CONNECTICUT COMMUNITY COLLEGE NURSING PROGRAM (CT-CCNP) Capital Community College, Gateway Community College, Norwalk Community College, Naugatuck Valley Community College, Three Rivers Community College Clinical Learning Experience Workbook CLEW For Nursing 201and 203 Medical/Surgical Clinical Learning Experiences January 2010 NUR*201 & 203 Clinical Learning Experience Workbook (CLEW) CLEW Component Holism, Caring: Nursing Assessment Cultural Status and Influences on Health Care: Advance Directives: Precaution Status: Admission Data / Health Perception & Health Management: Admitted from: Allergies: home Food nursing home Drug MD office other Other Specify nature of reaction: Primary Medical/Surgical Diagnosis/Reason for Hospitalization: Pathophysiology: Signs and Symptoms exhibited: Summary of current Treatment (nursing/ medical/surgical) include physician orders for the day: Significant Past Medical and Surgical History: January 2010 1 CLEW Component Safe and Competent Practice: Abnormal Pertinent Laboratory and Diagnostic Studies Test Normal Ranges Client Ranges Most Current Rationales for Abnormals (disease or medication related, include if improving) January 2010 2 CLEW Component Safe and Competent Practice: Medication Therapy Generic/Trade Name January 2010 Classification Rationale (Client/Pt. Specific) Usual and Route Actual Dose Admin Time Physiologic Action Only include onset, peak and duration if pertinent 3 Nursing Implications/ List top two Adverse Drug Reactions (ADRs) CLEW Component Safe and Competent Practice: Medication Therapy Generic/Trade Name January 2010 Classification Rationale (Client/Pt. Specific) Usual and Route Actual Dose Admin Time Physiologic Action Only include onset, peak and duration if pertinent 4 Nursing Implications/ List top two Adverse Drug Reactions (ADRs) CLEW Component: Critical Thinking Describe in the appropriate section: A) the physical characteristics specific to your client and their condition, include rationale B) Identify all the treatment modalities/interventions regarding clinical findings and diagnosis Neurosensory Motor / Sleep-Rest Respiratory - Activity Exercise Cardiac / Activity Exercise A) A) A) B) B) B) GU-Elimination / Sexuality - Reproductive A) A) A) B) B) B) Musculoskeletal GI – Nutritional / Metabolic Integumentary Endocrine – Activity Exercise Psych / Emotional A) A) A) B) B) B) January 2010 5 Pertinent Clinical Data/History Optimal Function Potential Complications Nursing Diagnosis Medical Diagnosis Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis S & S: S & S: S & S: S & S: Nursing Actions: Nursing Actions: Nursing Actions: Nursing Actions: Outcomes Outcomes Outcomes Outcomes January 2010 6 Reflection and Assessment of the Clinical Experience The core values within our program are critical thinking, safe and competent practice, caring, communication, holistic care and professionalism. Consider your experience in clinical this week and answer the following questions. 1. How did you demonstrate critical thinking within the nursing profession today? What was the most difficult part of the nursing process for you? What was the easiest and why? 2. What parts of the implementation of care showed safe competent practice today? Did you learn something new related to patient care…what? Is there anything you would do differently next week? 3. Caring as a professional can be challenging at times. How did you demonstrate empathy today? What difficulties did you have with caring in the clinical setting? January 2010 7 4. Communication is another important behavior in nursing. In providing care today, a. Who did you communicate with? Why? How? Was the communication effective? b. How did you communicate with your instructor to meet your learning needs and to deliver care? 5. How did you give holistic care today? Did you care for someone of a different culture who spoke another language or had never been in a hospital before? How did you plan to work with that client? Was your plan effective? 6. Professionalism reflects integrity, life long learning, legal, ethical principles, dress codes, timeliness, respect for peers, staff / faculty, joy within nursing and so much more. How do you see professionalism developing in you? Is it changing? How? January 2010 8 CT-CCNP Core Values and Sub Concepts 1. Core Value: Critical Thinking Subconcepts: (1) Nursing Process 2. Core Value: Safe and Competent Practice Subconcepts: (1) Evidence-Based Practice (2) Technological Competency (3) Application of Theory to Practice 3. Core Value: Caring Subconcepts: (1) Cultural Competency (2) Empathy (3) Respect for Human Dignity (4) Diversity (5) Advocacy 4. Core Value: Professionalism Subconcepts: (1) Legal-Ethical (2) Life-Long Learning (3) Integrity (4) Role Development (5) Confidentiality (6) Political Awareness (7) Collegiality 5. Core Value: Communication Subconcepts: (1) Teaching-Learning (2) Information Technology (3) Documentation (4) Therapeutic Communications 6. Core Value: Holistic Care Subconcepts: (1) Life Span (2) Wellness- Illness (3) Health Promotion, Maintenance, Restoration, Prevention (4) Spirituality (5) Community (6) Interdisciplinary January 2010 9