clinical focus: Emergency room

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STUDENTS CLINICAL FOCUS

Clinical Area: Emergency RoomAgency or Hospital: Mandaluyong City Medical Center

Area Description: The 2 weeks clinical exposure in the Emergency Room includes wide range of clinicallearning experiences on the care of patients with various health disorders, applying the nursing process, thecore of the nursing practice and application also of related skills learned during the previous years with theclinical Instructor and staffs supervision. Likewise, discussions will also be included which would mainly

revolve on diagnostic tests or procedures in relation to the organ systems involved to such cases in the area,the use of appropriate care plans and application of independent and as well as dependent interventions.Review on the medical and therapeutic concepts together with acquisition of current trends in the medicalfield will also be incorporated during the 8 hour shift together with the integration of holistic care and Christianconcern care to specific clientele/patient.

General Objectives: Within the two weeks of exposure in the Emergency Room, at least 95 % level ofperformance are expected to the students and be to carry out the following tasks:

1. Utilize appropriate knowledge, attitude and skills that the students learned in order to render rightand appropriate nursing care

2. Be oriented with the hospital policies, clinical set up as well as the medical staff and nonmedical personnel as well

3. Gain skills with accuracy in providing nursing care in areas such as:a. Admission care in the E.R.b. Assessment of medically ill patientsc. Accuracy in taking the vital signs and the need of continuous monitoring.d. Taking ECGe. Medication Administrationf. Placing NGT, Foley Catheter, Intubation etc..

g. Nebulizing and Suctioning4. Apply those nursing theories learned in the classroom at the clinical area

5. Promote and provide to their patients a competent, standard quality nursing care by ensuringthemselves the ethical standard in the nursing school and as prescribed in the nursing code.

6. To promote and adhere to the process specifically and correctly.

Week I

Day 1 (November 23, 2009)

TimeTable

Specific Activities Specific Objectives Evaluation

6:00AM

1. Checking of attendance, uniformsand paraphernalias.

2. Short prayer before beginning duty

3. Pre conference.

4. Listening to endorsement made by

outgoing staffs.

5. Group Orientation1. expectations2. requirements

At the end of the Shift, the studentwill gain and strengthen

confidence in performing differentnursing procedures with theapplication of the following:

1. Building and knowing theimportance of building rapport to

the patients

2. Giving due respect to the patientin all aspects.

3. Assessing correctly the conditionof the patient.

A short (action,reflection, feed

backing)evaluation bysharing whathas learnedespecially in

the emergency

room set up,personnel andbasic nursingprocedures.

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2:00PM

6. Orientation to the area:1. Ward set up, SOPs, policies2. Medical, surgical staff and other

professionals3. Equipments and Facilities

7. Students focus:a. distribution of taskb. triage nursingc. taking vital signs of the patientsd. reviewing list of medications to be

given.e. carrying out doctors orderf. giving oral / parenteral meds /

treatment and other proceduresg. arranging/ reviewing complete data

of the charts

h. nursing interventions> curative> educative> promotive> rehabilitative

8.30 mins. break for the 1st batch whilethe remaining students will takecharge in the area.

9. 30 mins. break for the 2nd batch whilethe 1st batch take charge.

10. Making of sample chartings.

11. Continuation of providing nursingcare.

12. Checking of individual charting.

13. Preparing for the endorsement toincoming shift.

--End of Duty --

4. Assessing and identifyingpresence of danger signs andreferring immediately ifnecessary.

5. Proper documentation of all

procedures done andobservations on the client.

6. Assisting subordinates and coworkers in the area in theexecution of nursing procedures.

7. Rendering health teachings in thearea.

8. Observing the basic rights of thepatients especially in givingmedications or performingprocedures.

Discussion onthe cases

encountered,

Problems andexperiences

during the firstday of duty.


TimeTable


6:00AM

1. Checking of attendance andparaphernalia.

2. Short prayer before the duty

Within the shift, the student willexpand their knowledge, recall

concepts and strengthenconfidence in performing the

following:

Pre Test: Amultiple choice

type quizregarding the

cases

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2:00

PM

3. Pre conference.

4. Listening to the endorsementsmade by outgoing staff

5. Initial rounds and assigningindividual assignments/tasks.

6. Triage Nursing

7. Taking initial V/S and generalassessment and charting.

8. Students focus:

a. admission proceduresb. carrying out doctors orderc. proper med. administrationc. giving oral / parenteral meds /

treatmentd. ECG, oxygen and IVF monitoring,

nebulization and surgicalprocedures

e. health teachings9. Making of sample chartings.

10. 30 mins. break for the 1st batchwhile the remaining students willtake charge in the area.

11. 30 mins. break for the 2nd batchwhile the 1st batch take charge.

12. Ward Class: Respiratory Disorder



15.Post conference: Pre-test.

16 Preparing for the endorsement toincoming shift

--End of Duty --

1. Building and express theimportance of building rapport tothe patients

2. Continue familiarizing with the E.R.

set up, SOP, policies, nursingpersonnel and other healthprofessionals

3. Assessing clients with respiratorydisorders and recognizing patientneeds and problems of the clientand referring immediately ifnecessary.

3. Proper documentation of allprocedures done and observations

for the management of client with

respiratory diseases.

4. Assisting subordinates and coworkers in the area to providetreatment.

5. Sharing of knowledge regardingthe case of the day.

6. Observing the basic rights of the

patients especially in givingmedications or performingprocedures.

7. Utilizes the existing chain ofcommand in implementingactivities.

encounteredin the area,importantdiagnosticprocedures

andpharmacologi-cal concepts.


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TimeTable


6:00AM

2:00PM

1. Checking of attendance andparaphernalia.

2. Pre conference

3. Short prayer before the start of duty

4. Listening to endorsement made byoutgoing staff

5. Assigning individual assignments.

6. Triage Nursing

7. Taking ofinitial V/S and generalassessment.

8. Students focus:a. admission proceduresb. carrying out doctors orderc. giving oral / parenteral meds /

treatmentd. discharge procedurese. health teaching

9. Making of sample charting.


11. 30 mins. break for the 2nd batchwhile the 1st batch take charge.

12. Ward class.



15. Preparing for the endorsement toincoming shift

--End of Duty --

During the shift, students will beable to do the following :

1. Doing appropriate assessmentespecially for patients withrespiratory disorders.

2. Gathers data using interview,observation, records review andreports.

3. Follows principles of timemanagement.

4. Accomplishes delegated taskswithin prescribed time frame.

5. Coordinates and collaborates withother members of the health teamand other administrative units in

theattainment of objectives.

6. Proper documentation of allprocedures done and

observationson the client.

7. Formulation of appropriate NCPsand health teachings in the area.

8. Drug recitation on the Drugsadministered on cases handled

inthe ward.

A multiplechoice type

quiz on the 3rd

day regardingrespiratorydiseases,importantdiagnostic

procedures inthe ward andpharmacologi-cal concepts.

Week 2Day 1 (November 30, 2009)

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TimeTable


6:00AM

2:00PM

1. Checking of attendance andparaphernalias

2. Short prayer before the start of duty

3. Brief pre conference and review onthe ward routines, procedures andpolicies

4. Listening to the endorsement fromthe outgoing staff.

5. Assigning individualresponsibilities.

7. Students focus:

a. admission proceduresb. taking vital signsc. carrying out doctors orderd. giving oral / parenteral meds /

treatmente. NGT administration, ECG taking

and I & O monitoring.f. health teaching



10. 30 mins. break for the 2nd batchwhile the 1st batch takes charge.


12. Ward class discussion.

13. Final checking of individualcharting.

14. Post conference and preparing for

the endorsement to incoming shift.

--End of Duty --

At the end of the shift, thestudents will recollect conceptslearned from the previous week

and will also demonstratecorrectly acquired learning such

as:

1. Proper assessment techniques.

2. Administration of prescribedmedication.

3. Performing drug recitation.

4. Proper carrying out of doctorsorders and documentation of all

procedures done andobservations

on the client.

5. Assisting subordinates and coworkers in the area in doing ttreatment and management care

toclients in the area.

6. Be enriched with current trends on

medical cases and updates onnursing issues.

7. Establishing NPI and observingpatient basic rights especially ingiving medications or performingprocedures.

8. Identifies specific and appropriatestrategies to attain objectives.

30 pointsindividual

defense. Thiswill be based

from thestudents

participation inthe group

discussion,relevance of

sharedconcepts

regarding thecase handled

and theindividuals

defense onthe nursing

procedure thathas beenrendered.

Day 2 (December 1, 2009)

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TimeTable


6:00AM

2:00

PM

1. Checking of attendance andparaphernalias.

2. Pre conference.

3. Short prayer before the duty starts.


5. Assigning individual assignmentsfor the day.

6. Taking initial V/S and generalassessment

8. Students focus:a. admission proceduresb. carrying out doctors orderc. giving oral / parenteral meds /

treatment.d. NGT administration, ECG taking

and I & O monitoring.e. health teaching



11. 30 mins. break for the 2nd

batchwhile the 1st batch takes charge.




15. Post conference and preparing forthe endorsement to incoming shift.

--End of Duty

Within the shift, students will beable to familiarize the following :

1. Performing the appropriate way in

taking ECG and administration ofoxygen its concepts and

indication.

2. How to study ECG tracings anddetermine some types of ECGabnormalities.

3. Continue formulating appropriateNCPs and rendering healthteachings.

4. Proper carrying out of doctorsorders and documentation of allprocedures done and

observationson the client.

5. Assisting subordinates and coworkers in the area in doing ttreatment and management careto clients in the area.

6. Be enriched with current trendson

medical cases and updates on

nursing issues.

7. Establishing NPI and observingpatient basic rights especially ingiving medications or performingprocedures.

8. Identifies specific and appropriate

strategies to attain objectives.

A multiplechoice typequiz on theregarding

heartdiseases,importantdiagnosticprocedures

(ECG reading,oxygenationtherapy andothers) in the

area andpharmacologi-cal concepts.

Day 3 (December 2, 2009)

TimeTable


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6:00AM

2:00

PM

1. Checking of attendance andparaphernalias.

2. Pre conference.

3. Short prayer before the duty starts.


5. Assigning individual assignmentsfor the day.

6. Taking initial V/S and generalassessment

8. Students focus:a. admission proceduresb. carrying out doctors order

c. giving oral / parenteral meds /treatment.

d. NGT administration, ECG takingand I & O monitoring.

e. health teaching



11. 30 mins. break for the 2nd batchwhile the 1st batch takes charge.




14. Post conference and preparing forthe endorsement to incoming shift.

--End of Duty

At the end of the shift, the studentshould be able to:

1. Utilize the nursing process in thecare of individuals.

2. Assesses with client/shis/her/theircondition/health status throughinterview, physical examination,

interpretation of laboratory findings

3. Identifies actual and at risk nursing

diagnosis

4. Plans appropriate nursinginterventions with client/s and

family for identified nursingdiagnosis.

5. Implements plan of care withclient/s and family.

6. Evaluates the progress ofhis/her/their clients condition adoutcomes of care.

7. Ensure a well organized andaccurate documentation system.

8. Relate with client/s and their family

and the health team appropriately.

9. Observed bioethical concepts/principles, core values, nursingstandard in the care of clients.

10. Promotes personal andprofessional growth of self andothers,

Post Test: Amultiple

choice typequiz regarding

the casesencountered

in the area,importantdiagnosticprocedures

rendered andpharmacologi-cal concepts

PRE TEST EXAMDirection: Choose the correct answer; Except for nos. 21-23 the question should be

rationalize.

1. Which of the following arteries primarily feeds the anterior wall of the heart?a. Circumflex artery

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b. Internal mammary arteryc. Left anterior descending arteryd. Right coronary artery

2. Which of the following is the most common symptom of myocardial infarction?a. Chest painb. Dyspneac. Edema

d. Palpitations3. Which of the following blood tests is most indicative of cardiac damage?

a. Lactate dehydrogenaseb. Complete blood countc. Troponin Id. Creatine kinase

4. After myocardial infarction, serum glucose levels and free fatty acids are both increase. What type ofphysiologic changes are these?a. Electrophysiologicb. Hematologicc. Mechanicald. Metabolic

5. Which of the following classes of medications protects the ischemic myocardium by blocking

catecholamines and sympathetic nerve stimulation?a. Beta-adrenergic blockersb. Calcium channel blockersc. Narcoticsd. Nitrates

6. Which of the following parameters should be checked before administering digoxin?a. Apical pulseb. Blood pressurec. Radial pulsed. Respiratory rate

7. Which oxygen delivery system would the nurse apply that would provide the highest concentrationsof oxygen to the client?A) Venturi maskB) Partial rebreather mask

C) Non-rebreather maskD) Simple face mask

8. A 57 year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be themost appropriate follow-up by the home care nurse?A) Ask the client if he has noticed any bleeding or dark stoolsB) Tell the client to call 911 and go to the emergency department immediatelyC) Schedule a repeat Hemoglobin and Hematocrit in 1 monthD) Tell the client to schedule an appointment with a hematologist

9. Following mitral valve replacement surgery a client develops PVCs. The health care provider ordersa bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IVsolution contains 2 grams of Lidocaine in 500 ccs of D5W. The infusion pump delivers 60microdrops/cc. What rate would deliver 4 mgm of Lidocaine/minute?A) 60 microdrops/minute

B) 20 microdrops/minuteC) 30 microdrops/minuteD) 40 microdrops/minute

10. A client is discharged following hospitalization for congestive heart failure. The nurse teaching thefamily suggests they encourage the client to rest frequently in which of the following positions?A) High Fowler'sB) SupineC) Left lateralD) Low Fowler's

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11. What is the first intervention for a client experiencing myocardial infarction?a. Administer morphineb. Administer oxygenc. Administer sublingual nitroglycerind. Obtain an electrocardiogram

12. What supplemental medication is most frequently ordered in conjuction with furosemide (Lasix)?a. Chloride

b. Digoxinc. Potassiumd. Sodium

13. Voluminous, watery stools can deplete fluids and electrolytes. The acid base imbalance that canoccur is:a. metabolic alkalosisb. metabolic acidosisc. respiratory acidosisd. respiratory alkalosis

Situation 9: Mr. Gerald Liu, 19 y/o, is being admitted to a hospital unit complaining of severe pain in the lowerabdomen. Admission vital signs reveal an oral temperature of 101.2 0F.

14. Which of the following would confirm a diagnosis of appendicitis?a. The pain is localized at a position halfway between the umbilicus and theright iliac crest.

b. Mr. Liu describes the pain as occurring 2 hours after eatingc. The pain subsides after eatingd. The pain is in the left lower quadrant

15. The doctor ordered for a complete blood count. After the test, Nurse Ray received the result from thelaboratory. Which laboratory values will confirm the diagnosis of appendicitis?a. RBC 5.5 x 106/mm3b. Hct 44 %c. WBC 13, 000/mm3d. Hgb 15 g/dL

16. What is the immediate home care management for diarrhea?a. Milk

b. Imodiumc. Waterd. Oresol

17. Aminophylline (Theophylline) is administered to a client with COPDs. Ms. Garcia administers themedication, knowing that the primary action of this medication is to:a. Promote expectorationb. Suppress the coughc. Relax smooth muscle of the bronchial airwayd. Prevent infection

18. Theophylline tablets are prescribed for a client with COPD. A nurse instructs the client about themedication. Which of the following nursing statements could not be a part of the teaching plan?a. Take the medication, on empty stomachb. Take the medication with food

c. Continue to take the medication even if you are feeling betterd. Periodic blood levels will need to be obtained19. A nurse is teaching a patient with chronic respiratory failure how to use a metered dose inhaler

correctly. The nurse instructs the patient to:a. Inhale to the noseb. Inhale quicklyc. Take 2 inhalations during 1 breathd. Hold the breath after inhalation

20. A patient with no history of respiratory disease is admitted with respiratory failure. A nurse assessesthe ABG report for which of the f following results that are consistent with this disorder

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a. PaO2 58 mm Hg, PaCO2 32 mm Hgb. PaO2 60 mm Hg, PaCO2 45 mm Hgc. PaO2 49 mm Hg, PaCO2 52 mm Hgd. PaO2 73 mm Hg, PaCO2 62 mm Hg

21 23. (3) Three points analytical question: A nurse is caring for a client who is receiving feedings vianasogastric tube. The client suddenly begins to vomit, and the nurse quickly places the client in a high

fowlers position. The client is coughing and having difficulty breathing and the nurse suspects that the clienthas aspirated the feeding. What is the nurses next action?

Suction the client. The client may be suffering from aspiration. The clients respiratory status wouldalso be monitored closely until respiratory pattern resumed.

24. An oxygen delivery system is prescribed to a client with a chronic airflow limitation [CAL] in order todeliver a precise oxygen concentration. Which of the following types of oxygen delivery systemswould the nurse anticipate to prescribe?a. Venturi maskb. Aerosol maskc. Face tentd. Tracheotomy collar

25. Which of the following is not true in implementing medical asepsisA. Wash hand before and after patient contactB. Keep soiled linens from touching the clothingsC. Shake the linens to remove dustD. Practice good hygiene

26. Where should you put a wet adult diaper?A. Green trashcanB. Black trashcanC. Orange trashcanD. Yellow trashcan

27. Which of the following if done by the nurse, is correct during NGT Insertion?A. Use an oil based lubricantB. Measure the amount of the tube to be inserted from the Tip of the nose, to the earlobe, to

the xiphoid processC. Soak the NGT in a basin of ice water to facilitate easy insertionD. Check the placement of the tube by introducing 10 cc of sterile water and auscultating forbubbling

sound

Situation Mr. Dizon, 84 years old, brought to the Emergency Room for complaint of hypertension, flushedface, severe headache, and nausea. You are doing the initial assessment of vital signs.

28. You are to measure the clients initial blood pressure reading by doing all of the following EXCEPT:A. Take the blood pressure reading on both arms for comparisonB. Listen to and identify the phases of Korotkoffs soundC. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated

D. Observe procedures for infection control

29. A pulse oximeter is attached to Mr. Dizons finger to:A. Determine if the clients hemoglobin level is low and if he needs blood transfusionB. Check level of clients tissue perfusionC. Measure the efficacy of the clients anti-hypertensive medicationsD. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

30. Discharge plans of diabetic clients include injection site rotation. You should emphasize that thespace between sites should be:A. 6.0 cm.B. 5.0 cm.

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C. 2.5 cm.D. 4.0 cm.

24. Which of the ff. colors would you expect a tank containing nitrous oxide (laughing gas) to have,based on the universally-accepted color codes?A. RedB. BlueC. Green

D. Orange24. From an ECG reading, a QRS Complex represents:A. Atrial depolarizationB. Ventricular repolarizationC. Ventricular depolarizationD. End of ventricular depolarization

25. When injecting subcutaneous injection in an obese patient, It should be angled at around:A. 45 B. 90 C. 180 D. Parallel to the skin

26. The following statements are all true about Z-Track technique except:A. Z track injection prevent irritation of the subcutaneous tissuesB. The technique involve creating a Zig Zag like pattern of medicationC. It forces the medication to be contained at the subcutaneous tissuesD. It is used when administering Parenteral Iron

27. Communication is best undertaken if barriers are first removed. Considering this statement, which ofthe following is considered as deterrent factor in communication?A. Not universally accepted abbreviationsB. Wrong GrammarC. Poor PenmanshipD. Old age of the client

RIZAL TECHNOLOGICAL UNIVERSITYCOLLEGE OF NURSING

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STUDENT CLINICAL FOCUS

(EMERGENCY ROOM)

Ncm 105 - RLE

Prepared by:

MACABALLUG, NICOLAI R.MANUBAY, JANUS ANGELO N.

Submitted to:

Prof. Ramel B. Espares RN, MANClinical Instructor

CLASS 2010

12

clinical focus: Emergency room

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