2 of 52 Table of Contents Course Outline... 4 Process... 4 Learning Outcomes... 4 Overview of Concepts... 5 Required Texts... 5 Resources 6 Evaluation

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1 BSN Program Nursing 3145: Family Practice Experience Section 1 and 2 Educators: Maternal-Newborn & Family Sandy Atwal Surrey Memorial Janita Sidhu Surrey Memorial (part A) Nancy Woo BC Women s Anne-Marie Hummelman Burnaby Hospital Hana Pecinova Richmond Hospital Educators: Infant, Child, Youth & Family Lysbeth Cunada Royal Columbian Hospital 3C Baljit KhunKhun BC Children s Hospital 3M Sabrina Chahal BC Children s Hospital 3R Mary Peters BC Children s Hospital 3F Rozana Lee Surrey Memorial (part B) [201120]

2 2 of 52 Table of Contents Course Outline... 4 Process... 4 Learning Outcomes... 4 Overview of Concepts... 5 Required Texts... 5 Resources 6 Evaluation... 7 Assignments... 8 Professional Responsibilities... 8 Schedule... 9 Appendix A: Maternal-Newborn Orientation Schedule Appendix B: Maternal-Newborn Assignment Schedule Appendix C: Infant, Child Orientation Schedule Appendix D: Infant, Child Assignment Schedule 16 Appendix E: Infant, Child Medication Packet 18 Appendix F: Decision-Making for Nursing Practice Framework 40 Appendix G: Clinical Practice Assignment Guidelines 44 Appendix H: Journal/Reflective Writing Guidelines. 47 Appendix I: Performance Appraisal Form.. 49 e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

3 3 of 52 Other things may change us but we start and end with family Anthony Brandt e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

4 COURSE OUTLINE 4 of 52 This course is a practice-based course that includes two distinct parts namely, the Maternal-Newborn and Family Practice Experience (perinatal) and the Infant, Children, Youth and Family Experience Practice (pediatrics). The learners in this course have the opportunity to practice family-centered care nursing, with emphasis on health promotion and illness prevention at the primary, secondary and tertiary levels. Building on previously learned concepts, learners are expected to apply evidence-based theories and concepts unique to the care of perinatal and pediatric populations in selected tertiary health care settings. PROCESS Nursing 3145 is delivered over two days, 15 hours per week for 12 weeks in selected practice settings. The students are assigned to practice for 6 weeks in a perinatal care setting and the other 6 weeks in a pediatric care setting. This course aims to provide the students with opportunities to practice perinatal and pediatric nursing to complement the concurrent theory classes of N3115 and N Students also engage in praxis, which involves the examination of the dynamic interplay between perinatal/pediatric theories and the lived experiences of assigned clients and those of the students themselves. Practice experiences are supported by seminars and other group learning activities to enhance criticalthinking and reflection on the students lived experiences of caring for perinatal and pediatric clients. Students and educators foster collaborative learning while in practice. SEMINAR OR CLINICAL PRACTICE CANCELLATION The nursing department makes every effort to replace a nurse educator when he or she is unable to attend a class or clinical practice. If a nurse educator needs to cancel a class or a clinical practice day, for whatever the reason, information regarding the class cancellation will be posted on Blackboard CE 6 as well as at the Registrar's Office (B-Building). As for the cancellation of clinical practice, individual nurse educators will inform his or her students of how cancellation will be conveyed during orientation week. It is important then to log on to Blackboard the day of class and of clinical practice. LEARNING OUTCOMES Students have the opportunity to: e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

5 5 of 52 Utilize a decision-making framework (DMNPF) in the care of perinatal and pediatric clients. Apply knowledge and skills unique to the care of perinatal and pediatric client populations. Apply principles of prevention and health promotion. Incorporate relevant knowledge of nursing and other sciences (e.g. anatomy/physiology; pharmacology, psychology, sociology) Develop, implement and evaluate health teaching to individuals and groups using relevant teaching-learning theories and principles. Collaborate with clients, health-care professionals, and peers. Access necessary resources within the clinical area and the community. Apply evidence-based knowledge in practice and in critique of health issues and current practice. Utilize pertinent standards of care and care protocols. Engage as an active participant and learner in the practice setting. Demonstrate and emulate the values of the e Department of Nursing OVERVIEW OF CONCEPTS The organization of this course is around the philosophical foundations of the curriculum and reflects the following concepts: Natural sciences (e.g. pharmacology, pathophysiology) Evidence-based practice Health promotion and Prevention (primary, secondary, and tertiary) Family, agency and community as resources Family as context/culture Ethical issues Teaching/learning challenges Decision-making for nursing practice Growth and development REQUIRED TEXTS (Pediatric Nursing) Hockenberry, M. J. and Wilson, D. (2007). Wong s nursing care of infants and children. (8 th ed.). St. Louis, Missouri: Mosby. (Perinatal Nursing) Ricci, S. S. (2009). Essentials of maternity, newborn, and women s health e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

6 nursing. (2 nd ed.). Philadelphia: Lippincott Williams & Wilkins. RESOURCES Nurse Educators responsible for this course: Sandy Atwal RN,BSN, MN Office: C316a (604) Office hours:monday (by appt) Surrey Memorial Hospital Janita Sidhu Office: Office hours: Surrey Memorial Mary Peters RN, BSN Office: 153A (604) Office hours: BC Children s Hospital (3F) Educator: Rozana Lee Office: (604) 323- rlee@langara.bc.ca Office Hours: Surrey Memorial Hospital Anne-Marie Hummelman RN,BSN,MN Office: C317b (604) amhummelman@langara.bc.ca Office hours: Burnaby General Hospital Nancy Woo RN, BSN, MEd Office: nwoo@langara.bc.ca Office hours: BC Women s Hospital Sabrina Chahal Office: (604) 323- schahal@langara.bc.ca Office hours: BC Children s Hospital (3R) 6 of 52 Hana Pecinova RN, MN Office: B147b (604) hpecinova@langara.bc.ca office hours: Richmond General; Lysbeth Cunada RN, BSN, MN Office: B148m (604) lcunada@langara.bc.ca office hours: Royal Columbian Hospital Bal KhunKhun Office: (604) 323- bkhunkhun@langara.bc.ca Office hours: BC Children s Hospital 3M Resources include required texts from previous terms and also: On-Line Canadian Nurses Association. (2008). Code of ethics. Ottawa: Author. College of Registered Nurses of British Columbia. (2008). Professional practice requirements. Vancouver, BC: Author. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

7 7 of 52 e Nursing Department. (2010). BSN handbook. Vancouver, BC: Author. e Nursing Department, (2008), Proficiency tracking tool. Vancouver, BC: Author. e Nursing Department. (2008). Term 6 Performance Appraisal Form. Vancouver, BC: Author. The Writing Centre, located on the second floor of the e Library. EVALUATION In order to receive a satisfactory (S) grade in Nursing 3145, students must complete and submit all clinical practice assignments. As per College policy, a failing or unsatisfactory (U) grade will be given if a student does not complete all of the course requirements. In addition to the assignments, a student must demonstrate satisfactory performance in all practice domains (see Practice Performance Appraisal Form, Appendix: I), by the Final Evaluation period. Nursing 3145 is comprised of two distinct clinical practice components including Maternal, Newborn and Family Experience (Perinatal) and Infant, Child, Youth and Family Experience (Pediatrics). All students will spend half of the total allocated time for the course in a Perinatal placement area and the other half in a Pediatric placement area. Each student will receive a performance evaluation at the end of both Perinatal and Pediatric clinical experiences. A student s performance evaluation of his/her first half of the clinical experience is the Midterm Evaluation ; and evaluation of the second half is the Final Evaluation. Students are required to achieve a minimum 65% or satisfactory (S) grade in each component to achieve Satisfactory (S) grade, for nursing Satisfactory standing is required in all the domains of practice within the Performance Appraisal Form. In the event that a student receives an Unsatisfactory Midterm Evaluation, the student and educator(s) will plan for ways to enhance learning in the second clinical period (eg.: Learning Contract). The final grade of a student will be the grade he/she obtains during the Final Evaluation. If the student does not demonstrate a satisfactory improvement by the final evaluation period, he/she will receive an unsatisfactory (U) grade. According to Nursing Department policy, 65% or a C+ or S grade is the minimum grade requirement for successful completion of all nursing courses. The grading scale for the Nursing Department is as follows: A % A % A % B % B 75 79% B % e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

8 C % C 60 64% C % D 50 54% F 49% or below ASSIGNMENTS Evaluation of the Learning Outcomes of Nursing 3145 include: Assignments Mark Due Dates 1. Clinical Decision-Making Assignment (DMF) S/U Week 5 2. Journal/Reflective Writing (x2) S/U Week 2&4 3. Midterm PAF S/U Week 6 4. Final PAF S/U Week Evidence Based Project S/U Week 5 6. Post-conferences/Participation (Post-conferences, as much as possible, should be student led. This will be a time to debrief and reflect on practice with a focus on integrating theory with practice.) S/U weekly 8 of 52 Please note that midterm and final evaluation meetings between student and nurse educator occur at e. These are usually scheduled in the 7 th and 14 th week of the semester. PROFESSIONAL RESPONSIBILITIES e requires all members of the College community (students and nurse educators) to conduct themselves in a manner that promotes a learning and working environment characterized by encouragement, free inquiry, integrity, mutual respect, professionalism, recognition of achievement, and social responsibility. The College community respects diversity, is civil, and provides for individual safety ( 1). Every practicing nurse in British Columbia, from the beginning student to the expert nurse, is required to assume full responsibility for knowing and adhering to the professional standards of practice. These standards serve primarily to ensure an acceptable level of professionalism (CRNBC, 2008). One of the College of Registered Nurses of British Columbia (CRNBC, 2008) standards of practice is Professional Responsibility and Accountability. Students are expected to have a working knowledge and adhere to the policies of e and those e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

9 9 of 52 outlined in the e Nursing Department Student Handbook. In particular, the following policies will be reviewed during Week 1 of the semester. 1. ATTENDANCE AND PARTICIPATION 2. SAFE PRACTICE APPRAISAL (SPA) 3. CLASS CONDUCT 4. PROFESSIONALISM & ACADEMIC HONESTY 5. ASSIGNMENTS AND EXAMS EXAM SECURITY WEB NETIQUETTE Students are also required to use appropriate language and APA style for all assignments. Questions relative to the methods of evaluation should be directed to the nurse educator teaching the course section in which students are registered. Any time during the term in clinical practice, a student whose clinical judgment or conduct constitutes a threat to client safety or non-adherence to the CRNBC s professional practice standards, he or she will not be permitted to continue practice in the clinical area and may receive and Unsatisfactory (U) grade. SCHEDULE (THIS IS AN EXAMPLE: DETAILS WILL VARY FOR EVERY CLINICAL GROUP) WEEK CLINICAL PLACEMENT ASSIGNMENTS 1 Orientation week: e NERC & Clinical site 2 Clinical 3 Clinical 4 Clinical 5 Clinical 6 Clinical 7 Midterm Evaluation: e 8 Orientation week: Langara & BC Women s 9 Clinical 10 Clinical 11 Clinical 12 Clinical Clinical Final Evaluation: e e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

10 APPENDIX A Maternal-Newborn and Family Practice Experience Clinical Practice Orientation Simulation Day Schedule hours Nursing Education Resource Center Meet as full group in A376 to introduce day View selected videos: Miracle Within (15 minutes, 5 minute discussion) and Bringing Baby Home 45 minutes, (10 minute debrief ) Break 10 of Postpartum Video 30 min (10 min debrief re: assessments), PURPLE Crying (10 minutes and 5 minute discussion) Time Station #1 =Hana #2 =Nancy #3 =Anne Marie #4 =Janita #5 = Sandy 1 C/S/ SVD 2 Newborn Group #1, 2 NERC Group #3 NERC Group #4, 5 Videos #3 #1, 2 NERC NERC #4 NERC #5 NERC #5 #4 NERC # 1, 2, 3 NERC 3 Videos 4 Discussio n 5 Lunch STATIONS Station #1: Lab: Sim Woman had a Casearean Section. Mannequin had a vaginal delivery. Practice assessment skills/head to Toe. All groups Group #4, 5 Group # 1, 2, 3 Station #2: NERC Lab. Neonate scenario with a vital sim. Physical assessment practice with educator using remote control altering RR, apex, e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

11 11 of 52 cough, fontanel. Practice Head to Toe including practicing counting fast apex with such variations such as murmur. Station #3: Booked classroom TBA. View relevant videos. Jack Neumann s Breastfeeding Video (40 minutes approx) Station #4 & 5: Discussion with clinical educator and lunch e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

12 APPENDIX B Maternal-Newborn Family Practice Experience Clinical Practice Assignment Schedule Date Focus Assignment / Exercise(s) Week Orientation: Simulation Activities: 1 -Nursing families Maternal/newborn -Safety Assessment -Communication -Unit and Routines Week 2 Week 3 Week 4 Coming to Know Client & Family Coming to Know Client (CTK) Salience Salience Pattern Recognition (PR) Healing Initiatives (HI) Reflection. Salience, Pattern Recognition, Healing Initiatives, Reflection. Journal #1 Due:. Readings 12 of 52 Binder as per clinical educator Pre-Readings in Ricci textbook: Chap. 15, 16. (Postpartum), Chap. 17, 18 (Newborn) Orientation Day Simulation Day Readings: Chap. 13, 14(Labour and birth) Readings: P. 565 (GDM), P (PP infection), Chap 16 (Breastfeeding), P. 149, P Journal #2 Due: Readings: Chap. 22 (Postpartum women at risk), Chap. 24 Week 5 Salience, Pattern Recognition, Healing Initiatives, Full DMNPF Assignment Due: e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

13 Reflection. 13 of 52 Week 6 Midterm Self-Performance Appraisal (PAF) Due: * The DMNPF (2006) should be used to guide weekly clinical practice preparation & critical thinking regardless of written assignment due dates. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

14 APPENDIX C Infant, Child, Youth, & Family Practice Experience Clinical Practice Orientation Day Schedule hours Nursing Education Resource Center 14 of 52 Students and educators to meet in Simulation Lab (East Lab), for introduction to the day, then divide into clinical practice groups for the day and work through the stations Meet as big group in Simulation Lab to introduce educators and overview of day s events. The class will break into individual clinical groups and follow own schedule as below. Group 4 Group 1 Group 2 Group Station: #1 #2 #3 # ~BREAK~ Station : #2 #3 #4 # ~ Lunch ~ Station: #3 #4 #1 # Station: #4 #1 #2 #3 STATIONS Station #1: Big Lab. Virtual Scenario from CD ROM of Carrie a 3 ½ month old infant with Bronchiolitis (no audio). Scenario projected on pull-down screen. Discuss various aspects of situation (health challenge, IV, meds etc), at beginning pediatric level. Station #2: Sim Lab. Jamie Jones manequin. Age 6 months. Physical assessment practice with educator using remote control altering RR, apex, e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

15 15 of 52 cough, fontanel. Practice Head to Toe including practicing counting fast apex with distracting sounds, as cough. Station #3: Sim Lab. Andie Anderson mannequin. Age 6 years. Physical Assessment practice with remote control. Adventitious breath sounds. Practice Head to Toe. Station #4: Small Lab. Discuss Pediatric Clinical Practice Binders. Preparation for tomorrow, day 2 orientation. Resource: Virtual Clinical Excursion Pediatric CD ROM software (Wilson, D., Hockenberry, M.J., Barrera, P, et al, 2007). e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

16 APPENDIX D Date Focus Assignment / Exercise(s) Week 1 Orientation: Simulation Activities: -Nursing children Infant/Child/Youth -Safety Assessment -Communic n with children and Journal #1 Due: families -Unit and Routines Week 2 Week 3 Coming to Know Client & Family Med Safety Coming to Know Client (CTK) Salience Salience 16 of 52 Infant, Child, Youth & Family Practice Experience Clinical Practice Assignment Schedule Medication Exercises Due: Tuesday Seminar. CTK (Head to Toe, Gordons, growth & development, family, culture, patient/family understanding of illness). Due in this clinical practice week on day. Readings Infant, Child, Youth & Family Resource Binder: Big Differences, Little People; BCCH Assessment Guidelines; first section. Binder in general. Hockenberry & Wilson (2007). Peds med admin theory. Discussion re: DMNPF paper Hockenberry & Wilson (2007): Pediatric Nursing Philosophy of Care p ; Family-Centered Care of Hospitalized Child p ; Functional Health Patterns p DMNPF Buchholz, S. (2006). Henke s Med Math: Calculation, Preparation and Administration (5 th ed.). Pattern Recognition (PR) Pharmacology Healing Initiatives Template: Mini- (HI) Presentation in clinical practice. Reflection. Hockenberry & Wilson (2007): Culturally Sensitive Interaction: Guidelines p. 41; Importance of Cultural Competence p ; Cultural Characteristics p ; Religious Beliefs p ; Differences in Color Changes of Racial Groups p Review Pediatric Binders Integration of classroom course theory into clinical practice Ongoing patient care knowledge development e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

17 Week 4 Week 5 Week 6 Salience, Pattern Recognition, Healing Initiatives, Reflection. Salience, Pattern Recognition, Healing Initiatives, Reflection. Full DMNPF paper Journal #2 Due: As Above As Above 17 of 52 Self-Performance As Above Appraisal (PAF) Due: * The DMNPF (2006) should be used to guide weekly clinical practice preparation & critical thinking regardless of written assignment due dates. * Always bring your medication and safe dose calculation prep to clinical practice, as well as other clinical preparation notes. Developed by S. Calvert September Revised Feb e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

18 APPENDIX E: 18 of 52 Infant, Child, Youth & Family Practice REVIEW GUIDE TO MEDICATION ADMINISTRATION IN PEDIATRICS While many of the important guidelines and principles you have learned relative to giving medications will apply in the pediatric setting, there are some very important considerations and critical differences to keep in mind when giving medications to children. The purpose of this guide is to address some of these important differences and to prepare you to administer medications safely with pediatric clients. Part I of this guide assists you to review relevant theory, while the focus of Parts II + III is on practice related mathematical calculations. Four client scenarios are presented in Part II, representing the typical clients you may encounter at BCCH; your facilitator may assign several or all of these scenarios, depending on the clinical ward you have been assigned to. In addition to this guide, it is recommended that you complete two related chapters in the Buchholz, S. (2006). Henke s med math: Calculation, preparation and administration (5 th ed.). Philadelphia: Lippincott. Adult and Pediatric Dosages Based on Body Weight, and Pediatric Oral and Parenteral Medications. For those wanting more of a refresher, the chapter on Dose Calculation Using Ratio and Proportion might also be of value. PART I - Theory Related to Administration of Medications in Pediatrics 1. What factors determine the dosage of a medication for a child? 2. What sources are available to the nurse who is checking the dosage of a medication ordered for a child? e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

19 19 of How can tablets and capsules be prepared so they are acceptable to infants and toddlers? 4. What sites are commonly used when administering intramuscular injections to infants? Why? e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

20 5. What general safety precautions must be taken when administering medications to young children? i 20 of Describe the approaches you would take to administering oral medications to each of the different age groups: The infant: The toddler/preschooler: The school-aged child: 7. The opportunity to give injectable medications is limited in the clinical settings, although you may be involved with assisting with IV insertions, and most certainly IV removals. Consider what approaches to take to make the experience the least traumatic for children. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

21 21 of 52 In this next section, Medication Administration Records (MAR s) are used for each client scenario. Please practice signing off the MAR's for each of the medications which you have noted as safe doses. NOTE: At RCH, CIRCLING the time MEANS THE DRUG HAS BEEN GIVEN. At BCCH, CIRCLING the time MEANS THE DRUG HAS BEEN OMITTED OR REFUSED by client. This practice is likely different from what you have been taught, thus it has been highlighted here. Instead of circling drugs when preparing each one, simply place a dot or check by the time. It is recommended that if a drug is circled, that you note beside it why the drug was not administered. Eg. Drug not available, refused by parent, withheld by physician. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

22 PART II - Calculation of Safe Drug Dosages + Volumes SCENARIO #1: 22 of 52 Three year old Ariel was admitted with a diagnosis of RAD (Reactive Airway Disease) and prescribed the medications as noted on her MAR on the following page. *Note where her weight is written on the MAR. Using the information from the MAR, and the drug information below, determine whether or not the doses ordered are safe, AND calculate the amount (volume) of medication you will be preparing. Show all work. Circle and label your answer. The BCCH drug dosage guidelines provide you with the following information. DRUG SUPPLIED DOSE ACETAMINOPHEN (Paracetamol, Tylenol, Tempra, Panadol) BUDESONIDE (Pulmicort) DEXAMETHASONE (Hexadrol, Decadron) tablet: 325 mg, 500 mg, 80 mg chewable elixir: 32 mg/ml drop: 80mg/ml suppository: 120 mg, 325 mg, 650 mg "turbuhaler" inhaler: 100 mcg/inhalation 200 mcg/inhalation respiratory solution: 0.25 mg/ml - 2mL nebule 0.5 mg/ml - 2mL nebule Mild to Moderate Pain/Antipyretic: mg/kg/dose PO Q4-6H. 35 mg/kg/dose PR Q8H Post-Surgical Analgesia: 20 mg/kg/dose PO Q6H x 48 hr then re-assess. Maximum: 90 mg/kg/24 hr. Respiratory Solution: mg/dose, repeated Q12H (may be given Q6H in severe cases). Turbuhaler: Low Dose <400mcg/24 hr. Medium Dose: mcg/24 hr. High Dose: 800-2,000 mcg/24 hr Average Dose: 200 mcg BID injection: 4 mg/ml Cerebral Edema: tablet: 0.5 mg, 0.75 mg, 4 mg Initial: 1-2 mg/kg /dose IV/IM/PO x1 oral solution (BCCH): 0.5 Maintenance: mg/kg/24 hr mg/ml IV/IM/PO div. Q6H X 5days then eye ointment: 0.1% taper. eye drops: 0.1% Airway Edema: unit dose size: mg/kg/dose IV/IM beginning e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

23 SALBUTAMOL (Ventolin, Albuterol) From: Sept To: Sept tablet: 0.5mg, 2mg, 4mg nebulizer solution: 5mg/mL inhaler: 100 mcg/puff diskus: 200 mcg/cap injection: 0.5 mg/ml - 1 ml amp., 10 ml amp., 0.05 mg/ml - 5 ml amp. unit dose size: nebulizer nebules: 2.5mg/2.5 ml 23 of hours before elective extubation then Q6H X 4-6 doses. Asthma: mg/kg/24 hr PO div. BID Croup: 0.6 mg/kg/dose IM/IV X 1 Anti-Emetic: 2-4 mg/m 2 /dose IV/PO Q6-12 H Anti-inflammatory: mg/kg/24 hr IV/IM/PO div. Q6-12H. Bacterial Meningitis: 0.15 mg/kg/dose IV Q6H X 2 days. Bronchodilator: Nebulizer: Dilute 1mL (5mg) in 3 ml NS (< 6 months old: 0.5 ml/3.5 ml NS) and nebulize at 6-8L/min. over 10 min. Q20 min. X 3 (acute exacerbation), then Q1-6H PRN. Metered Dose Inhaler: 4-8 puffs Q20 min. X3 (acute exacerbation), then Q1-6H PRN Diskus: 200 mcg via Rotahaler QID (Adolescents or Adults may require 400 mcg QID). Infusion: For use in ICU only mcg/kg/min. Medication Administration Record Wt.= 13.7 KG /0001 MSJ PEDS 472 r. Nasimohamed Jetha e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

24 24 of Medications Budesonide INH Soln. 0.5mg/ml (2ml) (Pulmicort or equivalent) 1 mg (2ml) inhaled q12h (via nebulizer) Dexamethasone Liquid 1mg/ml (100ml) (Decadron or equivalent) 2.1 mg(2.1 ml) po bid (take with food) Salbutamol sol. 5mg/ml (ventolin or equivalent) 5mg (1 ml) /3 ml ns via nebulizer inhaled q4h PRN Medications Acetaminophen drop 8o mg/ml (24ml) (Tylenol or equivalent) 40 mg (0.5ml) po q4-6h prn Salbutamol Inh Soln 5mg/ml (ventolin or equivalent) 5 mg (1ml) / 3 ml ns inhaled q2h prn (via nebulizer) RN Signature Printed: 1745 Sept Page1of1 e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

25 25 of 52 Order #1-3 Pulmicort Ordered Dose = Child s Wt = Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = Order #1-8 Dexamethasone Ordered Dose = Child s Wt = Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

26 Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = 26 of 52 Order #1-9 Ventolin Ordered Dose = Child s Wt = Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = Order #1-5 Tylenol Ordered Dose = Child s Wt = e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

27 27 of 52 Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = SCENARIO #2: Ten year old Jason was initially admitted with acute abdominal pain. His temperature was elevated significantly, and upon further investigation, it was determined that he had a ruptured appendix. An emergency appendectomy was carried out, following which the medications as noted on the MAR below were ordered. *Note where his weight is written on the MAR. Using the information from the MAR, and the drug information below, determine whether or not the doses ordered are safe, AND calculate the amount (volume) of medication you will preparing. Show all work. Circle and label your answer. The BCCH drug dosage guidelines provide you with the following information. DRUG SUPPLIED DOSE ACETAMINOPHEN (Paracetamol, Tylenol, Tempra, Panadol) Tablet: 325 mg, 500 mg, 80 mg chewable Elixir: 32 mg/ml Drop: 80mg/mL Suppository: 120 mg, 325 mg, 650 mg Maximum: 90 mg/kg/24 hr. Mild to Moderate Pain/Antipyretic: mg/kg/dose PO Q4-6H. 35 mg/kg/dose PR Q8H Post-Surgical Analgesia: 20 mg/kg/dose PO Q6H x 48 hr then re-assess. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

28 AMPICILLIN GENTAMICIN (Garamycin) Capsule: 250 mg, 500 mg Oral suspension: 50 mg/ml Injection: 500 mg, 1 g, 2 g Unit dose size: Capsule: 250 mg, 500 mg Injection: 10 mg/ml, 40 mg/ml Eye ointment: 0.3% Eye/ear drops: 0.3% Topical ointment: 0.1% Topical cream: 0.1% Medication Administration Record 28 of 52 Meningitis: mg/kg/24 hr IV div. Q6H Other infections: mg/kg/24 hr IV div. Q6H or 50 mg/kg/24 hr PO div. Q6H Usual Adult Dose: 1-2 g IV Q6H Intravenous: 7.5 mg/kg/24 hr IM/IV div. Q8H Maximum initial dose 500 mg/24hr; may be increased based on serum levels. Eye Ointment: cm ribbon to eye(s) BID-TID Eye Drops: 1 drop to eye(s) Q4H. Ear drops: 3-4 drops in the infected ear TID Topical: Apply a small amount of cream or ointment to lesion TID- QID. Allergies: No known Allergy Client: Jason Wt = 28.6 Kg Order #2-1 Ampicillin Inj 1 g (Penbritin or equiv) Ordered 09 Sep mg IV q6h e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

29 Order #2-2 Gentamicin Inj 40 mg/ml (2mL) Ordered 09 Sep mg IV q8h 29 of Order #2-3 Acetaminophen tab 325 (1 tab) Ordered 09 Sep tablets PO q6h Order #2-1 Ampicillin Ordered Dose = Child s Wt = Please put relevant drug doseage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = Order #2-2 Gentamicin Ordered Dose = Child s Wt = Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

30 Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = 30 of 52 Order #2-3 Tylenol Ordered Dose = Child s Wt = Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

31 31 of 52 SCENARIO #3: Baby Jenny, age 2 months, was diagnosed at birth with complex congenital heart anomalies. She was sent home on digoxin, and was just re-admitted for failure-to-thrive and a possible urinary tract infection. The plan was to assess closely her nutritional intake, and possibly commence oral gavage feeds. As well she was started on Lasix and Keflex. *Note where her weight is written on the MAR. Using the information from the MAR, and the drug information below, determine whether or not the doses ordered are safe, AND calculate the amount (volume) of medication you will preparing. Show all work. Circle and label your answer. The BCCH drug dosage guidelines provide you with the following information. DRUG SUPPLIED DOSE CLARITHROMYCIN (Biaxin) DIGOXIN (Lanoxin) liquid: 25 mg/ml tablet: 250 mg Children: 15 mg/kg/24 hr PO div. Q12H. Adults: mg PO Q12H. Maximum: 1g/24 hr. tablet: mg, mg, Digitalizing Dose: 0.20 mg Term Infants 2 years old: elixir: 0.05 mg/ml 17 mcg/kg/dose PO Q8H x 3 injection: 0.05 mg/ml (1mL), doses 0.25 mg/ml (2mL) 12 mcg/kg/dose IV Q8H x 3 doses > 2 years old : Unit dose size: 13 mcg/kg/dose PO Q8H x 3 tablet: mg, 0.25 mg doses 10 mcg/kg/dose IV Q8H x 3 doses Maintenance Dose : Start 12 hours after last digitalizing dose. Term Infants 2 years old: 10 mcg/kg/24 hr. PO once daily or div. Q12H. >2 years old: 8 mcg/kg/24 hr. PO once daily or e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

32 FUROSEMIDE (Lasix) injection: 10 mg/ml 2mL, 25 ml amp. PFS: 40 mg/4ml Tablet: 20 mg, 40 mg Unit dose size: tablet: 20 mg, 40 mg oral liquid: 3 mg, 5 mg, 10 mg div. Q12H. Medication Administration Record 32 of 52 Oral Dose: 1-2 mg/kg/dose Q6-8H (or prn) Parenteral: mg/kg/dose Q6-12H PRN IM or IV. Maximum single dose is 6 mg/kg/dose PO/IM/IV. May be used by intravenous infusion in critical care areas; mg/kg/hr. Allergies: No known Allergy Client: Jenny Wt = 2680 Gm Order #3-1 Digoxin elixir 0.05 mg/ml Ordered 12 Sep mcg PO BID Order #3-2 Ordered 12 Sep 2004 Furosemide 5 mg PO q8h Order #3-3 Clarithroymycin (25 mg/ml) Ordered 12 Sep mg PO q12h e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

33 of 52 Order #3-1 Digoxin Ordered Dose = Child s Wt = Please put relevant drug doseage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = Order #3-2 Furosemide Ordered Dose = Child s Wt = Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

34 Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = 34 of 52 Order #3-3 Clarithromycin Ordered Dose = Child s Wt = Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

35 SCENARIO #4: 35 of 52 At age 6, Twyla has been in and out of the hospital several times in the last two years. Having been on hemodialysis for renal failure almost a year, she was excited to receive a kidney transplant three months ago. Her recovery was uneventful, and she was discharged home on the usual post transplant medications. On a recent check-up, her physician was concerned with her progress, and suggested closer follow-up as an in-patient. Her admission diagnosis was noted as Nephrotic Syndrome. She was placed under strict fluid balance monitoring, and continued the meds she was on at home. *Note where her weight is written on the MAR. Using the information from the MAR, and the drug information below, determine whether or not the doses ordered are safe, AND calculate the amount (volume) of medication you will preparing. Show all work. Circle and label your answer. The BCCH drug dosage guidelines provide you with the following information. DRUG SUPPLIED DOSE ATENOLOL (Tenomin) CYCLOSPORINE Neoral, Sandimmune) tablet: 50 mg, 100 mg oral suspension (BCCH): 10 mg/ml capsule: 10 mg, injection: 50 mg/ml oral solution: 100 mg/ml mg/kg/dose PO once daily Maximum: 200 mg/24 hr. unit dose size: capsule: 25 mg, 50 mg, 100 mg Bone Marrow Transplant: 3-6 mg/kg/24 hr IV div. Q8-12H mg/kg/24 hr IV div. Q8-12H. Renal Transplant: Initial dose: <6 yrs: 500 mg/m2/24 hr PO div. Q8H >6 yrs: mg/kg/24 hr PO div. Q12H Maintenance: 5-12 mg/kg/24 hr PO div. Q12H Switching from IV to PO: Multiply IV dose x 3; recheck serum level in 2 days. PREDNISONE (Deltasone) Physiologic Replacement: 1-2 mg/m2/24 hr PO div. BID Asthma: tablet: 1 mg, 5 mg, 50 mg oral liquid (BCCH): 1 mg/ml, 5 mg/ml Acute Exacerbation: 1 e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

36 unit dose size: tablet: 1 mg, 2.5 mg (1/2 of a 5 mg), 5 mg, 25 mg (1/2 of a 50 mg), 50 mg 36 of 52 mg/kg/dose PO Q6H x 48 hrs (or until symptoms improve) Followed by: 1 mg/kg/24 hr PO div. BID Maximum: 60 mg/24 hr Anti-inflammatory or Immunosuppressive: mg/kg/24 hr or mg/m2/24 hr PO div. Q6-12H. Immune Thrombocytopenia Purpura: 4 mg/kg/24 hr PO div. Q8-12H x 6 days then taper to discontinue by day 21 Nephrotic Syndrome: Initial: 1-2 mg/kg/24 hr or 60 mg/m2/24 hr PO div. TID to QID (maximum 90 mg/24 hr) until urine is protein-free x 5 days (to a maximum of 28 days). Maintenance: 1-2 mg/kg/dose or 60 mg/m2/dose PO every other day x 28 days, then taper as appropriate. Medication Administration Record Allergies: No known Allergy Client: Twyla Wt = 20 Kg Order #4-1 Prednisone oral liquid 5 mg/ml Ordered 18 Sep mg PO BID Order #4-2 Atenolol suspension 10 mg/ml e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

37 Ordered 18 Sep mg PO q8h 37 of Order #4-3 Cyclosporine (100mg/mL) Ordered 18 Sep mg PO q12h Order #4-1 Prednisone Ordered Dose = Child s Wt = Please put relevant drug doseage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = Order #4-2 Atenolol Ordered Dose = Child s Wt = Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

38 Show math to determine correct amount (volume) to administer. Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = 38 of 52 Order #4-3 Cyclosporine Ordered Dose = Child s Wt = Please put relevant drug dosage research and/or calculations in this space to indicate if ordered dose is safe. Show math to determine correct amount (volume) to administer. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

39 Safe Dose = Ordered Dose Safe? Amount (Volume) to Administer = PART III - Additional Calculations 39 of 52 i) In pediatrics, critical weight changes in infants from one day to the next can signify impending major health concerns. Thus to verify significant weight changes, the following rule is generally applied: FOR INFANTS, ALL WEIGHT CHANGES OF 100 grams (g) MORE OR LESS THAN THE PREVIOUS WEIGHT MUST BE DOUBLE-CHECKED BY A SECOND REGISTERED NURSE. Indicate for the following infants the difference between the present and previous weights and the weights must be double checked by a yes or no. Previous Weight Present Weight Difference in grams!! Double checking required? 1. Jennie 4.26 Kg 4.15 Kg 2. Chris 2.98 Kg 3.04 Kg 3. Arlene 6.94 Kg 8.00 Kg 4. Victor 3.15 Kg 3.33 Kg 5. Jeff 3.57 Kg 2.44 Kg 6. Carrie 2.44 Kg 2.36 Kg ii) Oral medications often come in an elixir form in pediatric units. Calculate the volume of medication you will be preparing given the orders below and how the medication is supplied : 1. Cloxacillin 300 mg PO Supplied as oral liquid: 25 mg/ml 2. Clarithromycin 150 mg PO Supplied as oral liquid: 25 mg/ml e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

40 40 of Dilantin 200 mg PO Supplied as suspension: 6 mg/ml OR 25 mg/ml 4. Nystatin 4000,000 U PO Supplied as suspension: 100,000 U/mL 5. Prednisone 35 mg PO Supplied as oral liquid: 1mg/mL OR 5 mg/ml 6. Ampicillin 650 mg PO Supplied as oral suspension: 50 mg/ml Developed 1983; Various revisions through to 2005 by B. Lee. Revised 2009 S. Calvert. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

41 APPENDIX F 41 of 52 Decision Making For Nursing Practice Framework (DMNPF) May 2006 The purpose of this Framework is to facilitate student nurses decision making and process of learning within the realm of their nursing practice. Philosophical underpinnings of the Collaborative Curriculum are incorporated within this Framework and focus on health promotion principles of client-centeredness, egalitarian relationships, phenomenology, and client advocacy (Collaborative Curriculum Guide of British Columbia, CCGBC, 2004). Also inherent to this Framework, is Story-Based Learning (Young, 2007), a pedagogical model designed to support the teaching and learning of clinical decision-making. The Story-Based Learning Model is based on student-centered learning and client centered caring. Both the Clinical Decision Making for Nursing Practice Framework (CCGBC, 2004) and the Story Based Learning Model (Young, 2007) provide theoretical support in the use of this Framework. Central to the circular nature of the process, as well as the development of learning and understanding is Participatory Dialogue (PD) between the nurse and the client, as indicated on the circular model. COMING TO KNOW THE CLIENT The nurse comes to know the client by learning of the client s lived experience of health and healing through in-depth caring interactions (CCGBC). What is the client s story? What is the client telling me? What do I know? How do I know it? How will I learn more? What are my resources? (Young, L.) SALIENCE Salience refers to the deliberative process of choosing: what is important in a situation; what stands out; what is most critical to attend to; and what has most relevance for the client and nurse. Through praxis and engaging in critical dialogue, reflection and questioning, the client and nurse are able to mutually discover what is salient. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

42 Consider the different ways of knowing: empirical, personal, ethical, and aesthetic to determine (CCGBC): 42 of 52 What is going on here What is going well in this client s situation? What are the challenges from the client s perspective? What are my concerns? What do I need to know/learn more about (e. g. social or ethical issues, theories, symptoms, A&P, diagnostics, or treatments)? What resources will I use? How do all the various issues/aspects inter-relate? What is important for this client? What are the critical questions? Are there issues with the health care team or the organization? PATTERN RECOGNITION (Young, L) Pattern recognition refers to the process of thematic development. This involves the ability to see how relevant events and information fit together as a complex whole. The identification of health issues is based on pattern recognition and knowing what is salient in the situation through critical analysis of knowledge gained though the previous phases (CCGBC). What are the key health related concerns from the client s perspective? What patterns are evident? Are there patterns of wholeness/health? Are there patterns of disruption What are the apparent themes? What are the mutually identified and understood strengths and challenges? Are there one or two main concepts that impact the patterns? (Young, L) HEALING INITIATIVES Healing initiatives arise from the understanding of both the client s potential for health and healing and specific health issues of concern. It includes the implementation of specific therapeutic, preventative and health promotive modalities, utilizing interdisciplinary collaboration, along with multiple resources and services, or using harm reduction strategies to reduce client vulnerability. Most importantly, healing initiatives need to result in the empowerment of clients to gain control, expertise and autonomy in decision making that influences their health and healing. Because this is an ever-evolving process, healing initiatives are non-static and change in response to the health and healing of the client (CCGBC). e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

43 Develop a priorized and individualized plan of care 43 of 52 What are the desired outcomes (short and long term goals)? Who should be involved now? What are the initial and long term actions? What resources/referrals/advocacy are useful/acceptable to my client? What are the implementation issues or problems? What are the standards of practice that guide my interventions? What should be included in discharge planning? What should be assessed on an ongoing basis in order to evaluate the care plan? (Young, L.) REFLECTION/PRAXIS According to Young (2007) the process of reflecting on one's practice provides the "opportunity to connect experiences, feelings, and knowledge, [which] is an important quality for professional practice and a crucial dimension of critical thinking" (p. 178). Therefore, praxis and critical reflection are central to decision making for nursing practice (CCGBC). Was my plan of care appropriate? Did I involve the client in planning the care? Were short and long term goals outlined and were they realistic and measurable? Did the plan address the client s needs and expectations? How would I know this? Did it address my expectations? How would I know this? What ways of knowing did I use in planning the care? Was my nursing care effective? What evidence based practice did I use? How did I know it was relevant to the care you provided? Was the outcome of care measurable and is it what I expected to see? How would I know this? Were the short term and long term goals achieved? How would I know this? Which nursing intervention do I need to change and why? What have I learned from this process of evaluation? How would this experience influence my future practice? (Young, L) REFERENCE LIST e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

44 Collaborative Curriculum Guide (May, 2004). Decision making for nursing practice. Collaborative Nursing Program: British Columbia. 44 of 52 Young, L. (2001). Story-based learning: User s manual. University of Victoria Course Packet N493B: Complex challenges-acute-care setting. Young, L.E., & Patterson, B. L. (2007). Teaching nursing: Developing a studentcentered learning environment. Philadelphia, PA: Lippincott Williams & Wilkins. e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

45 APPENDIX G Clinical Practice Assignment Guidelines: Decision-Making for Nursing Practice Framework (DMNPF) 45 of 52 Use the following guidelines to prepare yourself to care for your patient and family, and to organize your clinical practice patient assignments. Use the Decision-Making for Nursing Practice Framework (near beginning of this Course Packet) to give direction to this assignment. 1. *Keep your clinical practice assignments attached together in a folder with the following clearly visible! Example: Nursing 3140, James Bond, , Educator: Susan Calvert, February 14, Use a pseudonym to identify client. Acknowledge on your paper that you have done this. COMING TO KNOW THE CLIENT / ASSESSMENT 3. Client s story as to why the client is in the hospital. Personal health history, family history and any significant previous health challenges that may impact health status, hospitalization and recovery. Growth & Development. Culture/ethnicity- how does the cultural background of the client influence the nature of your nursing care (i.e., communication, diet, values/beliefs, gender interaction, family involvement/role, perspective on health and healing). Allergies to medications, food etc. and reaction(s). 4. Gordon s Functional Health Patterns and Head to Toe Assessment. SALIENCE / ANALYSIS 5. What is important about what is going on here? 6. Describe the diagnosis. How does the diagnosis relate to this client in terms of anatomy and pathophysiology? 7. Surgery and how many days post op. Describe the surgery in terms of anatomy and procedure. Why was the surgery warranted? 8. Related health history (if applicable)- What type of health condition(s) does the client have? e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_

46 46 of 52 How does this relate in terms of anatomy and pathophysiology? What effect does this chronic/episodic health challenge have in relation to this client? 9. What is happening regarding prevention of further heath challenges (client/family and nursing actions)? 10. Medications- Use Pharmacology Template to guide your study and write-up. 11. Diagnostic tests -What is the test and why was it ordered for this client? -What were the results? Look for trends as well as extreme high/low values. -What is the significance of the results? 12. Draw or provide a diagram(s) (from the web/literature) of the surgery/medical condition that demonstrates your understanding of the pathophysiology and/or how the surgery/medical condition is intended to address the health challenge. Use of diagrams is helpful to support your explanations. Concept map could also be used. 13. Nutrition (impact on medications, health status and wellness outcome). 14. Equipment What equipment does your client need and Why? (E.g., NG tube, chest tube, tracheostomy, PCA, IV, oxygen therapy, suction, drains etc.) 15. What do I need to know more about? What are my learning needs? PATTERN RECOGNITION / CLINICAL IMPRESSIONS 16. What themes or patterns are you seeing? List 3-5 actual and/or potential clinical Impressions. HEALING INITIATIVES / NURSING ACTIONS 17. What nursing care and teaching is significant in promoting health for this individual and his/her family? e & [Calvert_Cunada_Kim_Pecinova_Tong], Jan_ Revised by Pecinova_ Aug_