First Day Assignment for Students: FUNDAMENTALS

STUDENT ASSIGNMENT
1. Log into thePoint and DocuCare following all instructions given to you earlier.
2. After entering the instructor-assigned case, review the patient’s entire medical record to explore her health status and reason for seeking care.
3. Complete the following:

Data
Guidelines
A.
Choose two nursing diagnoses, tailor them to the patient’s current health condition, and document them in the chart.
Document in DocuCare
B.
Document the following vital signs: BP: 124/82, P: 86, R: 18, T: 98.9 (oral), O2sat: 93% RA
Document in DocuCare
C.
Document a Nurse’s note regarding the vital signs. Are they improving or worsening? What data do you have to support this?
Document in DocuCare
D.
Record a pain assessment of 0
Document in DocuCare
Click on the icon next to the phrase Chronic Obstructive Pulmonary Disease. Answer the next two questions from the information you find there.
E.
What are the top two causes of COPD listed there?
Document HERE

F.
What is the medication listed to treat ‘mild COPD’?
Document HERE

G.
Document the following assessment findings in DocuCare:
i. Respiratory:
• Wheezes in bilateral upper lobes, clear otherwise
• Respirations regular
• Sputum yellow
• Respiratory symptoms: cough, difficulty breathing with activity.
ii. Cardiac:
• Normal S1S2
• Edema: 2+ all extremities
• All pulses +2;
• Cap refill: all <3sec
• Skin color and description: warm dry and intact
H.
Be creative and fill out all other assessment body systems.
Document in DocuCare

4. Submit for instructor review:
i) This paperwork
ii) DocuCare work

Copyright © 2014 Lippincott Williams & Wilkins | Wolters Kluwer Health. All Rights Reserved.