regulations, the student’s total absences must not

exceed 15% of the total class hours with out excuse. This is equal to one day

clinical. Students are expected to take written and clinical exams when scheduled.

If a student cannot attend a testing session, the faculty must be notified prior to the

scheduled examination. Please refer to the Hashemite University’s Student

Handbook for further explanation. Also please note that it is a new university

policy that if a student failed to take an examination as scheduled, there will be one

make-up examination. A committee of three examiners will present the students

with a set of oral and written essay type questions. Only students with acceptable

reasons (i.e., urgent medical condition approved by the University Health Center,

death of a first-degree relative, etc.) for absence will have the opportunity for a

make-up examination.

2. Practice: There is a set of guidelines for practical training that will also be

provided to each student on a separate sheet to keep with them at hospitals. These

guidelines include:

Practical training starts at 8:00 and ends at 3:00.

The student has to manage his/her own transportation to the hospital except for

those who will be trained in the areas where a university bus will be provided.

The student has to wear the specified uniform (For female-Gray dress and white

scarf and for Male-Dark blue shirt and Navy trousers) and shoes (Black for both

male and female) at all times while at the hospital. The uniform must be clean and

ironed properly.

All students have to maintain a professional appearance. This includes shaving

for male students who do not grow their beards, and a proper hair cut, and tied hair

for female students, and for those who wear a scarf, it should not be left dangling.

It is the student’s responsibility to maintain good personal hygiene.

Jean pants are not allowed as well as colored scarves other than cream or page.

Students are not allowed to chew gum or smoke in the clinical areas.

Students should have their break time as scheduled and shall not exceed that.

The following items are prohibited at clinical training: bracelets, rings other than

the wedding ring, high heels or sandals, nail polish, long nails, and improper make-

up.

Every student must have the following on a clinical day: a pocket-size note book,

a pen, and a stethoscope.

The student has to inform either the nurse in-charge or the instructor when leaving

his/her assigned clinical area.

Research presentation, teaching, and case-studies presentation will be started and

ended according to the schedule that will be prepared by each instructor.

Students are expected to use proper communication skills and to be cooperative

with their instructors, colleagues, and other health team members.

Students Must NOT perform the following:

1. Take verbal orders or phone orders from physicians or laboratory reports.

2. Act as a witness to signing of documents (surgical permits, etc.)

3. Carry medication/narcotic keys.

4. Unless under supervision by clinical instructor or RN:

a. Give any medications IV push

b. Add anticoagulant or insulin to IV solutions.

c. Insert or remove intestinal decompression tubes.

d. Perform venipuncture.

Students With Special Needs:

Students with special needs should consult with their course coordinator to be able to

provide them with resources and help when needed.

Evaluation Methods

Item Grade Due date Special notes

Comprehensive

clinical evaluation

10*2 Once per Rotation

Nursing Care Plan 5*2 Once per Rotation

Case study

2nd Rotation 5

To be determined later

for each student

The presentation will be

bedside, individually, 30 min

for discussion, and with no

written part.

Seminar

1st Rotation 5

To be determined later

for each student

You need to submit written

part at the same day of

presentation.

Group work

Nursing Process

and notes 10*2 once per Rotation

Bedside nursing

Care 5*2

Whole period of

training

Final written

exam 10 Announcement later

Final Clinical

Exam 20

Within the last two

weeks of clinical

training

Total 100%

Clinical Training Schedule 2011/ 2012

Date Week Number Notes

st1 Introductory Labs

nd2

rd3

th4

th5

th6

th7

1st Rotation

th8

th9

th10

th11

th12

2nd Rotation

th13

th14 Final Exam

Mark 2nd 1st Items

20% 10% 10% Comprehensive Evaluation 1

5% 5% Seminar 2

5% 5% Case study 3

10% 5% 5% Bed side nursing care 4

20% 10% 10% Nursing Process and Notes 5

10% 5% 5% Nursing Care Plan 6

10% 10% Final written exam 7

20% Final Exam 8

100% Total Mark

FIRST ROTATION

Marks

Grade Student’s

Grade Item #

10 Comprehensive Evaluation 1-

5 Seminar 2-

10 Nursing Process and Notes 3-

5 Nursing Care Plan 4-

5 Bed-Side Nursing Care 5-

35 Total

Weekly Objectives

Weekly Objectives (1st week)

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Additional Activities

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Instructor Notes’:

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Nursing Process and Notes

Date: -----------------------------------------------------------------------------

Patient name: -------------------------------------------------------------------

Age: -------------------------------------------------------------------------------

Setting: ---------------------------------------------------------------------------

Date of admission (0.25): -----------------------------------------------------

Medical diagnosis (0.25): -----------------------------------------------------

Chief complaint (1.5): --------------------------------------------------------------------------

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History of present illness (3):------------------------------------------------------------------

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History of past illness (2):---------------------------------------------------------------------

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Medications

Scientific name trade

name &

Classification (1)

Dose &

frequency

(.5)

Route(.5)

Side effect (.5)

Indications (1)

Nursing interventions

(2)

15 14 13 12 11 10 9 8

VIT

AL

SIG

NS

(2.5

) Blood Pressure

Pulse Rate

Respiratory

Rate

Temperature

Oxygen

Saturation

Orally

INT

AK

E (

1)

IVF(1)

IVF(2)

IVF(3)

Blood

Products

Feeding

Total intake /

hour (0.5)

Urine output

OU

TP

UT

(1)

NGT

Bowel Motion

Drain(1)

Drain(2)

Drain(3)

Total Output /

hour

(0.5)

Fluid Balance (over shift):

(0.5)

Plan

(1)

Glasgow Comma Scale (GCS)

Time Items

15 14 13 12 11 10 9 8

4 Spontaneous E

YE

S(.

5)

3 Open to speech

2 Open to pain

1 Remain closed

5 Oriented

VE

RB

AL

(.5)

4 Confused

3 Words

2 Sounds

1 No response

6 Obeys commands

MO

TO

R(.

5)

5 Localized

4 Withdrawal

3

Abnormal flexion

2

Abnormal

extension

1 None

TOTAL (.5)

Test Name Normal Value (1) Date & Results (2) Nursing intervention (1.5)

/ / 2012

/ / 2012

/ / 2012

/ / 2012

/ / 2012

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/ / 2012

/ / 2012

Nursing Notes

Date (0.25): ………………………………..

Sign

(0. 5)

(2.0) (2.0) (2.0)

(Receiving, , nursing care & follow up care)

Time

(0.25)

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List the subjective and objective data according to patient current

complain:

1-Subjective Data: (2)

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2-Objective Data: (2)

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Nursing Process: List the most important 2 nursing diagnosis according to priority:

First Nursing Diagnosis: (3)

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Planning (Out come): (.5)

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Objectives: (1)

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Nursing Interventions and rational: (1.5)

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Evaluation and Evidence: (0.5)

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Second Nursing Diagnosis: (3)

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Planning (Out come): (.5)

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Objectives: (1)

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Nursing Interventions and rational: (1.5)

4. ……………………………………………………………………………………………………………

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Evaluation and Evidence: (0.5)

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Evaluation Tools

Comprehensive Evaluation Form

Item

N/A

Nev

er

Rar

ely

Som

etim

es

Alm

ost

Alw

ays

Alw

ays

1. Professionalism

1- Arrives on time. 0 2 4 6 8 01

2- Keeps personal hygiene. 0 2 4 6 8 01

3- Shows commitment to professional faculty guided uniform. 0 2 4 6 8 01

4- Behaves in professional manner. 0 2 4 6 8 01

5- Accepts constructive criticism. 0 2 4 6 8 01 6- Protects worthiness, dignity, privacy, & uniqueness of each

patient. 0 2 4 6 8

01

7- Shows motivation toward patient care. 0 2 4 6 8 01

2- Communication

1- Communicates respectfully with Patients, family, preceptors &

hospital staff. 0 2 4 6 8

01

2- Demonstrates competence with verbal & non-verbal

communication. 0 2 4 6 8

01

3- Nursing procedure performance

1- Safely 0 2 4 6 8 01

2- Competently 0 2 4 6 8 01

3- According to faculty protocol. 0 2 4 6 8 01

4-Provides verbal rational for overall procedure &its steps. 0 2 4 6 8 01

5- Organized manner. 0 2 4 6 8 01

4- Role development

1-Assumes accountability for practice. 0 2 4 6 8 01

2-Initiate plans for his/her own learning experience with the

instructor based on self –evaluation. 0 2 4 6 8

01

6—Assignments

1- Submits assignments as required & on time. 0 2 4 6 8 01

2-Submits weekly objective sheet as required & on time 0 2 4 6 8 01

7- Knowledge & Development of Critical Thinking

1. Student knowledge about the disease process.(Causes, S & S)

and Path physiology 0 2 4 6 8

01

2. Using appropriate medical terms. 0 2 4 6 8 01

3. Demonstrate knowledge for appropriate care and follow up care 0 2 4 6 8 01 4. Student knowledge about medications 0 2 4 6 8 01

5. Demonstrate knowledge of interpretation data: diagnostic test

results and physical examination finings related to patient condition 0 2 4 6 8

01

6. Articulates rationale for decisions & actions. 0 2 4 6 8 01

7. Differentiates between normal & abnormal findings. 0 2 4 6 8 01

8. Organizes care in a way that reflects priorities. 0 2 4 6 8 01

9. Utilizes different resources in nursing such as text books, articles 0 2 4 6 8 01

10. Creating competent and appropriate nursing process 0 2 4 6 8 01

Total Mark = ( ) /28 =-( )

Instructor's Sign------------

Evaluation Criteria for Seminar

Evaluation Criteria (Seminar)

Items

Grades’ scale

Failed Weak Fair Good Very

Good Excellent

Outline 0 1 2 3 4 5

Objectives 0 1 2 3 4 5

Introduction 0 1 2 3 4 5

Core knowledge

Thorough knowledge 0 1 2 3 4 5

Organized 0 1 2 3 4 5

Critical thinking 0 1 2 3 4 5

Nursing focusing 0 1 2 3 4 5

Presentation

Use audiovisual aids effectively 0 1 2 3 4 5

Initiate & encourage discussion 0 1 2 3 4 5

Use proper presentation skills

Proper eye contact 0 1 2 3 4 5

Clear voice 0 1 2 3 4 5

Response to questions 0 1 2 3 4 5

Accepting constructive criticism 0 1 2 3 4 5

Speak in clear & simple Language 0 1 2 3 4 5

Team work

Presenters work together well 0 1 2 3 4 5

Equal distribution of material among presenters 0 1 2 3 4 5

Effective time management & organization 0 1 2 3 4 5

Supported by research article (purpose, sample

size, results and summary or conclusion) 0 1 2 3 4 5

Conclusion or summary 0 1 2 3 4 5

References (Specific)

e.g., (www.google .com) isn’t accepted 0 1 2 3 4 5

Total Presentation Mark : ( ) / 100

Written seminar

Complete out line 0 1 2 3 4 5

Introduction related to the core of seminar 0 1 2 3 4 5

Thorough knowledge 0 1 2 3 4 5

Organization 0 1 2 3 4 5

Related research article (Abstract) 0 1 2 3 4 5

Conclusion or summary 0 1 2 3 4 5

References 0 1 2 3 4 5

Total Written Mark = ( ) / 35

Total mark = ( )*5 / 135

Note: written part to be submitted at the same day of presentation, Submitting papers after the deadline is not accepted.

Bedside Nursing Care Criteria

Total Mark: ( )/ 8 = ( )

Instructor Sign: ……………………

Item

Fail

ed

Wea

k

Fair

Good

V. G

ood

Exce

llen

t

1. Collect subjective and objective data effectively. 0 1 2 3 4 5

2. Measure vital signs correctly. 0 1 2 3 4 5

3. Communicate with the patient and health team appropriately 0 1 2 3 4 5

4. Apply physical examination appropriately 0 1 2 3 4 5

5. Nursing skills (Tracheostomy care, ABGs drawing, suctioning, ECG, CPR ….)

- Identify the unit equipment and devices

0

.25

.75

1

1.5

2

- Provides verbal rational for the overall procedure & its steps

0

.25

.75

1

1.5

2

- Identify nursing skill steps according to standardized policy

0

.25

.75

1

1.5

2

- Perform nursing skills in safe, organized and efficient way.

0

.25

.75

1

1.5

2

- Show correct understanding and interpretation of result

0

.25

.75

1

1.5

2

6. Patients’ Education

- Collect subjective and objective data related to the patients

educational needs

0

.25

.75

1

1.5

2

- Identify nursing diagnosis related to the patient's educational

needs.

0

.25

.75

1

1.5

2

- Content of education is complete and related to the patient's

need

0

.25

.75

1

1.5

2

- Presentation is organized and it shows attention

0

.25

.75

1

1.5

2

- Present materials that facilitate understanding of the patient

(Pamphlet and brochures).

0

.25

.75

1

1.5

2

Nursing Skills Sheet

Skill Items of application

ECG procedure, interpretation of normal sinus

rhythm, arrhythmia; identify causes, and

nursing interventions-

ABGs Procedure, nursing interventions,

interpretation, nursing interventions

CPR Identify steps of BCLS,

Mechanical

ventilator

Indications, Mode, setting, intubation,

nursing care, alarms

Emergency

medications

Indications, preparation, calculation ,

administration, nursing consideration

Invasive line care ;

CVP, arterial line

Indications, , measuring, interpretation,

nursing interventions

Chest tube Indications, procedure, , nursing

interventions

Tracheostomy Indications, procedure, nursing

interventions

NGT(Nasogastric

tube)

Indications, procedure, nursing

interventions

Colostomy, illeostomy

Urinary catheter

Indications, procedure, nursing

interventions

Seminar Topics

ABGS (Arterial Blood

Gases)

1. Definition

2. Indication

3. Procedure

4. Interpretation (give examples)

5. Comparing between metabolic acidosis,

metabolic alkalosis, respiratory acidosis

and respiratory alkalosis with regard to

causes, clinical manifestations,

diagnosis, and nursing management

Diagnostic tests

X-rays

Lumber puncture

Endoscopy

Colonoscopy

bronchoscopy

MRI and CT-scan

1. Definition

2. Indications

3. Procedure

4. Nursing Interventions (Pre-Intra-Post)

5. Contraindications

ECG

1. Definition

2. Indications

3. Normal sinus rhythm

4. ECG changes of MI and arrhythmia.

5. Nursing care & management

Hemodialysis

Continuous renal

replacement therapies

peritoneal dialysis

1. Definition of each one

2. Indications of each one

3. Types

4. Nursing interventions (Pre-Intra-Post)

5. Complications

Chest Tube

1. Definition

2. Indications

3. Procedure

4. Comparison of chest drainage systems.

5. Nursing Interventions (Pre-Intra-Post)

6. Complications

SECOND ROTATION

Marks

Grade Student’s

Grade Item #

10 Comprehensive Evaluation 1

5 Case Study 2

10 Nursing Process and Notes 3

5 Bed-Side Nursing Care 4

5 Nursing Care Plan 5

35 Total

Weekly Objectives

Weekly Objectives (1st week)

1. ………………………………………………………………………

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2. ………………………………………………………………………

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3. ………………………………………………………………………

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4. ………………………………………………………………………

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5. ………………………………………………………………………

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Weekly Objectives (2nd week)

1. ………………………………………………………………………

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2. ………………………………………………………………………

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3. ………………………………………………………………………

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4. ………………………………………………………………………

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5. ………………………………………………………………………

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Weekly Objectives (3rd week)

1. ………………………………………………………………………

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2. ………………………………………………………………………

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3. ………………………………………………………………………

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4. ………………………………………………………………………

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5. ………………………………………………………………………

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Weekly Objectives (4th week)

1. ………………………………………………………………………

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2. ………………………………………………………………………

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3. ………………………………………………………………………

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4. ………………………………………………………………………

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5. ………………………………………………………………………

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Weekly Objectives (5th week)

1. ………………………………………………………………………

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2. ………………………………………………………………………

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3. ………………………………………………………………………

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4. ………………………………………………………………………

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5. ………………………………………………………………………

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Weekly Objectives (6th week)

1. ………………………………………………………………………

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2. ………………………………………………………………………

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3. ………………………………………………………………………

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4. ………………………………………………………………………

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5. ………………………………………………………………………

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Additional Activities

………………………………………………………………………………

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…………………………………………………...........................................

Instructor Notes’:

………………………………………………………………………………

………………………………………………………………………………

………………………………………………………………………………

………………………………………………………………………………

………………………………………………………………………………

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Evaluation Tools

Comprehensive Evaluation Form

Item

N/A

Nev

er

Rar

ely

Som

etim

es

Alm

ost

Alw

ays

Alw

ays

2. Professionalism

1- Arrives on time. 0 2 4 6 8 01

2- Keeps personal hygiene. 0 2 4 6 8 01

3- Shows commitment to professional faculty guided uniform. 0 2 4 6 8 01

4- Behaves in professional manner. 0 2 4 6 8 01

5- Accepts constructive criticism. 0 2 4 6 8 01 6- Protects worthiness, dignity, privacy, & uniqueness of each

patient. 0 2 4 6 8

01

7- Shows motivation toward patient care . 0 2 4 6 8 01

2- Communication

1- Communicates respectfully with Patients, family, preceptors &

hospital staff. 0 2 4 6 8

01

2- Demonstrates competence with verbal & non-verbal

communication. 0 2 4 6 8

01

3- Nursing procedure performance

1- Safely 0 2 4 6 8 01

2- Competently 0 2 4 6 8 01

3- According to faculty protocol. 0 2 4 6 8 01

4-Provides verbal rational for overall procedure &its steps. 0 2 4 6 8 01

5- Organized manner. 0 2 4 6 8 01

4- Role development

1-Assumes accountability for practice. 0 2 4 6 8 01

2-Initiate plans for his/her own learning experience with the

instructor based on self –evaluation. 0 2 4 6 8

01

6—Assignments

1- Submits assignments as required & on time. 0 2 4 6 8 01

2-Submits weekly objective sheet as required & on time 0 2 4 6 8 01

7- Knowledge & Development of Critical Thinking

1. Student knowledge about the disease process.(Causes, S & S)

and Pathophysiology 0 2 4 6 8

01

2. Using appropriate medical terms. 0 2 4 6 8 01

3. Demonstrate knowledge for appropriate care and follow up care 0 2 4 6 8 01 4. Student knowledge about medications 0 2 4 6 8 01

5. Demonstrate knowledge of interpretation data: diagnostic test

results and physical examination finings related to patient condition 0 2 4 6 8

01

6. Articulates rationale for decisions & actions. 0 2 4 6 8 01

7. Differentiates between normal & abnormal findings. 0 2 4 6 8 01

8. Organizes care in a way that reflects priorities. 0 2 4 6 8 01

9. Utilizes different resources in nursing such as text books, articles 0 2 4 6 8 01

10. Creating competent and appropriate nursing process 0 2 4 6 8 01

Total Mark = ( ) /28 =- ( )

Instructor's Sign------------

Bedside Nursing Care Criteria

Total Mark: ( )/ 8 = ( )

Instructor Sign: ……………………

Item

Fail

ed

Wea

k

Fair

Good

V. G

ood

Exce

llen

t

1. Collect subjective and objective data effectively. 0 1 2 3 4 5

2. Measure vital signs correctly. 0 1 2 3 4 5

3. Communicate with the patient and health team appropriately 0 1 2 3 4 5

4. Apply physical examination appropriately 0 1 2 3 4 5

5. Nursing skills (Tracheostomy care, ABGs drawing, suctioning, ECG, CPR …. )

- Identify the unit equipment and devices

0

.25

.75

1

1.5

2

- Provides verbal rational for the overall procedure & its steps

0

.25

.75

1

1.5

2

- Identify nursing skill steps according to standardized policy

0

.25

.75

1

1.5

2

- Perform nursing skills in safe, organized and efficient way.

0

.25

.75

1

1.5

2

- Show correct understanding and interpretation of result

0

.25

.75

1

1.5

2

6. Patients’ Education

- Collect subjective and objective data related to the patients

educational needs

0

.25

.75

1

1.5

2

- Identify nursing diagnosis related to the patient's educational

needs.

0

.25

.75

1

1.5

2

- Content of education is complete and related to the patient's

need

0

.25

.75

1

1.5

2

- Presentation is organized and it shows attention

0

.25

.75

1

1.5

2

- Present materials that facilitate understanding of the patient

(Pamphlet and brochures).

0

.25

.75

1

1.5

2

Case Study (Bed side)

Patient’s Name: …………………………………………….

Unit: ……………………………………………………….

Medical Diagnosis: …………………………………………

Items

Grades’ scale

Fai

led

Wea

k

Fai

r

Go

od

Ver

y G

oo

d

Ex

cell

ent

1. Bed side nursing care 0 1 2 3 4 5

2. Demographic data 0 1 2 3 4 5

3. History

a. History of present illness 0 1 2 3 4 5

b. History of past illness 0 1 2 3 4 5

4. Disease process

a. Definition 0 1 2 3 4 5

b. Causes and Pathophysiology 0 1 2 3 4 5

c. Signs and symptoms 0 1 2 3 4 5

5. Physical Assessment 0 1 2 3 4 5

6. Diagnostic tests 0 1 2 3 4 5

7. Medications (classification, indication, dose, nursing

interventions) 0 1 2 3 4 5

8. Compare case categories with text book 0 1 2 3 4 5

9. Nursing Process

a) Nursing Diagnosis 0 1 2 3 4 5

b) Nursing Objective 0 1 2 3 4 5

c) Nursing Interventions 0 1 2 3 4 5

d) Evaluation and evidence 0 1 2 3 4 5

10. Critical thinking (one situation) 0 1 2 3 4 5

Total Mark = ( )*5/ 80 = ( )

Instructor Note:

………………………………………………………………………………

………………………………………………………………………………

………………………………………………………………………………

………………………………………

The Hashemite University

Faculty of Nursing

Adult Care Nursing II/ Clinical

Clinical Care Plan

2011-2012

1-Assessment sheet:

Demographical Data

Student profile: Student Name……………………University No…………………………………

Instructor name:………………… Date of receiving patient:……………………..

Area of Practice………………… Rotation No:…………………………….…….

Client profile :( 0.5)

Client Name……………………… Age…………………………………….

Marital Status……………………….Medical diagnosis…………………………

Admission Date…………………..…Diet (specify)……………………….….……

Source of data……………………….Date of current Surgery (if available)……

Blood Group……………………….. Educational level………………

Religion……………………………………..

Specific medication taken at home: (specific name, indication, and Dose)

(0.5)

Name Dose, route, and frequency Indication

Assessment (subjective data)(1) Health related habits

A: Smoking …………………………….……..

Cigarettes/day……………………………..

B: Alcohol……………………………….……..

C: Allergy………………………………………

Nutritional/metabolic pattern (1)

A: Diet :( at home )……………………….…… Prescribed Diet

………………………………………

B: Appetite…………………………………………

C: Weight changes within last 6months:…………………………………..…

D: Abnormal finding: No……. Yes (describe)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………

Elimination pattern (.5)

A: Bowel habits

Number of bowel movement/day …………. Last bowel movement………….

Abnormal finding: No……. Yes

(describe)………………………………………………………….

…………………………………………………………………………………………

…………….

B: Urinary Habits: (.5)

Frequency (times/day)…………………… color……………………

Abnormal finding: No……. Yes

(describe)………………………………………………………….

…………………………………………………………………………………………

……………

Sleep/rest pattern (1)

A: Sleeping hours at night…….,Am Naps……,Pm naps……

B: Medication Used : No………, yes(describe)……

C: Disturbing Factors : ………………………………

Current Health status: Chief complaint :(.5)

(Use the patient word and try to describe the problem)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………

History of present illness :( 2)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………………………….

Current complaint : (2)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………………………….

Past health history

Past health problem :( co-morbidities) (.5)

…………………………………………………………………………………………

……….…………………………………………………………………………………

………………………….………………………………………………………………

…………………………………………….…………

Socio-economic factors (1)

Income (average)………………..……….

Occupation………………………………..…………..

No. of household………………………………………………………….…………….

Job Satisfaction / concerns& it’s relation to present illness

…………………………………………………………………………………………

……….……………………………………………………………………….…………

…………………………………………………………………………………………

……….………… (Specify the patient own words towards his / her occupation)

Family History (1)

Draw family tree: Grandparents, Parents, Siblings, Children and Grand children.

Indicate health status of each as age and (alive or dead, Cause of death and significant

illness or problems).

Key:

Glasgow Comma Scale (GCS)

Time Items

14 13 12 11 10 9 8

4 Spontaneous E

YE

S(.

5)

3 Open to speech

2 Open to pain

1 Remain closed

5 Oriented

VE

RB

AL

(.5)

4 Confused

3 Words

2 Sounds

1 No response

6 Obeys commands

MO

TO

R(.

5)

5 Localized

4 Withdrawal

3 Flex to pain

2 Extension

1 None

TOTAL (.5)

Physical Exam (5) (to general survey and affected systems)

A. General Survey Level of Consciousness…………………………………………

Orientation ……………………………………………………..

Height………. Weight……..

Vital Singe ………………………………………………

General appearance:……………………………………………..

B. Integumentary system

Skin: Color…………………… Temperature…………………

Turgor and Mobility ………………. Texture………………….

Moisture………………… Lesions…………………………

Edema…………………………….

C. Respiratory system

Respiration

(describe)……………………………………………………………………………

Diameter and contour of chest………………………………………………………

Lung expansion (describe)

………………………………………………………………………………………

Diaphragmatic excursion

……………………………………………………………………………...

Breathing sounds (describe)

…………………………………………………………………………..

………………………………………………………………………………………

Adventitious sounds………………………………………………………………...

D. Cardiovascular system Carotid artery (describe)

……………………………………………………………………….......

………………………………………………………………………………………

Jugular venous pressure (describe)

………………………………………………………............

………………………………………………………………………………………

Apical pulse (describe)………

…………………………………………………………….

………………………………………………………………………………………

Heart sounds (describe) ………………………………………………………….....

………………………………………………………………………………………

Abnormal heart sounds

……………………………………………………………………………….

………………………………………………………………………………………

Peripheral pulses (describe)

…………………………………………………………………........

………………………………………………………………………………………

……………..

E. Head and neck A. Oral cavity (describe)

Lips ………………………………………………………………………

Gums ……………………………………………………………………..

Teeth ………………………………………………………………………

Oropharynx……………………………………………………………….

B.Neak (describe)

Thyroid ……………………………………………………………………..

Lymph nodse ………………………………………………………………….

F. Abdomen Contour……………………………………………………………………………

Symmetry…………………………………………………………………………

Umbilicus…………………………………………………………………………

Skin Color…………………………………………………………………………..

Lesions: No ……., Yes (Describe)………………………………………………

Bowel Sound………………………………………………………………………

Abnormal Sound……………………………………………………………………

Organomegally : No ….. Yes

(Describe)…………………………………………………………..

G. Musculoskeletal system (describe ) Temopmandibular joint……………………………………………………………

……………………………………………………………………………

CervicalSpine………………………………………………………………………

………………………………………………………………………………………

…………………

Upper extremities

………………………………………………………………...............................

………………………………………………………………………………………

Lower extremities

……………………………………………………………………………………

………………………………………………………………………………………

Spine………………………………………………………………………………

……………………………………………………………………………………………… H. Neurological system Deep tendon reflexes (draw a picture )

Intake/Out put

Date

and

time

Intake (0.25 )

Total

intake/hrs

(0.5)

Output (0.25)

Total

output/hrs

(0.5)

IVF

1 n

ame

……

……

……

IVF

2 n

ame

……

……

……

Blo

od p

roduct

Infu

sed R

x

NG

T

Oral

Vom

it

Sto

ol

Drain

s

Urin

e

8 am

9 am

10am

11am

12

MD

1pm

2 pm

3 pm

Balance (0.25 )

………………………………………………………………………………………………….………

…………………………………………………………………………………………………….……

……………………………………………………………………………………………………………

………………………………………………………………….…………………………………….…

Plan (0.25)

………………………………………………………………………………………………….………

…………………………………………………………………………………………………….……

……………………………………………………………………………………………………….…

………………………………………………………………………………………………………….

……………………………………………………………………………………………………………

.…………………………………………………………………………………………………………

….………………………………………………………………………………………………………

Test name

(0.5)

Normal

value (1)

(2)

Date &

results

Date &

results Nursing intervention(1.5)

/ /12 / /12 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /12 / /12 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /12 / /12 …………………………………………………………

…………………………………………………………

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……

/ /12 / /12 …………………………………………………………

…………………………………………………………

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/ /12 / /12 …………………………………………………………

…………………………………………………………

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……

/ /12 / /12 …………………………………………………………

…………………………………………………………

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……

/ /12 / /12 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /12 / /12 …………………………………………………………

…………………………………………………………

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……

/ /12 / /12 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /12 / /12 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

Medications Name (Trade And

Scientific)

Classification

(2)

Dose,

Frequency,

and Route

(2)

Indications

(2)

Major side

Effects

(1)

Contraindications

(1)

Major nursing interventions

(2)

1

2

3

4

5

6

Nursing Process:

List the most important nursing diagnosis:

First Nursing Diagnosis (1.5)

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

Nursing Goal (.5)

………………………………………………………………………………………………

……………………………………………………………………………………

Nursing Objective: (1)

………………………………………………………………………………………………

……………………………………………………………………………………

Planned Intervention: (1.5)

1. ………………………………………………………………………………………

………………………………………………………………………………………

2. ………………………………………………………………………………………

………………………………………………………………………………………

3. ………………………………………………………………………………………

………………………………………………………………………………………

Actual interventions: (1.5)

1. ………………………………………………………………………………………

………………………………………………………………………………………

2. ………………………………………………………………………………………

………………………………………………………………………………………

3. ………………………………………………………………………………………

………………………………………………………………………………………

Evaluation and Evidence: (1)

………………………………………………………………………………………………

………………………………………………………………………………………………

Second Nursing Diagnosis (1.5)

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

Nursing Goal (.5)

………………………………………………………………………………………………

……………………………………………………………………………………

Nursing Objective: (1)

………………………………………………………………………………………………

……………………………………………………………………………………

Planned Intervention: (1.5)

4. ………………………………………………………………………………………

………………………………………………………………………………………

5. ………………………………………………………………………………………

………………………………………………………………………………………

6. ………………………………………………………………………………………

………………………………………………………………………………………

Actual interventions: (1.5)

4. ………………………………………………………………………………………

………………………………………………………………………………………

5. ………………………………………………………………………………………

………………………………………………………………………………………

6. ………………………………………………………………………………………

………………………………………………………………………………………

Evaluation and Evidence: (1)

………………………………………………………………………………………………

………………………………………………………………………………………………

Third Nursing Diagnosis: (1.5)

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

Nursing Goal (.5)

………………………………………………………………………………………………

……………………………………………………………………………………

Nursing Objective: (1)

………………………………………………………………………………………………

……………………………………………………………………………………

Planned Intervention: (1.5)

7. ………………………………………………………………………………………

………………………………………………………………………………………

8. ………………………………………………………………………………………

………………………………………………………………………………………

9. ………………………………………………………………………………………

………………………………………………………………………………………

Actual interventions: (1.5)

7. ………………………………………………………………………………………

………………………………………………………………………………………

8. ………………………………………………………………………………………

………………………………………………………………………………………

9. ………………………………………………………………………………………

………………………………………………………………………………………

Evaluation and Evidence: (1)

………………………………………………………………………………………………

………………………………………………………………………………………………

Appendix

Obtaining a History of Present Illness for Pain

(PQRSTU)

P (Provocation and Palliation)

What seems to trigger it? Stress? Position? Certain activities?

Arguments?

Does it seem to be getting better, or getting worse, or does it remain the

same?

What relieves it: changing diet? Changing position? Taking medications?

Being active? Resting?

What makes (the problem) worse?

Q (Quality)

How does it feel, look or sound?

Is it sharp? Dull? Stabbing? Burning? Crushing?

If describing a discharge: Thick? Runny? Clear? Colored?

R (Region and Radiation)

Where is it?

Does it spread?

Where does the pain radiate?

S (Severity and Scale)

How does it rate on a severity scale of 1 to 10?

T (Timing and Type of Onset)

When did it begin?

How often does it occur?

Is it sudden or gradual?

How long does it last?

U (understand patients perception)

What do you think it means?

Other questions to ask:

Associated factors.

Location of pain

Obtaining Past History

Serious or chronic illnesses

Past surgical history

Allergies

Previous hospitalization

Accident and injuries

Family history

Medication taken at home

Pain assessment tool

Numeric scale

0 1 2 3 4 5 6 7 8 9 10 No

pain Mild pain Moderate pain Severe pain Very sever

pain Worst

possible pain

Visual analog scale

0 ??

Very happy, no hurt

Hurts just a little bit

Hurts a little more

Hurts even more

Hurts a whole lot

Hurts as much as you can imagine (don’t have to be crying to feel this much pain)

Normal range of vital signs

Normal range of vital signs

Vital sign Normal value

Temperature 36.6 -37.5 °C orally

Blood pressure

category Systolic BP

(mmHg)

Diastolic

BP(mmHg)

normal <120 <80

Pre-hypertension 120-139 80-89

Stage 1 hypertension 140-159 90-99

Stage 2 hypertension ≥160 ≥100

Pulse 60-100 beat/min

Respiratory rate 12-18 breath/min

Homodynamic Parameters

Cardiac output (CO = HR X SV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4–8 L/min

Cardiac index (CO/BSA) . . . . . . . . . . . . . . . . ….. . . . . . . . . . . . . . 2.5–4 L/min

Central venous pressure (CVP) . . . . . . . . . . . . . …... . . . . . . . . . . . 2–8 mm Hg

Cerebral perfusion pressure (CPP) . . . . . . . . …...2–6 mm Hg or 5–12 cm H2O

Ejection fraction (Ej Fx or EF) . . . . . . . . . . . . . . .... . . . . . . . . . . . . . 60%–75%

Mean arterial pressure (MAP) . . . . . . . . . . . . . . . . …... . . . . . .70–100 mm Hg

Pulmonary capillary wedge pressure (PCWP) . . . . . . … . . . . . . . 4–12 mm Hg

Stroke volume (SV = CO/HR) . . . . . . . . . . . . . . . . . . . . . . . . . 60–100 mL/beat

Systemic vascular resistance (SVR) . . . . . . . . . . …..900–1,600 dynes/sec/cm-5

Intracranial pressure (ICP)………………………………….……0-15 mm Hg

ABGs analysis

The following steps are recommended to evaluate arterial blood gas values. They are

based on the assumption that the average values are:

PH = 7.4

PaCO2 = 40 mm Hg

HCO3 = 22 mEq/L

1. First, note the pH. It can be high, low, or normal, as follows:

pH > 7.4 (alkalosis)

pH < 7.4 (acidosis)

pH = 7.4 (normal)

A normal pH may indicate perfectly normal blood gases, or it may be an indication

of a compensated imbalance. A compensated imbalance is one in which the body

has been able to correct the pH by either respiratory or metabolic changes

(depending on the primary problem).

2. The next step is to determine the primary cause of the disturbance. This is done by

evaluating the PaCO2 and HCO3 in relation to the pH.

Example: pH > 7.4 (alkalosis)

a. If the PaCO2 is < 40 mm Hg, the primary disturbance is respiratory

alkalosis.

b. If the HCO3 is >22 mEq/L, the primary disturbance is metabolic

alkalosis.

Example: pH < 7.4 (acidosis)

a. If the PaCO2 is >40 mm Hg, the primary disturbance is respiratory

acidosis.

b. If the HCO3 is <22mEq/L, the primary disturbance is metabolic

acidosis.

3. The next step involves determining if compensation has begun. This is done by

looking at the value other than the primary disorder. If it is moving in the same

direction as the primary value, compensation is underway. Consider the following

gases:

pH PaCO2 HCO3

(1) 7.20 60 mm Hg 22 mEq/L

(2) 7.40 60 mm Hg 37 mEq/L

The first set (1) indicates acute respiratory acidosis without compensation (the

PaCO2 is high, the HCO3 is normal). The second set (2) indicates chronic

respiratory acidosis. Note that compensation has take place; that is, the HCO3 has

elevated to an appropriate level to balance the high PaCO2 and produce a normal

pH.

Mechanical Ventilation Mechanical ventilation may be required, to oxygenate the blood when the patient’s

ventilatory efforts are inadequate, and to rest the respiratory muscles.

Indication for Mechanical Ventilation: The following criteria for mechanical ventilation guide the decision to place a patient

on a ventilator:

PaO2 <50 mm Hg with FiO2 >0.60

PaO2 >50 mm Hg with pH <7.25

Vital capacity <2 times tidal volume

Negative inspiratory force <25 cm H2O

Respiratory rate >35/min

Classification of ventilator: The two general categories are negative-pressure and positive-pressure ventilators. The

most common category in use today is the positive pressure ventilator.

Negative-Pressure Ventilators

Negative-pressure ventilators exert a negative pressure on the external

chest, decreasing the intrathoracic pressure during inspiration allows air to

flow into the lung; there are several types of negative-pressure ventilators:

iron lung, body wrap, and chest cuirass.

Positive-Pressure Ventilators

Positive-pressure ventilators inflate the lungs by exerting positive pressure

on the airway, forcing the alveoli to expand during inspiration. Expiration

occurs passively. Endotracheal intubation or tracheostomy is necessary in

most cases.

Types of positive-pressure ventilators:

PRESSURE-CYCLED VENTILATORS

The pressure-cycled ventilator ends inspiration when a preset pressure has been

reached. In other words, the ventilator cycles on, delivers a flow of air until it

reaches a predetermined pressure, then cycles off.

This form of mechanical ventilation includes pressure control ventilation (PCV),

pressure support ventilation (PSV),

o Pressure control ventilation is similar to A/C; each inspiratory effort

beyond the set sensitivity threshold delivers full pressure support

maintained for a fixed inspiratory time. A minimum respiratory rate is

maintained.

o Pressure support ventilation, a minimum rate is not set; all breaths

are triggered by the patient. Pressure is typically cut off when back-

pressure causes flow to drop below a certain point. Thus, a longer or

deeper inspiratory effort by the patient results in a larger tidal volume.

TIME-CYCLED VENTILATORS

Time-cycled ventilators terminate or control inspiration after a preset time. The

volume of air the patient receives is regulated by the length of inspiration and the

flow rate of the air.

VOLUME-CYCLED VENTILATORS

In this mode, which includes assist-control (A/C) and synchronized intermittent

mandatory ventilation (SIMV), the volume of air to be delivered with each

inspiration is preset. Once this preset volume is delivered to the patient, the

ventilator cycles off and exhalation occurs passively.

o Assist-control (A/C) ventilation is the simplest and most effective means

of providing full mechanical ventilation. In this mode, each inspiratory

effort beyond the set sensitivity threshold triggers delivery of the fixed

tidal volume. If the patient does not trigger the ventilator frequently

enough, the ventilator initiates a breath, ensuring the desired minimum

respiratory rate.

o Synchronized intermittent mandatory ventilation (SIMV) also delivers

breaths at a set rate and volume that is synchronized to the patient's efforts.

In contrast to A/C, however, patient efforts above the set respiratory rate

are unassisted, although the intake valve opens to allow the breath.

NONINVASIVE POSITIVE-PRESSURE VENTILATION

Positive-pressure ventilation can be given via facemasks or nasal masks. NIPPV

can be given as continuous positive airway pressure (CPAP) or bi-level positive

airway pressure (BiPAP). In CPAP, constant pressure is maintained throughout

the respiratory cycle with no additional inspiratory support. In (bi-PAP)

,ventilation offers independent control of inspiratory and expiratory pressures

while providing pressure support ventilation. It delivers two levels of positive

airway pressure provided via a nasal or oral mask. Bi-PAP is most often used for

patients who require ventilatory assistance at night, such as those with severe

COPD or sleep apnea.

Assessing the ventilator setting In monitoring the ventilator, the nurse should note the following:

Type of ventilator (such as volume-cycled, pressure-cycled, Negative-pressure)

Controlling mode (such as controlled ventilation, assist– Control ventilation,

synchronized intermittent mandatory ventilation)

Tidal volume and rate settings (tidal volume is usually 10 to 15 mL/kg; rate is

usually 12 to 16/min)

FiO2 (fraction of inspired oxygen) setting

Inspiratory pressure reached and pressure limit (normal is 15 to 20 cm H2O; this

increases if there is increased airway resistance or decreased compliance)

Sensitivity (a 2-cm H2O inspiratory force should trigger the ventilator)

Inspiratory-to-expiratory ratio (usually 1:3 [1 second of inspiration to 3 seconds of

expiration] or 1:2)

Minute volume (tidal respiratory rate, usually 6 to 8 L/min) volume ×

Sigh settings (usually 1.5 times the tidal volume and ranging from 1 to 3 per

hour), if applicable.

PEEP and/or pressure support level, if applicable. PEEP is usually 5 to 15 cm

H2O.

Respiratory weaning Respiratory weaning the process of withdrawing the patient from dependence on the

ventilator, takes place in three stages: the patient is gradually removed from the

ventilator, then from the tube, and finally from oxygen.

Criteria for Weaning If the patient is stable and showing signs of improvement, weaning indices should be

assessed. These indices include:

• Vital capacity: the amount of air expired after maximum inspiration. Used to

assess the patient’s ability to take deep breaths. Vital capacity should be 10 to 15

mL/kg to meet the criteria for weaning.

• Maximum inspiratory pressure (MIP): used to assess the patient’s respiratory

muscle strength. It should be at least -20 cm H2O.

• Tidal volume: volume of air that is inhaled or exhaled from the lungs during an

effortless breath. It is normally 7 to 9 mL/kg.

• Minute ventilation: equal to the respiratory rate multiplied by tidal volume.

Normal is about 6 L/min.

• A PaO2 of greater than 60 mm Hg with an FiO2 of less than 40%.

Glasgow Coma Scale (CGS)

There are three components to the GCS:

• Best eye opening

• Best motor response

• Best verbal response

Best Eye Opening (4 – 1)

4 = eyes open spontaneously when a person approaches the bedside.

3 = eyes open to either spoken or shouted verbal stimulation.

2 = eyes open to a painful stimuli

1 = failure to open eyes regardless of stimuli.

Best Verbal Response (5 - 1)

5= oriented to: (Time, Person, place)

4=Confusion:

A patient may be able to hold a conversation with the observer but

responses are Inappropriate or disoriented.

A patient who talks in sentences, is confused but not orientated, and will

score four.

3=Inappropriate Speech :

Does not carry on conversation, poor attention span, uses inappropriate

words and phrases.

2=Incomprehensible Speech:

Patients are less aware of their environment and their verbal response is in

the form of incomprehensible sounds

1=no response

Best Motor Response (6 – 1)

6=Obeys Commands:

Patients are aware of their environment, have understood the observer's

instructions, and are able to carry them out

5=Localizes to Pain:

This is a response to a central painful stimulus.

It tells the body to do something about removing the source of the pain -

usually a motor response such as moving an arm towards the source of the

pain in order to remove it and stop the pain from continuing.

4=Withdraws from pain

• Patients flex or bend their arm towards the source of the pain, but do not

actually localize or try to remove the source of the pain

3=Abnormal Flexion

Patients flex or bend the arm at the elbow and rotate the wrist, resulting in

a spastic posture in response to a central painful stimulus.

It is an abnormal response and indicates severe cerebral damage and an

interruption of nerve pathways from the brain's cortex to the spine.

2=Abnormal Extension

In response to a central painful stimulus, patients will extend or straighten

an arm at the elbow, or may rotate the arm inwards.

Abnormal response and emanates from the brain stem.

It shows that patients are not able to send information to and from the

cerebrum due to damage to the brain stem.

1= no response

Level of consciousness GCS 13 - 15: mild traumatic brain injury

CS 9 -12: moderate traumatic brain injury

GCS 3 – 8: severe traumatic brain injury

Best Eye-Opining Response Score Spontaneously 4

To speech 3

To pain 2

No response 1

Best Motor Response Score Obeys commands 6

Localized stimuli 5

Withdrawal from stimulus 4

Abnormal flexion (decorticate) 3

Abnormal extension (decerebrate) 2

No response 1

Best Verbal Response Score Oriented 5

Confused conversation 4

Inappropriate words 3

Garbled sounds 2

No response 1

A total score of 3 to 8 suggests severe impairment,

9 to 12 suggests moderate impairment, and 13 to

15 suggests mild impairment.

NARRATIVE NOTE SAMPLE ENTRIES

General concepts

1. Besides the initial entry and assessment, narrative notes include all patient care

activities such as diet, hygiene, ambulation, elimination, visits from health care

professionals or family, tests, specific problems, how addressed and how

resolved. All entry are signed and dated. Every timed entry must have a legal

signature: 1st initial, last name and legal status. “M. Nurse, BCNS”

2. Each page of narrative notes is a legal document must be dated–and signed.

3. Safety checks: Most hospital protocols require you to document that your patient

has been checked for safety at the initial entry, q 2 hours and the last entry. This

must also be included in your narrative notes.

4. When referring to another nurse in your documentation, include her 1st initial, last

name and legal title. “Pt c/o shortness of breath, P. Smith, RN notified”.

Initial entry:

When you perform your initial assessment, you will take vital signs, briefly assess the

patient’s status in all systems, and check that all ordered modalities, equipment, and

treatments are in place and properly functioning. Your initial entry will include: level of

consciousness; ability to follow directions; general status of the skin, respiratory system,

cardiac system, and bowel sounds; the status of systems related to current diagnosis or

surgery; any untoward findings; the status IVs, drainage tubes, dressings, and any special

equipment; and then end with a safety check.

07:30 Alert, awake, orientated to person place and time. Follows commands. Skin warm and dry. Respirations unlabored @18. Apical Pulse = 82, regular. Bowel Sounds absent. Hand grasps equal. O2@ 4L via nasal cannula. IV D5/1/2NS infusing @100 to R forearm via pump. Site clean and dry with no swelling or redness. Abdominal dressing dry and intact. Foley draining clear amber urine. Bed in

low position, call bell in reach, siderails. M. Nurse, BCNS

Documenting diet:

The amount of fluid in mL is recorded in the I&O sheet. In the narrative note document

the type of diet, percentage consumed, and any pertinent information :

08:00 Took 100% of low sodium, soft diet. Had difficulty swallowing chopped meat._M. Nurse, BCNS

Documentation of complete physical assessment:

Complete your assessment before 9 a.m. and before giving any medications or

treatments. It may not all be actually completed at the same time, but document it

in one paragraph making sure that any abnormal or critical findings are

documented and reported immediately.

Ask the patient specifically when he had last BM. In addition to stating “no

complaints of constipation diarrhea or flatus”, describe your patient’s specific

status.

0830 Awake, alert, oriented to person, place & time. Skin warm and dry. Turgor recoil brisk. Face symmetrical. PERRLA. EOM intact. Follow spoken commands. Mucous membranes pink & moist. Swallows without difficulty. Neck supple, trachea midline, carotids equal, no cervical nodes palpated. JVD (-) @ 45°. Respirations even and unlabored, rate 16. Breath sounds clear bilaterally & A&P. Apical Pulse=72, regular. Abdomen soft, non-tender, bowel sounds present in all 4 quadrants. No complaints of constipation, diarrhea, flatus. States last BM yesterday evening. Urine amber, no complaints of burning. Peripheral pulses 2+. Homan’s sign (-). Capillary refill brisk. Bed in low position, call light within reach. _M. Nurse, BCNS

Documentation of hygiene care:

Most institutions have a check-off list of nursing interventions for hygiene, such as back

care, pedicure, Foley care, mouth care. However, they should be included in a narrative

note. Also indicate how much of the care the patient did independently and any pertinent

observations.

09:30 Complete bath care given with mouth care, peri-care, Foley care, back care.__M. Nurse, BCNS

Documenting ambulation:

Describe gait, strength, amount of assistance needed, how tolerated.

09:30 OOB to chair with the assistance of two staff members. Gait steady, but slow. Ambulated in hallway 5 minutes. C/O “feeling tired.”, assisted back to bed_________________________________________________________________M. Nurse, BCNS

Documenting a problem such as pain:

State the problem, what was done to solve it, and record result.

10:15 States “sharp pain” points to LLQ of abdomen, 8 on a scale of 1-10. States “gets a little better when lying on left side.” Respirations 20. Demerol 75 mg IM R ventral gluteal site by M. RealNurse,

RN. Side rails, bed in low position, call light in reach. M. Nurse, BCNS

and the result (or evaluation of whether your intervention was successful): 11:00 States pain 3 on scale of 1-10. Watching TV.__________________M. Nurse, BCNS

Documenting a physician visit, a test, therapy, treatment, specimen:

10:30 Dr. Jones in to see patient._________________________________M. Nurse, BCNS 10:40 To x-ray via w/c for chest x-ray_____________________________M. Nurse, BCNS 11:45. Sputum Specimen to lab.__________________________________M. Nurse, BCNS 12:00 Abdominal dressing change. 8" midline, vertical abdominal incision well-approximated. Staples intact. No redness, swelling or drainage noted. Dry sterile dressing applied._________M. Nurse, BCNS

FINAL ENTRY: Verify status of your patient and include safety check

12:15 States pain “almost gone”, now a 1 on 1-10 scale. Husband visiting. Watching TV. Side rail call bell in reach, bed in low position._____________________ ____M. Nurse, BCNS

Oxygen Delivery Systems

Method

Amount delivered FiO2

(Fraction Inspired

Oxygen)

Priority Nursing

Interventions

Nasal cannula

Low flow

1 L/min = 24%

2 L/min = 28%

3 L/min = 32%

4 L/min = 36%

5 L/min = 40%

6 L/min = 44%

Check frequently that both

prongs are in patient's nares.

Never deliver >2–3 L/min

to patient with chronic lung

disease.

Simple mask

Low flow

6–8 L/min = 40–60%

Monitor patient frequently

to check placement of the

mask. Support patient if

claustrophobia is a concern.

Secure physician's order to

replace mask with nasal

cannula during meal time.

Partial rebreather mask

Low flow

8-11 L/min = 50-75%

Set flow rate so that mask

remains two thirds full

during inspiration. Keep

reservoir bag free of twists

or kinks.

Non rebreather mask

Low flow

12 L/min = 80–100%

Maintain flow rate so

reservoir bag collapses only

slightly during inspiration.

Check that valves and

rubber flaps are functioning

properly (open during

expiration and closed

during inhalation). Monitor

SaO2 with pulse oximeter.

Venturi mask

High flow

4–8L/min = 24–40%

Requires careful monitoring

to verify FiO2 at flow rate

ordered. Check that air

intake valves are not

blocked.

Name of the

Drug

Dosage/Route Action/Classification Indication/ Contraindications Adverse Effects/

Side Effects

Nursing Responsibilities

Generic

Name:

epinephrine

Brand Name:

Adrenalin

Chloride

Cardiac arrest:

1 mg IV of 1:10,000

solution q 3-5 min;

double dose if

administering

via ET tube

Anaphylaxis: 0.1- 1

mg SQ or IM of

1:1000 solution.

Asthma: 0.1-0.3 mg

SQ or IM of

1:10,000 solution

Action:

Stimulates beta

receptors in lung.

Relaxes bronchial

smooth muscle.

Increases vital

capacity

BP, HR, PR

Decreases airway

resistance.

Classification:

Beta2 Adrenergic

Agonists

Indications:

o Asthma

o Bronchitis

o Emphysema

o All cardiac arrest,

anaphylaxis

o Used for symptomatic

bradycardia.

o Relief of bronchospasm

occurring during

anesthesia

Contraindications:

Contraindicate in patients with

angle-closure glaucoma, shock

(other than anaphylactic shock),

organic brain damage, cardiac

dilation, arrhythmias, coronary

insufficiency, or cerebral

arteriosclerosis

Adverse Effects:

nervousness,

tremor, vertigo,

pain, widened

pulse pressure,

hypertension

nausea

Side Effects:

headache

Monitor V/S. and check for cardiac

dysrhythmias

Drug increases rigidity and tremor in

patients with Parkinson’s disease

Epinephrine therapy interferes with tests

for urinary catecholamine

Avoid IM use of parenteral suspension into

buttocks. Gas gangrene may occur

Massage site after IM injection to

counteract possible vasoconstriction.

Observe patient closely for adverse

reactions. Notify doctor if adverse reaction

develop

Generic

Atrophine

Sulfate

Brand

Isopto

Atropine

Bradycardia: 0.5 -1

mg IV (may give via

ETT at double dose)

q 3-5 min, max 0.04

mg/kg

Cardiac arrest: 1

mg q 3-5 min, max

0.04 mg/kg

Nerve gas and

organophosphate

symptoms, may

repeat in 2 mg

increments q 3 min

tiltrated to relief

symptoms.

Action

cholinergic receptor

sites so response to

acetylcholine is

decreased

Classification

Anticholinergics

Indication

to prevent or reduce secretions of

the respiratory tract

To restore cardiac rate and

arterial pressure during anesthesia,

when vagal

stimulation produced by intra-

abdominal surgical traction causes

a sudden decrease in pulse rate

and cardiac action

Antidote for cardiovascular

collapse from the injudicious use

of a cholinergic drug.

Contraindication

Contraindicated in patients

hypersensitive to drug and those

with acute angle closure

glaucoma, obstructive uropathy,

obstructive disease of GI tract,

paralytic elius, toxic magacolon,

intestinal atony, unstable CV

status in acute hemorrhage,

asthma, or myasthenia gravis.

Adverse Effects

CNS:

restlessness,

ataxia,

disorientation,

insomnia,

agitation,

confusion.

CV: tachycardia,

angina,

arrhythmias,

flushing.

GI: dry moth,

constipation,

vomiting.

GU: urine

retention.

Hematologic:

leukocytosis

Side Effects

CNS: headache,

excitement.

CV: palpitations

Monitor VS.

Report HR

Monitor for constipation, oliguria.

Atrophine could result in CNS

stimulation (confusion, excitement) or

drowsiness

Instruct to take 30 mins before meals

Eat foods high in fiber and drink

plenty fluids.

Instruct client not to drive a motor vehicle or

participate in activities requiring alertness.

Advise to use hard candy, ice chips, etc.

for dry mouth.

Name of the Drug Dosage/Route Action/Classification Indication/

Contraindications

Adverse Effects/ Side Effects Nursing Responsibilities

Generic Name:

Dopamine HCl.

Brand Name:

Intropin; Revimine

Adults: initially,

1 to 5

mcg/kg/minute

by I.V. infusion.

Adjust dose to

desired

hemodynamic or

renal response,

increase by 1 to 4

mcg/kg/minute at

10 to 30-minute

intervals.

Action

Stimulates

dopaminergic and

alpha and beta

receptors of the

sympathetic nervous

system. Action is

dose-related; large

doses can cause

mainly alpha

stimulation.

Classification: Inotropic, vasopressor

Indications:

To treat shock and correct

hemodnamic imbalances,

improve perfusion of vital

organs, to increase

cardiac output, and to

correct hypotension.

Contraindications:

Contraindicated in patient

with uncorrected

tachyarrhythmias, or

ventricular fibrillation.

- Use cautiously in

patients with occlusive

vascular disease, cold

injuries, diabetic

endarteritis, and arterial

embolism; in pregnant

woman; with a history of

sulfite sensitivity; and in

those taking MAO

inhibitor.

Adverse Effects: Cv: anginal pain, arrythmias,

bradycardia, conduction

disturbances ectopic

breasts,hypertension,

hypotension, palpitations,

tachycardia, vasoconstriction,

widening of QRS complex.

GI: vomiting.

GU: azotemia

Respiratory: asthma attacks,

dyspnea

Skin: necrosis,piloerection,

tissue sloughing with

extravasation.

Other: anaphylaxis.

Side Effects:

CNS: headache

GI: nausea

Blood is not a substitute for blood or

fluid volume deficit. If deficit occurs,

replace fluid deficit first before

giving meds.

During infusion, frequently monitor

ECG, BP, cardiac output, CVP,

pulmonary artery wedge pressure,

pulse rate, urine output, and color

and temperature of the limbs.

If diastolic pressure rises

disproportionately, decrease

perfusion rate and watch out

carefully for further signs of

vasoconstriction unless such action is

desired.

Check for urine output. If urine flow

is decrease without hypotension,

notify physician.

After drug is stopped, Tamper

dosage slowly to evaluate stability of

blood pressure.

Acidosis decrease effectiveness of

dopamine.

Generic

Dobutamine

Hydrochloride

Brand

Dobutrex

Adults

individualized:

2.5-15

mcg/kg/min.

Rate of

administration

and duration of

therapy depend

on the response

of client as

determined by

HR, presence of

activity, BP and

urine flow

Action

Enhancing the force

of myocardial

contraction

HR, CO, and

SV with minor effects

to HR.

elevated

ventricular filling

pressure and helps

AV node conduction

Classification

Inotropic, Adrenergic

Indication Short term treatment of

cardiac decompensation

in organic heart disease of

cardiac surgical pressures.

Contraindication

Contraindication in

patients hypersensitive to

drug or any of its

components and in those

with idiopathic

hypertrophic subaortic

stenosis.

Adverse Effects

CV: angina, hypertension,

hypotension, increased heart

rate, nonspecific chest pain,

phlebitis, PVCs.

GI: nausea and vomiting.

Respiratory: asthma attacks,

shortness of breath.

Others: anaphylaxis.

Side Effects

CNS: headache

Musculoskeletal: mild leg

crams or tingling sensation.

Monitor CVP to assess vascular

volume and cardiac pumping

efficiency.

(Elevated CVP may indicate

disruption on CO, as in pump failure

or Pulmonary edma; low CVP may

indicate hypovolemia)

Monitor ECG and BP continuously

during drug administration

Record I&O

Monitor glucose in diabetes patients

Drug is administered IV to improve

cardiac function thus increasing BP

and improving urine output.

Report any chest pain, increase SOB,

headaches or IV site pain.

Bloom's Taxonomy Verbs

Apply Analyze Synthesize Evaluate Knowledge Comprehend

Act

Administer

Articulate

Assess

Change

Chart

Choose

Collect

Compute

Construct

Contribute

Control

Demonstrate

Determine

Develop

Discover

Dramatize

Draw

Establish

Extend

Imitate

Implement

Interview

Include

Inform

Instruct

Relate

Report

Select

Show

Solve

Transfer

Use

Utilize

]Paint

Participate

Predict

Prepare

Produce

Provide

Break down

Characterize

Classify

Compare

Contrast

Correlate

Debate

Deduce

Diagram

Differentiate

Discriminate

Distinguish

Examine

Focus

Illustrate

Infer Limit

Outline

Point out

Prioritize

Recognize

Research

Relate

Separate

Subdivide

Adapt

Anticipate

Categorize

Collaborate

Combine

Communicate

Compare

Compile

Compose

Construct

Contrast

Create

Design

Develop

Devise

Express

Facilitate

Formulate

Generate

Incorporate

Individualize

Initiate

Integrate

Intervene

Invent

Make up

Pretend

Produce

Progress

Propose

Rearrange

Reconstruct

Reinforce

Reorganize

Revise

Rewrite

Structure

Substitute

Model

Modify

Negotiate

Organize

Perform

Plan

Validate

Appraise

Argue

Assess

Choose

Compare

Criticize

Critique

Decide

Defend

evaluate

Interpret

Judge

Justify

Predict

Prioritize

Prove

Rank

Rate

Reframe

Select

Support

Count

Define

Describe

Draw

Enumerate

Find

Identify

Label

List

Match

Name

Quote

Read

Recall

Recite

Record

Reproduce

Select

Sequence

State

Tell

View

Write

Classify

Cite

Conclude

Convert

Describe

Discuss

Estimate

Explain

Generalize

Give examples

illustrate

Interpret

Locate

Predict

Report

Restate

Review

Summarize

Normal value of diagnostic study

HEMATOLOGY VALUES

Red Blood Cell Values

4.6 – 6.2 * 10*12/L RBC (Male)

4.2-5.4 * 10*12/L RBC (Female)

White Blood Cell Values

4.500-11.00/cu mm WBC

45-73% Neutrophils

20-40% Lymphocytes

2 - 8% Monocytes

0-4% Eosinophils

0 -1% Basophils

Hemoglobin Values

13 - 18 g/dL Hgb (Male)

12 - 16 g/dL Hgb (Female)

Hematocrit Values (HCT) or packed cell volume (PCV)

42-52% Hct (Male)

35 - 47% Hct (Female)

KFT:kidney function test

(0.7-1.4) mg/dl. Creatinine

10-20 mg/dl Blood Urea Nitrogen (BUN)

135-145 mEq/L Sodium (Na+)

3.5-5.0 mEq/L Potassium (K)

2.5-8mg/dl uric acid

LFT : liver function test

Total: 0.3 -1.0 mg/dl Direct(conjugated): 0.1-0.4 mg/dl Indirect(unconjugated): 0.1-0.4 mg/dl.

Billirubin:

3.5-5.5 g/l Albumin

male 10-40u/ml Female 15-30u/ml

AST(SGOT)

male 10-40u/ml Female 8-35u/ml

ALT (SGPT)

50-120 u/m Alkaline phosphatase

ELECTROLYTE

2.5-4.5mg/dl. Phosphorus

8.6 -10.2 mg/dl Calcium (Ca)

97-107 mEq/L Chloride (Cl)

1.3-2.3 mg/dL Magnesium

2.5 - 4.5 mg/dL Phosphorus

LIPID profile

150-200 mg/dL Cholesterol (total)

Male 35-70 mg/dL Female 35-85 mg/dL

High density lipoprotein : HDL

Desirable level:

Less than 160 mg/dl if no coronary artery disease or less than 2 risk factors.

Less than 130 if no coronary artery disease and 2 or more risks factors.

Less than 100 mg/dl if coronary artery disease present.

Low density lipoprotein : LDL

100-200 mg/dL

Triglycerides

COAGULATION

21 - 35 seconds aPTT

140,000 - 450,000 / ml Platelets

9.5-12 seconds PT

Lower limit of normal :20-25 seconds Upper limit of normal:32-39 second

PTT

1.0

2-3 for therapy in AF, DVT and PE. 2.5-3.5 for therapy in prosthetic heart valves

INR

1.5-9.5 minutes Bleeding time

CEREBRAL SPINAL FLUID

Clear Appearance

40 - 80 mg/dL Glucose

70 - 180 mm/H2O Pressure

16 - 45 mg/dL Protein

0 - 5 cells Total cell coun ( WBC's)t

ARTERIAL VALUES

7.35 - 7.45 pH

35 - 45 mm Hg PaCO2

19-25 mEq/L HCO3

95 - 99% O2 sat

85 - 95 mm Hg PaO2

-5 to +5 mmol/L

BE

URINE VALUES

Straw Color

1.003 - 1.040 Specific Gravity

4.6 - 8.0 pH

75-200 mEq/24hr Na

26-123mEq/24hr K

150 mg/24hr Protein

250-900 mOsm/kg Osmolality

CARDIAC MARKERS

<0.35 ng/ml Troponin I

< 0.2 ng/ml Troponin T

5-70 ng/ml Myoglobin

Male:50-325 mU/ml Female:50-250 mU/ml

Creatine phosphokinase (CPK)

GENERAL CHEMISTRY

15-45 mg/dL Ammonia

60-160 U/dL Amylase

Fasting 60 - 110 mg/dL ( Postprandial(2hr)65-140 mg/dL

Glucose

275 - 300 mOsm/kg Osmolarity

6-8 gm/dL Protein (total)

Classification of Nursing Diagnoses by Functional Health

Patterns Health Perception-Health Management:

Health-See king Behavior (Specify)

Altered Health Maintenance.

Ineffective Management of Therapeutic Regimen, Individual

Effective Management of Therapeutic Regimen, Individual

Ineffective Family management of Therapeutic Regimen.

Ineffective Community Management of Therapeutic Regimen.

Noncompliance (Specify).

Risk for Infection.

Risk for Injury.

Risk for Trauma.

Risk for Preoperative Positioning Injury.

Risk for Poisoning.

Risk for Suffocation.

Altered Protection.

Energy Field Disturbance.

Risk for Altered Body Temperature.

Nutritional-Metabolic:

Altered Nutrition: More than Body Requirements.

Altered Nutrition: Risk for More than Body Requirements.

Altered Nutrition: Less than Body Requirements.

Ineffective Breastfeeding.

Interrupted Breastfeeding.

Effective Breastfeeding

Ineffective Infant Feeding Pattern.

Impaired Swallowing.

Risk for Aspiration.

Altered Oral Mucous Membrane.

Fluid Volume Deficit.

Risk for Fluid Volume Deficit.

Fluid Volume Excess.

Risk for Impaired skin Integrity.

Impaired Skin Integrity.

Impaired Tissue Integrity.

Ineffective Thermoregulation.

Hyperthermia.

Hypothermia.

Elimination:

Constipation.

Colonic Constipation.

Perceived Constipation.

Diarrhea.

Bowel Incontinence.

Altered Urinary Elimination.

Functional Incontinence.

Reflex Incontinence.

Stress Incontinence.

Total Incontinence.

Urge Incontinence.

Urinary Retention.

Activity-Exercise:

Activity Intolerance.

Risk for Activity Intolerance.

Fatigue.

Impaired Physical Mobility.

Risk for Disuse Syndrome.

Self-Care Deficit, Bathing/Hygiene.

Self-Care Deficit, Dressing/Grooming.

Self-Care Deficit, Feeding.

Self-Care Deficit, Toileting.

Diversional Activity Deficit.

Impaired Home Maintenance Management.

Ventilatory weaning Response, Dysfunctional.

Inability to Sustain Spontaneous Ventilation.

Ineffective Airway Clearance

Ineffective Breathing Pattern.

Impaired Gas Exchange.

Decreased Cardiac Output.

Altered Tissue Perfusion (Renal, Cerebral,

Cardiopulmonary,Gastrointestina,Peripheral).

Dysreflexia.

Disorganized Infant Behavior.

Risk for Disorganized Infant Behavior.

Potential for Enhanced Organized Infant Behavior.

Risk for Peripheral Neurovascular Dysfunction.

Altered Growth and Development.

Sleep-Rest:

Sleep-Pattern Disturbance.

Anxiety.

Energy Field Disturbance.

Fear.

Dysfunctional Grieving.

Relocation Stress Syndrome.

(See also Self-Perception - Self-Concept)

Cognitive-Perceptual:

Pain.

Chronic Pain.

Sensory/Perceptual Alterations (Specify)

Unilateral Neglect.

Knowledge Deficit (Specify).

Altered Thought Processes

Acute Confusion.

Chronic Confusion.

Impaired Environmental Interpretation Syndrome.

Impaired Memory.

Decisional Conflict (Specify).

Decreased Intracranial Adaptive Capacity.

Self – Perception – Self – Concept:

Fear.

Anxiety.

Risk for Loneliness.

Hopelessness.

Powerlessness.

Self – Esteem Disturbance.

Chronic Low Self - Esteem

Situational Low Self – Esteem.

Body Image Disturbance.

Risk for Self – Mutilation.

Personal Identity Disturbance

Role – Relationship:

Anticipatory Grieving.

Dysfunctional Grieving.

Altered Role Performance.

Social Isolation.

Impaired Social Interaction.

Relocation Stress Syndrome.

Altered Family Processes.

Altered Family Processes: Alcoholism.

Altered Parenting.

Risk for Altered Parent Infant/ Child Attachment.

Caregiver Role Strain.

Impaired Verbal Communication.

Risk for Violence.

Sexuality – Reproduction:

Altered Sexuality Patterns.

Sexual Dysfunction.

Rape – Trauma Syndrome.

Rape – Trauma Syndrome: Compound Reaction.

Rape – Trauma Syndrome: Silent Re action.

Coping – Stress Tolerance:

Ineffective Coping (Individual).

Defensive Coping.

Ineffective Denial or Denial.

Impaired Adjustment.

Post – Trauma Response.

Defensive Coping.

Family Coping: Potential for Growth.

Ineffective Family Coping: Compromised.

Ineffective Family Coping: Disabling.

Ineffective Community Coping.

Potential for Enhanced Community Coping.

Value – Belief:

Spiritual Distress (Distress of Human Spirit).

Potential for Enhanced Spiritual Well-Being.

Glossary

COPD ChronicObstructive Pulmonary Disease

HF Heart Failure

CHF Congestive Heart Failure

IHD Ischemic Heart Disease

MI Myocardial Infraction

US Unstable Angina

SA Stable Angina

CABG coronary Artery Bypass Graft

CAD Coronary Artery Disease

CRF Chronic Renal Failure

ARF Acute Renal Failure

CVA Cerebral Vascular Accident

DM Diabetic Mellitus

HTN Hypertension

TB Pulmonary Tuberculosis

HAP Hospital Acquired Pneumonia

DKA Diabetic Ketoacidosis

ESRD End Stage Renal Disease

PT Prothrombine Time

PTT Partial Prothrombine Time

BT Bleeding Time

RBCs Red Blood Count

WBCs White Blood Count

HB Hemoglobin

KFT Kidny Function Test

LFT Liver Function Test

BUN Blood Urea Nitrogen

CRE Creatinnine

PPD Purified Protein Derivative

BCG Bacilli – Calmette Guerin

IS Incentive Spirometry

CT chest tube, computed tomography

U/S Ultrasound

DX Diagnosis

ERCP Endoscopic Retrograde

CholangiopancreAtography

NPO Nothing by Mouth

N&V Nausea & Vomiting

ICP Intracranial Pressure

ICU Intensive Care Unit

IDDM insulin dependent diabetes mellitus

ARDs Acute Or Adult Respiratory Distress

Syndrome

BA Bronchial Asthma

CF Cystic Fibrosis

PTCA Percutenous Trnsluminal Coronary

Angiography

PCI Percutenous Coronary Intervention

CO Cardiac Output

SV Stroke Volume

SOB Shortness of Breath

ACS Acute Coronary Syndrome

DOE Dyspnea on Exertion

PND Paroxysmal Nocturnal Dyspnea

DVT Deep Vein Thrombosis

DF Diabetic Foot

UGB Upper Gastrointestinal Bleeding

PE Pulmonary Edema

Pulmonary Embolism

CAP Community Acquired Pneumonia

ALP Alkaline Phosphatase

ALT Aalanine Transaminase, Alanine

Aminotransferase

AST Aspartate Aminotransferase

C&S Culture and Sensitivity

CBG Capillary Blood Glucose

CBC Complete Blood Count

BS Blood Suger

ABGs Arterial Blood Gases

FBS Fasting Blood Sugar

RBS Random Blood Suger

LDL Low Density Lipoprotein

HDL High Density Lipoprotein

INR International Normalize Ratio

CPT Chest Physiotherapy

MV Mechanical Ventilator

ICD Implantable Cardioverter Defibrillator

CXR chest x-ray

DIC Disseminated Intravascular Coagulation

FX fracture

KVO keep Vein Open

ADH Antidiuretic Hormone

IBD inflammatory bowel disease

IVP intravenous pyelography

KUB kidney, ureter, bladder

Medications Assignment 2011/2012

At the end of the two rotations the nursing student should know the following

information about this medications list:

Trade name

Scientific name

Classification

Indication

Side effect

Nursing consideration

Medication List:

1. Atropine Sulfate

2. Epinephren

3. Dopamine

4. Dobutamine

5. Nor-epinephren

6. Lidocaine

7. Adenosine

8. Amidrone

9. Thrombolytic agents (Streptokinase)

10. Vitamin K

11. Sodium bicarbonate

12. Manitol

13. Verapamil

14. Nitrogylecerine Sublingual

15. midazolam

16. Phenytoin

17. Ciprofloxacin

18. Naloxon

19. KCL

20. Calcium chloride

Clinical Training Schedule 2011/ 2012

Date Week Number Notes

st1 Introductory Labs

nd2

1st R

ota

tio

n

ORINTATION

rd3

Seminar :- ABGs

Atropine Sulfate

Epinephren

th4

Seminar :- diagnostic test

Dopamine

Dobutamine

th5

Seminar :-ECG

Nor-epinephren

Lidocaine

th6

Seminar :-Dialysis

Adenosine

Amidrone

Dead line of NCP

th7 Seminar :- chest tube

Thrombolytic agents (Streptokinase)

Vitamin K

th8

2n

d R

ota

tio

n

Sodium bicarbonate

Manitol

th9 Verapamil

Nitrogylecerine Sublingual

th10 midazolam

Phenytoin

th11 Ciprofloxacin

Naloxon

Dead line of NCP

th12 KCL

Calcium chloride

th13

th14 Final Exam