Amanda, Davies
Professional Role Transition
Revised Critical Thinking Clinical Activity
Description
The Critical Thinking Clinical Activity allows the Role Transition student to present a clinical case utilizing the nursing process to their clinical faculty and peers. The student will incorporate particular categories/subcategories from the NCLEX-RN test plan, as well as emphasize target interventions. The student will provide a written reflection on their experiences in clinical relating to their transition to practice.
Instructions
Select one patient on which to complete the Critical Thinking Clinical Activity. You will present to your clinical group and individual faculty via prearranged Zoom meeting. The clinical faculty will assess student work and provide feedback. See separate grading rubric for this activity.
Guidelines:
1. Complete information on your patient to provide your classmates and faculty with some context.
a. Background: age, sex, ethnicity, allergies, significant med/surg history
b. Reason for visit or hospitalization
c. Social history
2. Utilize the SOAP format to critically think through the nursing process related to the top priorities you have identified for this patient. Be sure that the content in the assessment and plan sections correspond to the information in the subjective and objective sections.
a. SUBJECTIVE is only what the patient tells you (statements or questions; complaints or concerns)
b. OBJECTIVE includes physical assessment data, interval test data, lab or blood work, other objective data, current orders, current medications
c. ASSESSMENT includes the interpretation of information in the previous two sections. This is your “summary” which includes medical/nursing diagnoses. Prioritize your patient’s problems or diagnoses. Clearly identify nursing priorities. Identify treatment goals for each problem or diagnosis.
d. PLAN includes the interventions which were/are/will be implemented. Be sure and establish priorities for the interventions. (You may notate them as #1, #2, #3, etc.). Provide a brief explanation as to why you have prioritized them this way.
e. Identify the following patient needs and provide specific information about each need:
i. Case management or discharge planning
ii. Patient education
iii. Psychosocial, spiritual, and/or family support
3. Complete the reflection at the end. (This is just for the clinical instructor and is not presented to the group during oral presentation.)
4. Students will present their SOAP activity (#1-2 above) orally to fellow clinical students and clinical faculty instructor. This is a graded activity, and successful completion is a requirement of Role Transition clinical.
NUR 4642: Professional Role Transition
Critical Thinking Clinical Activity
Student name:
(Refer to instructions and grading rubric when completing this activity.)
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Patient initials: J. G. |
Date of care: |
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Background: 64-year-old African-American female. No known Allergies. PMH: Arthritis, Depression, Diabetes Mellitus, Hypertension, Thyroid disease (Hyperthyroidism- no treatment), COPD, Multi nodular Goiter. PSH: Angiogram, Breast Surgery.
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Reason for visit or hospitalization: Reason for Visit- S.O.B and Bilateral Leg Swelling Reason for Hospitalization- Acute Ischemic right MCA stroke
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Pertinent social history, including living situation, for discharge planning or case management purposes: Patient lives with family. Former smoker, with 1 pack/day for 50 yrs. Quit smoking 2 year
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S: Client reports having dyspnea on exertion and orthopnea. Client complained of having worsening bilateral lower leg swelling over the past 5 days that radiates to the abdomen. Complained to the PCP few days before and was directed to go the emergency room. She claims she has a dry cough, denies any fever, chills, congestion, sore throat, vomiting, diarrhea and chest pain.
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O: BP 165/83, Pulse 110, Temp 98.6 F (37 C)- Oral, Resp 20, Height 1.626m(5’4”), Weight 89kg(196lbs). General appearance: Lethargic, Head: Normocephalic, Mouth: Moist oral mucosa, Neck: Midline trachea, Heart: Irregular heart rhythm, Lungs: Breathing comfortably on supplemental oxygen, Abdomen: Nondistended, Extremities- No significant lower extremity edema present. Skin; No rash on visible skin Lab: WBC 16.4, RBC 4.85, HGB 10.6, HCT 34.6, PLT 369, Glucose 202, Na 150, K 3.4, CL 114, CO2 28, Calcium 7.6, Creatinine 1.01, BUN 7.6. I/O (gross per 24 hrs.) Input- 735ml, Output-1525ml
Medications: Scheduled: diltiazem (CARDIZEM), Pantoprazole (PROTONIX), fluticasone Furoate-vilanterol (BREO ELLIPTA), Insulin aspart (NOVOLOG), Lidocaine 1%injection, Metoprolol succinate, phosphorus K, Piperacillin-tazobactam (ZOSYN), magnesium oxide, clonidine (CATAPRES) tablets. PRN: Bisacodyl (DULCOLAX) suppository, hydralazine (APRESOLINE) injection, Ipratropium-albuterol (DUONEB) nebulizer solution,
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A: Acute Ischemic right MCA stroke status post thrombectomy, Atrial fibrillation on Eliquis, Acute on Chronic combined systolic and diastolic congestive heart failure, Acute respiratory failure with hypoxia, COPD not affecting current episode of care, Esophageal dysphagia, Hypertension, lab test positive for detection of COVID-19 virus, peripheral arterial disease, Kidney injury secondary to Covid nephropathy and component of urine retention, Hypernatremia, Hypokalemia.
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P:
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Case management or discharge planning needs |
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Patient education needs |
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Psychosocial, spiritual, and/or family support needs |
1. How do you feel about the experiences you are encountering in clinical? What are your strengths of performance and areas needing growth?
2. How have you integrated in the healthcare team? Provide examples. Describe the partnership/relationship you share with those preceptors /nurses with whom you work.
3. How would you characterize your transitioning to the role of professional nurse? What is helping or hindering your transition? What is your plan to continue to progress forward?
Rev. JD/2.28.21