Clinical Check List: Day 1 N345 UCSF Acute Clinical Peds Rotation Fall, 2003

Day 1 is reserved mostly for observation of the RN you are matched with for the day to see how she/he organizes her/his day. It is important to get a sense of how the day is organized and how that schedule might change based on the circumstances of each patient’s situation and condition. I would like you to use the clinical organization tool on this day to make a plan for one of the patients’ care for the day, and then see how the day goes according to the original plan. Once again this day is mostly for observation, but you may assist the RN in tasks she/he deems appropriate and as indicated below. Medications may only be given under direct supervision of the RN or clinical instructor and should be preceded by the usual tasks of looking up medications to be given, doing drug calculations to assure accurate dosing, completing the five 'rights' of medication administration and also by observing the RN as she/he gives medications first.

  1. Orientation to the unit. Where is the:

    Linen closet Clean and dirty utility Supply room r Report room

    Medication room Charting area Cafeteria Break room

    How are the patient rooms organized?

  2. How and where do I:

    Receive and give report. What is the unit policy for reporting shift to shift.

    Access supplies. Access medications (with RN guidance only). Stock meds, IV meds, PIXIS.

    Look up medications. What resources are available to do this?

    How does the patient call light system work? Very important! Access chart and lab/test results for review

  3. Observations and activities: i.e. you will mostly observe the RN in these activities on Day 1, but may participate under direct RN/instructor supervision as appropriate:

    RN Report Documentation. Get to know the flow sheets and how to document:

    Frequency of VS Intake/Output Initial assessments AM care

    What is charting by exception and how is it used at UC? What is a critical element of this type of charting method???

    Administering Medications, PO, PR, IV, IM Physical, respiratory and play therapy Treatments and procedures

  4. Other experiences to take note of in your observations:

    MD rounds Respiratory treatments Physical Therapy by PT On or off unit studies or tests ordered (CXR, Ultrasound, CT scan, MRI, other)

  5. Assignments to be turned in:

Patient data record and care plan for one patient followed this day.

Care plans should reflect the most relevant 2 or 3 problems identified for this client on this day. I want to see that you are prioritizing your problem focus, so briefly give the rational for why you chose each problem as a priority for this patient on this day in your care plan.