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UNIVERSITY
BLOOMINGTON CAMPUS
BSN PROGRAM
This clinical experience will build on the foundational concepts to provide holistic and culturally
congruent nursing care for adult clients in a sub-acute and long-term care setting. Students practice will
be guided by clinical practice guidelines and standard policy and procedures, while learning to provide
direct nursing care such as performing delegated medical treatments. Students will be required to collect
and interpret a variety of data to provide client and family centered care.
Learning Activities:
Work on communication critique with peer (See attached rubric) DUE by-Week 4 (P/NP)
Begin/Plan a holistic health assessment on an assigned patient (see attached) DUE by Week 4
(50 points)
Review:
Essential Elements of Therapeutic Communication
Holistic health assessment tool
Ackley (2014) Section 1
Review components of the nursing process
o Assessing:
o Diagnosing
o Planning
o Implementing care
o Evaluating the nursing care that has been given and making necessary revisions
Come to class prepared to discuss:
Nursing Process See Attachment 1 and Attachment 2
Post-class:
Review nursing process
Review therapeutic communication
Learning Objectives
1. Discuss the steps of the nursing process
2. Describe the relationship between data collection and data analysis
3. Explain the relationship between data interpretation, validation, and clustering
4. Differentiate between a nursing diagnosis, medical diagnosis, and collaborative problem
5. Discuss criteria used in priority setting
6. Discuss the process of selecting nursing interventions
7. Develop ability to analyze therapeutic communication in practice for self and another
Student _____________________________
Instructor ___________________________
1. Health Promotion
Health Awareness/Management:
Current health problems: _______________________________________________________________________________________________________________________________________
Allergies and reaction (food, medication, hives, asthma, eczema, hay fever)
_________________
______________________________________________________________________________
Past accidents/illnesses/hospitalizations/surgeries
______________________________________
______________________________________________________________________________
______________________________________________________________________________
Childhood Illnesses: measles, mumps, rubella, chicken pox, whooping cough,
rheumatic fever, scarlet fever, polio (circle)
Immunizations: Last flu shot ________ Pnuemovax ___________
Tetanus/Diphtheria_______
Last physical exam ___________________Blood transfusion history
______________________
Self and family history of the following conditions: (first entry: self, second
entry: designate mother, father, daughter, son, sister, brother, etc.)
Heart__________________________________________________________________________
Lung__________________________________________________________________________
Kidney______________________________Diabetes ___________________________________
Hypertension _________________________Stroke ____________________________________
Arthritis_____________________________TB________________________________________
Drug addiction________________________Alcoholism ________________________________
Cancer ______________________________COPD ____________________________________
Mental Illness ________________________Rheumatic fever ____________________________
Thyroid _____________________________ Liver _____________________________________
Current medications, prescription and OTC, herbs, herbal teas, vitamins. (List here,
also complete medication sheet and submit to instructor)
____________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Note current risk factors (e.g. smoking, hypertension, obesity,
immobility).__________________
What is your impression of the patients knowledge of their risk factors?
____________________
______________________________________________________________________________
Does the patient follow through with appropriate health plan? (Circle)
usually
sometimes
never
Reasons for unwillingness to follow through._________________________________________
Do you believe your medication helps you? What makes you believe this?
______________________________________________________________________________
What do you believe is the cause of this illness?
______________________________________
______________________________________________________________________________
Who is responsible for making decisions about your health? Explain.
_____________________
_______________________________________________________________________________
Is there anything special that makes you recover from an illness?
________________________
_______________________________________________________________________________
What do you think would help you to reach a higher level of health?
_____________________
_______________________________________________________________________________
2. Nutrition
Ingestion:
Teeth__________________________________ Gums__________________________________
Dentures, partials _______________________________________________________________
Difficulty chewing _____________________________ Difficulty Swallowing_______________
Nausea or Vomiting ________________________Where does client eat____________________
Number of meals per day ___________Special diet ____________________________________
Current therapy NPO ________ NG suction ______ Tube feeding ___________TPN
_______
Nutritional Supplements__________________________________________________________
Which foods does the patient recognize as healing foods? (Ex. yin/yang, hot/cold)
_______________
Food preferences/intolerances ______________________________________________________
How is your appetite?___________________________________________________________
6
11 pm 7
am
7 am 3
pm
3pm11pm
24 hour total
+2 = palpable
+1= weak
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Carotid
Brachial
Radial
Femoral
Poplitea
l
Posterio
r tibial
Dorsalis
pedis
R __ L __
R __ L __
R__ L __
R __ L __
R __ L __
R __ L __
R __ L __
easily distracted
disoriented
Judgment realistic (circle) yes
no
Orientation:
Glasgow Coma Scale Total (see scale in medical/surgical text)
Pupils (circle)
Left 2 3 4 5 6 mm
Right 2 3 4 5 6 mm
Reaction: Brisk
Reaction: Brisk
Sluggish
Sluggish
____________
Nonreactive
Nonreactive
Have you noticed any change in your ability to feel pain, pressure, or different
temps?_______
Cognition:
Last grade completed ____________________________________________________________
What is your impression of the patients ability to learn at this time?
______________________
How happy are you with how you read? ____________________________________________
OPTIONAL ASSESSMENT: Executive Dysfunction/Cognitive impairment assessment
(include copy of completed assessment and result of tests) found at:
http://consultgerirn.org/uploads/File/trythis/try_this_d3.pdf
Communication:
Primary language ____________________________
English (circle) read write understand
no
Speech (circle) appropriate /
clear
slurred
aphasic (receptive/expressive)
Non-speech communication (e.g. word board, bell, signaling)
___________________________
If patient needs an interpreter: Would you be comfortable with someone you did not
know?
______________________________________________________________________________
______________________________________________________________________________
6. Self Perception
Self Concept/Self Esteem:
What is your impression of the patients feelings about their state of health and self?
__________
______________________________________________________________________________
______________________________________________________________________________
Appearance (circle) neat
clean / disheveled / erect position /
good eye
contact
General mood:
quiet / withdrawn / irritable / pleasant / cooperative
Thoughts about self (circle) appropriate / low self-esteem / grandiosity
paranoia / phobias / depression / isolation
Observations of visitors, cards, gifts, phone calls, living space
____________________________
Are you lonely? Explain. _______________________________________________________
Body Image:
Are you comfortable having someone assist you with hygiene needs? (Is modesty
an issue, does client mind if someone touched their head when shampooing their
hair?) _______________________
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8. Sexuality
Sexual Function:
Problems with sexual activities: ____________________________________________________
Effect of illness on sexuality:_______________________________________________________
What are your sexual concerns? _________________________________________________
Reproduction:
Breasts SBE ___________frequency ______________ lymph nodes _______________
Symmetry ______________ nipple discharge _________ masses ____________
Date of last mammogram ____________ frequency _______________
Female: Gravida __________ Para _______________
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______________________________________________________________________________
Belief System/ Faith/ Religion______________________________________________________
What is the source of your hope, strength, and daily comfort?
___________________________
______________________________________________________________________________
What are your religious practices? _______________________________________________
Do you read the Bible or other religious
texts?_______________________________________
If so, are you able to do this reading
now?___________________________________________
What does your belief mean to you?_______________________________________________
Value/Belief/Action Congruence:
Is there anything about your faith or spiritual beliefs that is causing you distress,
discomfort or
conflict?______________________________________________________________________
What role do you think your faith has had in your illness and
healing?____________________
How do you feel about death?____________________________________________________
What would you say has been the most meaningful experience of your
life?________________
______________________________________________________________________________
11. Safety/Protection
Infection/Defensive Processes//Thermoregulation:
Temperate _________ Route ___________ Moisture____________
(For each of the following, indicate size and draw location on the figure below)
Any sores, pain, white or red patches in mouth
________________________________________
Rashes ____________________ Lesions ___________________Petechiae __________________
Surgical incisions/scars _______________________Bruising ____________________________
Abrasions _____________
MANDATORY ASSESSMENT: Braden Score _______ (include copy of completed
assessment)
Found at:
http://www.ruralfamilymedicine.org/educationalstrategies/braden_scale_for_predicting_pres.
htm
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___________
12. Comfort
Physical:
Pain (draw location and radiation of pain on figures below)
Onset _____________________________
Duration ___________________________________
Intensity (0-10, 10 is worst) ____________ Quality (e.g. sharp, dull)
______________________
What increases pain _____________________________________________________________
What decreases pain _____________________________________________________________
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13. Growth/Development
Growth/Development:
Developmental Summary: (Ericksons Psychosocial Stage, what stage are they in and
what is the resolution to this stage what data helped you to determine the
resolution?)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Adapted from:Dossey, B., Keegan, L., & Guzzetta, C. (2005) Holistic Nursing: A handbook for practice 4th Ed.. Massachusetts:
Jones and Bartlett Publishers.
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2. What elements of verbal or nonverbal cue did your peer use in order to communicate
effectively? As a reminder, again Potter and Perry are helpful. See pages 313-314 for
review.
3. How did your peer show respect for his/her client through this interaction? Was
AIDET (either precisely or in other words) incorporated into the interaction?
4. Were there ways in which your peer needed to adapt communication in order to
improve the patients understanding of the information? Did the patient have special
needs for effectively communicating with him/her?
5. Do you have any general comments or suggestions for your peer concerning this
interaction?
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