LEVEL 2 CLINICAL GUIDELINES LONG TERM CARE CLINICAL

***These guidelines are considered a clinical tool and you must have these with you at clinical at all times. If you do not understand or have questions about these guidelines, ask your instructor prior to clinical to avoid showing up to clinical

unprepared.***

CLINICAL IS WHERE YOU LEARN TO PROVIDE BEDSIDE NURSING CARE. USE THE NURSING PROCESS TO MAKE CLINICAL DECISIONS THAT WILL HELP TO DECREASE OR RESOLVE PATIENT PROBLEMS. ANTICIPATE AND MEET THE NEEDS OF YOUR PATIENT. In Level 2, you will rotate through various clinical sites such as Long Term Care settings (Nursing Homes), & Clinics (Culture of Life Ministry). Each site will expose you to different areas of Nursing in hopes that you will gain a broad spectrum of knowledge and experience as you rotate through the different clinical sites. LONG TERM CARE SETTING (Nursing Home):

****It is required that you carry a Blank Case Study with you at all times in the event that your patient is discharged or transferred to another facility, at which point your new assignment will be at the instructors discretion. The Case Study of your discharged or transferred patient is due at the time of discharge/transfer. Regardless of when the forms are due, you must have all required forms (2 Case Studies; the one you are using for your patient and a clean/blank one) in your possession at the start of clinical. Failure to have a blank case study on hand means you are unprepared for clinical and you may be sent home and absence hours accrued. ****

In the Long Term Care setting (Nursing Home), you will work in pairs and a patient will be assigned to you. You will work with the same patient and the same partner for the clinical week.

Although you will be working in pairs, each person will be responsible for their own work (data collection, decision making, interventions and evaluations). Be able to answer for yourself.

Data collect from the medical record (Prior to patient assessment and Nursing Care): You will need to collect data from the chart regarding your patient. Data will be used for face sheet, med cards, action plans, and skills needed to perform (wound care, IV therapy, PEG feedings, NG insertions/DC, & etc.). When reviewing the medical record, be sure to look for pertinent data:

Case Study Face Sheet; fill out completely, should be complete before the end of the day on the first day of clinical. (DNR/Full Code, Precautions, & etc.)

Diet: PO or PEG (PO: Use of Thickeners, Consistency of liquids and solids, & etc.) If PEG include Formula, Pump & Rate or Bolus; don’t forget water flushes)

Oxygen use: be sure to include rate of oxygen flow and oxygen delivery device, & etc.

Tubes/Drains: (devices if applicable and device settings)

Side rail use and or other protective devices (safety devices) Communicate with the primary nurse for a verbal report prior to assessment and bedside nursing care. Anticipate the needs of your patient: PREPARE; what skills (that have been tested and successfully completed by you the student) does your patient offer? Make sure you refresh on those skills and be prepared to perform those skills. Your instructor will ask you questions about the skill to be performed, failure to answer appropriately will be considered as being unprepared for clinical and you will not be allowed to perform the skill on that day. This will also reflect on your clinical evaluation. Preparedness is the key to success, so strive to be prepared everyday for every scenario.

BEDSIDE NURSING CARE: a plan must always be developed for the duration of the clinical (shift). The plan is probably never 100% executed without interruptions. When the plan is interrupted due to reprioritization, take care of the problem, and as soon as you are able to, return to the plan. If patient is not in proper alignment, correct immediately prior to starting assessment.

Initially you will go into the patients room and make an initial observation of the patient and Perform an “Initial Assessment”. Assess vital signs, and Document your findings. Report the Initial Assessment/Initial observation to instructor. REPORT ANY AND ALL ABNORMALITIES regardless of how small you may think the abnormality is.

If V/S are stable, 2 complete sets of vital signs will be taken by you during the clinical.

If V/S are not stable, report the abnormal readings to your instructor and primary nurse. Increase the frequency of vital sign assessment. Your instructor and primary nurse can help you decide how often they should be monitored. Continue to report abnormal vitals to Instructor and Primary Nurse.

Your patient should have a pitcher of fresh water at bedside, with or without ice, according to patients preference. (monitor for NPO status, thickened liquids, and fluid restrictions). Otherwise encourage fluid intake.

Prevention of aspiration on ALL patients.

Monitor and document I&O on all patients.

Patient should be neat and tidy. Clean face and hands Hair Combed Clean perineal area; incontinent care after each incontinent episode Fresh gown/Fresh incontinent brief/Fresh linen

Patients room should be neat and tidy which promotes a safe environment.

Patients need to be turned and repositioned at least every 2 hours and more frequently. Whether it is self turning or with your assistance. Keep in mind Braden Scale Score and how to prevent pressure ulcers.

Prevention of fluid collection in the lungs. (Deep breathing and movement) The following instructions are applicable throughout your Level 2 Clinical. Advancement will occur throughout Level 2; Instructions will be posted on your Clinical Quia page or sent via email as advancement occurs. CASE STUDY: Nurses notes and any forms not completed at the clinical site, is to be completed as homework. Case studies will be reviewed for completion on Day 2, at the start of clinical. Incomplete work (forms, Nurses Notes, etc.) will result in being sent home from the clinical and absence hours being accrued. White Out is not allowed on any clinical paperwork/forms.

Face Sheet (only one per patient): is to be filled out in its’ entirety by the end of day one of Clinical (prior to leaving facility for the day.) including rationales for the risk factors. Example: at risk for bleeding due to patient taking Coumadin Example: at risk for aspiration due to dysphagia, GERD

Initial Assessment (one for each clinical day): due promptly as it is completed, it must be reported to your instructor (any & all abnormals should also be reported to Primary Nurse). Once you have reported the initial assessment to your instructor and/or Primary Nurse, you will perform an Initial observation which will be documented in your Nurses Notes. (List ALL Dressings on this Initial Assessment sheet. Example: pegsite dressing, trach dressing, wound dressing and etc.)

System Disorder: is based on your patients Primary Medical Diagnosis. You can use your MedSurg Book, ATI MedSurg Book, or Credible Online Resources. Identify the resource used at the bottom of the page. Due On Day 2 at the Start of Clinical.

Medication List: must complete by listing all of your assigned patients medications, including PRN medications. Ensure all boxes/columns are filled out completely. Due On Day 2 at the Start of Clinical. If there is a current order for a medication, it must be listed.

Maslows Cluster Sheet: As you assess your patient, you will list your patient problems under the column in which it falls under. This will help you find your patients priority problem for your Action Plan. Should be completed by end of day on day one of clinical prior to leaving facility for the day.

Action Plan: action plans consist of Priority Patient Problem (highest priority problem) (YOU ABSOLUTELY CANNOT USE MEDICAL DIAGNOSIS, you are not a doctor, but you may use Nanda Approved Nursing Diagnosis for Patient Priority Problem). Action Plan Consists of Patient Priority Problem,Desired Outcome/Goal, Focused assessments, Interventions to assist patient towards desired outcome, and Evaluation of the progress towards desired outcomes. ALL sections of the action plan except for the evaluation of progress will be Due On Day 2 at the Start of Clinical. The evaluation will be due at end of day 2, prior to leaving facility for the day.

Braden Scale: assess daily. Must be completed by end of each clinical day prior to leaving facility for the day.

Fall Risk Assessment: assess on day one of clinical. Must be completed by end of day, on day one of clinical prior to leaving facility for the day. Reassess on day two and if changes need to be made then a new fall risk assessment sheet is done and turned in at the end of day two of clinical. If there are no changes, then only one Fall Risk Assessment per Clinical Week is required.

Nurses Notes – document in present terms (as if it is happening as you are writing), refrain from documenting in past tense (was, had). document only what pertains to your patient. Remember Nurses Notes are part of your patients medical record. Leave out conversations with CNAs, your breaks, or the décor in the room. Document your Initial Assessment/Observation, Head to Toe, the care you provide (Skills, procedures, problems encountered, interventions performed, evaluations of the interventions you performed & etc.). (Nurses notes must be documented on blank Nurses Notes only (no blank white sheets of paper or notebook paper). Print as many as you feel you will need for each day and always have extra in case you need them.): due at the end of each clinical day prior to leaving the facility for the day. Any and all care that you provide for your patient and your Head-to-Toe Assessment will be documented in a narrative nurses note as the care is provided. Avoid using terms that could be interpreted as uncertainty. (Example: bluish, pink “ish”, looks like and etc.) Make the necessary assessments to be sure and certain of your documentation. Also, you want to avoid making assumptions. (Example: patient asleep, resting comfortably) Never assume! Document only facts! Your opinions should not be part of your patients’ medical record. Document what you see, feel, hear, smell! (Example: patient resting quietly, eyes closed, supine in bed in a low fowlers position, respirations regular and unlabored, skin pink, warm to touch).When continuing your documentation on to a second page, be sure to leave a space on page one for your signature with credentials. On page two, be sure to note the date and time the note was started, and just continue with your documentation where you left off. The end of every note entry must be accompanied by your legible signature and credentials. At the very bottom of the note there is a box with space provided for your initials, legible signature and credentials. See example below:

JH JaNene Hoover SVN/VGI SBAR Report (2 for each clinical day) (End of shift reports): due at the end of each clinical day prior

to leaving the facility for the day. (List ONLY Wound Dressings on the SBAR Report sheet. Example: Stage 2 with duoderm to coccyx, Left Hip with Mepilex dressing, Abdominal wound with 4x4 dressing, and etc.) You are to fill out End of Shift report (two each day – one to keep in your case study and one to leave with your clinical instructor after giving report) and be prepared to give a

full report on your patient using SBAR. (Situation, Background, Assessment, Recommendation). Due at end of day each day.

CULTURE OF LIFE MINISTRY CLINIC (2 Page Case Study): Students assigned to Culture of Life Ministry Clinic will use the Culture of Life Ministry Nursing Case Study. Student must have case study in their possession at the start of day one of clinical. On day 2, at the start of clinical, case study should be 50% completed. Case study must be 100% completed by the end of clinical on day 2. Only 1 case study will be turned in per week. OPERATION COVID SHIELD: At this time there is no case study for students assigned to Operation Covid Shield. This may be subject to change, you will be notified of any changes.

***All Case Studies will be turned in to Instructor for grading at the end of day 2 Clinical. No extra time will be given.***

***ALL STUDENTS, REGARDLESS OF CLINICAL SITE ASSIGNED, ARE REQUIRED TO TURN IN 2 MEDICATION CARDS PER WEEK, ON DAY ONE OF CLINICAL, AT THE START OF CLINICAL. ADVANCEMENT WILL OCCUR AT CLINICAL INSTRUCTORS DISCRETION. The Instructors will slowly advance the number of medication cards due every week until a maximum of 5 medcards will be due every week. Instructions will be posted on your Clinical Quia page or sent via email as advancement occurs.*** MEDICATION CARDS: All Medication cards must be hand written, clear and legible, in easily visible Blue or Black ink. No Colored ink allowed. Typed Medication Cards Will Not be accepted. Before you start writing your medication card, make sure that the paper you will be writing on is intact, and has all its’ edges otherwise, the medication card will not be accepted. No White Out will be allowed on any clinical paperwork including MedCards! No Staples On MedCards.

2 - Medication Cards will be due every week on day one of clinical at the start of clinical. In the event you are absent on day one of clinical, your medication cards will be due on the first day you arrive back from being absent. ADVANCEMENT WILL OCCUR AT CLINICAL INSTRUCTORS DISCRETION. The Instructors will slowly advance the number of medication cards due every week until a maximum of 5 medcards will be due every week. Instructions will be posted on your Clinical Quia page or sent via email as advancement occurs.

Be sure to include Black Box if the drug has a black box.

Identify Brand & Generic. Remember, drugs with the Canadian (Maple) leaf are only found/distributed/sold in Canada. When looking for a brand name, use only drugs which do not have this leaf next to them.

Interactions: Please Include Drugs, Food, Herbal and Labs.

Please Remember: *Once you have signed in at the clinical site, you are not allowed to leave the clinical facility at any time for any reason unless you have signed out for the day or you have permission from your clinical instructor due to instructions from administration. Once you sign out and leave the Clinical for the day, you are not allowed to return for any remaining clinical hours on that day. *Leaving post conference to obtain grades or assignments for another course (or any other reason other than to use the bathroom) will be considered as abandoning your assignment. Students caught leaving the classroom during post conference to obtain grades or assignments for another course will be sent home and absence hours accrued. Keep in mind that the Board of Nursing considers patient/assignment abandonment to be a very serious offense with a consequence of licensure revocation. Valley Grande Institute agrees with the Board of Nursing

which is why your student handbook states that patient/assignment abandonment could result in termination from the VN Program. *”You are Always Responsible for how you act regardless of how you feel.” *”I’m not here to be average I’m here to be Awesome!” *”You are not studying to pass an exam. You are studying for the day when you are the only thing between your patient and the grave.”