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11/2/2014 3:42 PM
Troy Davis
Clinical Journal #1
Shift 10/17/2014

PRIORITIZATION:

Priorities- Patient 1- XX 65, Dx acute CHF/ chronic hypoxia, Foley in place, cardiac diet/ strict fluid
restriction, Lasix drip, 3+ edema in legs with a nonproductive cough, sinus tach Hx of ETOH and
antifreeze consumption. BUN 25 and Creat 3.37
Patient 2- XX 97, Dx TIA, echo 55, NS 100ml/hr, q4 Neuro, sinus brady PVC, negative MRI, came in
with slurred speech, DNR/DNI
Patient 3-XX 63, Dx DVT, assist, normal labs, regular diet, elevated glucose 235

Revised Priorities- New admit XX 73, Dx PE, with a Hx of leukemia and arthritis, full code, heparin
drip, check labs for therapeutic level and titrate accordingly initial assessment allergy to latex, then
Pt 1 because of Lasix drip, we pulled off 4 liters of fluid, check electrolytes. Pt 2 for nuro checks. Pt 3


LONG TERM GOAL:

Caring: Demonstrate caring behaviors that incorporate client and family advocacy; respect for persons and
cultural diversity; and ethical principles.


SHORT TERM GOALS:

Establishes and maintains relationships of trust with clients and colleagues I was able to develop a trusting
relationship with the nurses I was working alongside. I was able to build trust with patients by promptly
responding to call lights and taking care of what ever I could for them while I was in there.

Demonstrates interest in clients and client care by giving individualized, quality, nursing care to complex,
difficult clients, and in resolving difficult problems/situations I was able to accomplish this task by staying
mobile and prioritizing care. I took advantage of down time and made hourly checks. We were able to cluster
care since it was a night shift, that way they could get rest. We were able to evaluate their care and the
interventions we preformed.


OUTCOME:

All of our patients were stable throughout the night with out incidence. We were able to stay on task and keep
up with assessments, meds, neuro checks, and patient education. Pt safety was a priority, beds were in the
lowest position, bed rails up, alarms in place.


THINGS THAT WENT ACCORIDNG TO PLAN:

Everything went according to plan. I was able to get reoriented to the floor and how to navigate though the
charting.




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11/2/2014 3:42 PM
THINGS I WOULD CHANGE IF I WAS ABLE TO DO A DO OVER AND WHY:

I dont have anything that I would change. We worked a night shift even though my preceptor works days. I
would have tried harder to prepare for a night shift if I had more time. Everything was ok because Im use to
long shifts and working into the night.


CHALLENING:

This was my first precepting shift, so of course I was nervous. I think just getting back into the grove of things
was a little nerve racking. Working a night shift with my nurse was great because we could get to know one
another after the evening rush.


LEARNING THAT TOOK PLACE DURING MY SHIFT:

I had learned that you can really stand out if you are productive when it is slow and jump in to help where ever
possible. I was refreshed on how to chart in the computer.


SKILLS PERFORMED:

Patient assessments, Blood sugar checks, Insulin, Set up pumps, Replaced fluids, Heparin drip


Instructor _____Phyllis Swift_____________ Date____________________ Points_________