Patient is a 38 years old male remains on ventilator in ICU . VS:155/91,T98.3 P:91, Lung sound diminished breath sounds, abdomen is soft , Edema plus 1 to BLLE. History of acute respiratory failure, history of failure. HTN. Aneurysm urgency, obesity. Assessment morbid obesity, right heplegia, severe hypertension.
Plans control the blood pressure. New medication to decrese blood pressure: Methyldopa.
I need to make it sounds like I am in ICU nursing student rotation and take care of this patient following the nurse.
1, Narrative patient assessment( why here, what happening, devices, meds, Provide overview narrative in order to express your experience with your patient (include assessment, diagnosis, personal medical history).
Summarize how the patient correlates to the clinical focus
- Nursing process /ADPIE 2 examples of nursing diagnosis NANDA like acute pain as evidence by….plan( what we are going to do (report to a nurse) Reflect on the nursing process, critical thinking, and clinical judgment, policies learned, research
Plan , implementation. Evaluation.
- clinical experience 2 new skills or meds I learned, lease talk about Methyldopa and Cavelon skin prep. Reflect and paraphrase on new skills (new labs, medication, etc.), assessments, procedures, and or areas of practice
- Communication/diversity , therapeutic like open ended question, like he was in distress and I held his hand and in the nice voice calmed him an etg. Reflect, identify and describe examples of therapeutic communication that were used at the clinical experience
Reflect, and identify key cultural characteristics and application of nursing cultural considerations used at the clinical experience
- Personal growth, like LPN verus RN role in this setting. Reflect on lessons learned from clinical experience and the impact self, and on the future nursing practice, roles
Language use form and style
The narrative provided an in-depth reflection on the patient and summarized how the patient correlated to the clinical focus.
The reflection provided an in-depth explanation of how the student incorporated the nursing process, critical thinking, clinical judgement, policies/research learned with the reflected experience incorporating different examples.
The reflection provided an in-depth paraphrased explanation of what was learned at the clinical experience (new labs, meds, etc.) so that reader has no questions. Identifies how previous knowledge helped, or didn’t help, in the learning process of this new skill, assessment, procedure.
The reflection identified and described in depth examples of therapeutic communication that were used at the clinical experience. The reflection identified in-depth key cultural characteristics and application of nursing cultural considerations used at the clinical experience
The reflection thoroughly expressed the lessons learned from the clinical experience and thoroughly expressed the impact on self, future nursing practice and roles. The reflection uses language and sentence structure that implicitly reveals feelings and thoughts; uses comparison and imagery.