cheif complaint clinicals 2015

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Carrington College
NUR 261
Patient Centered Care

Chief Complaint Worksheet
Student Name ________Carol Hand______ Date ___1/5/15________Unit ___Med-Surg_________

COURSE OUTCOMES ADDRESSED:
1. Administer patient-centered nursing care combining previous knowledge with current knowledge. 4. Operate within systems of care and care processes to affect outcomes for patients and families. 5. Create a culture of safety in own nursing practice.

CONCEPTS (see Concept definitions):
Individual Domain: as appropriate to individual patients.
Nursing Domain: Assessment, Caring interventions, Clinical Decision Making, Collaboration, Communication, Teaching, Patient-centered care, Safety. Healthcare Domain: Advocacy, Educator, Health, Managing Care, Evidence-Based Practice.

Assignment Description: Learning to associate symptoms and complaints with disease processes helps the nurse clinician hone assessment skills and provide better care to patients.

Assignment Directions: Complete the following table on two patients.

Reflections on the Chief Complaint Worksheet:

As a result of this activity, I have learned how to:

I have learned how to properly assess my patients by doing specific system assessments based on their diagnosis. I have also learned how to ask questions in order to further investigate the patient’s problem and what could be happening as a result.

This activity shows that I have more to learn about:

I have more to learn about what interventions should be prioritized and how to incorporate all interventions as well as medications more efficiently.

This activity shows my growth because:

This activity shows my growth because I was able to figure out the different needs of my patients and what to teach them while they are in my care. This activity helped me because I was also able to formulate teaching plans for when my patients become discharged. I believe this is important because teaching patients is my responsibility as a nurse and I want to be able to reach out to my patients and make sure they go home with all the tools they need to improve their health.

Chief Complaint Worksheet Grading Rubric

Description
Points
Percentage
Points
Earned
Comments
Accurately obtains information on two patients
16/40%

Completes assessments and answers questions regarding emergency department visit 16/40%

Completes reflections on tool
8/20%

Total
40/100%

1.Indicate Patient Age, Gender, Final Diagnosis
Patient One
Patient Two
59 year old male with Hep C, cirrhosis, polysubstance abuse, and enterocolitis.

44 year old male with sepsis secondary to pleural effusion, TB in lungs.

2.What was the “chief complaint” that prompted the patient to seek medical attention? Patient One

Patient was found on the ground lying in his own stool.

Patient Two

Severe chest pain (pleuritic pain) radiating to back on deep inspiration.

3.What signs and symptoms were noted on arrival at the hospital? Patient One

Anxiety, fever, chills, abdominal pain, back pain, nausea, and confusion.

Patient Two

Vomiting, chest pain, fever, fatigue, and weakness.

4.What diagnostic tests were completed relative to these signs and symptoms? Why were they ordered? Patient One

CBC with diff. for infection, drug screen for current use of substance, liver tests for symptoms of cirrhosis, CT of pelvis and abdomen with contrast for symptoms of pain.

Patient Two

Chest CT with contrast for chest pain (lung pain) and CBC with diff. for infection.

5.What medical treatments/interventions were implemented to treat these signs and symptoms (include medications)? Patient One

Flagyl, Xanax, Morphine, Levofloxacin, Zofran.

Patient Two

Insulin for diabetes, Metoclopramide, Isonazid, Moxifloxacin, rifampin, Lisinopril, Potassium Chloride.

6.What nursing interventions were implemented to treat these signs and symptoms? Why were these...
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