WEEK 10 CLINICAL PAPERWORK FOR 209 1

Week 10 Clinical Paperwork for 209

Morgan Metzger

Aultman College of Nursing and Health Sciences

WEEK 10 CLINICAL PAPERWORK FOR 209 2

Week 10 Clinical Paperwork for 209

In clinical this week, I learned that simply talking with the patient and listening to them

allows for them to feel more comfortable. I have heard many professors mention this throughout

their lectures, and today, I was able to experience that myself. My patient and I talked about his

family, today for about 15 minutes before starting my assessment. He was also asking me

questions pertaining to being a student nurse. I felt that after this conversation, he felt more

comfortable with me performing my head to toe assessment on him. He seemed calmer

throughout the assessment. In addition, I made sure to employ therapeutic communication in

order to allow the patient to know exactly what I would be doing.

Today, our weekly concepts included health promotion, clinical judgement, safety,

mobility and functional ability, elimination, fluid and electrolytes, perfusion, gas exchange,

thermoregulation, and our new concepts infection and isolation. I utilized health promotion by

educating the patient on the signs and symptoms of blood loss such as dizziness and

lightheadedness to name a few. In addition, I educated the patient on call light use. I observed

clinical judgement when the patients nurse asked me to evaluate the patients stools and report

them back to her so that she was able to use interventions in order to maintain the bleeding so

that it does not get worse. I utilized safety throughout the day by performing safety checks. In

addition, I also made sure to utilize the 5 universal precautions. I was unable to observe the

patient’s mobility. However, he was able to independently ambulate to the bathroom and back to

his bed. His functional ability was independent as he was independent at home and in the

hospital when ambulating. As for elimination, I made sure complete a thorough abdominal

assessment through inspection, auscultation, and palpating. I made sure to ask elimination

questions as this was an important concept due to the patient’s reason for seeking care. I made

sure to keep the patients’ “hats” in the toilet empty, making sure to measure the elimination. As
WEEK 10 CLINICAL PAPERWORK FOR 209 3

for fluid and electrolytes, I made sure to calculate intake and output throughout the day and

observe lab values and weight. I checked perfusion by assessing for any edema, as well as

observing SCD’s and checking his peripheral pulses. For gas exchange, the patient was on room

air. The patient did not have any thermoregulation issues that I noted.

As for our new concepts of infection and isolation, I was able to observe the donning of

personal protective equipment (PPE) before the nurse entered the room. First, she donned a

gown, she had already had the face mask and goggles on for COVID precautions, and finally she

donned gloves after performing hand hygiene. The isolation was contact isolation, so the nurse

certainly needed gloves and a gown. I feel that the mask and goggles were also important to wear

to ensure safety.

This week, I thought it worked well communicating with the patient’s nurse throughout

the day frequently. We communicated about the patient and his elimination processes, as she

wanted to keep a close eye on them. I felt that it was a little difficult to know what to educate the

patient on at first as the healthcare professionals were usure of what was causing the bleeding

until they were able to take a closer look the following day. After talking with Mrs. Groubert, she

was able to assist me with the type of education to give this patient, which was very helpful.

No adverse events of issues happened throughout the day. I felt that there were no

concerning events that had occurred.

I did not witness any healthcare workers not utilize hand hygiene before entering or after

leaving a room.