ACP Flip Book

ACP Portfolio Flip Book

Deania L Hoffpauir MSN RN

Spring 2016

Table of Contents

1. Syllabus Snapshot
2. Student Preparation Strategy
3. BOPPPS Lesson Plan
4. Power Point Lesson Plan

4a. Lesson Plan Introduction
4b. CAT
4c. Narrative Examples
4d. Blank Narrative Form
4e. Technology Tool
4f. Concept Map
5. Test Questions
5a. Test Questions-Socrative
6. Grading Rubric
7. Showcase Presentation
8. Reflective Essay

Successful course completion will be Pass/Fail grading, Deania Hoffpauir, MS RN
based on learning outcomes combined with: Adjunct Faculty Instructor
a teaching project [email protected]
concept map
three SBARs Memorial Herman NE
10 PrepU quizzes.
Bring with you: Humble, Texas
See Syllabus for complete listing in your D2L course. o Mosby or Davis Drug Guide 6AM to 4:30PM

o Taylor’s Clinical Nursing Skills: A Nursing

Process Approach

What I expect: Be on time!
 Professionalism Dress for
 Ethical Behavior Success!
 Safety and Competence Come prepared!
 Participation in Post Conference
 Completion and timely submission of written/oral

assignments

The amount of relief and comfort experienced by the sick after the skin has been carefully washed and dried, is one
of the commonest observations made at a sick bed. ~~~ Florence Nightingale

Student Prep Strategy

Nursing Documentation and Paper Charting
With the advent of computers, you’d think paper charting would be a thing of the past but not so.
You will experience times when you are not able to chart on the computer and must revert back
to paper charting. This class will show you how to create a nurse narrative on paper.
Introduction
Blank paper nursing narrative
Examples of nurse narratives

Read Chapter 1 & 2 in Nursing Documentation: Quick and Easy. Download these three
documents. Using the examples provided, create a 7AM “head to toe” assessment on a patient
using the blank narrative above and bring it to class. Be prepared to discuss what to include and
not include in your narrative.

BOPPPS LESSON PLAN

COURSE: RNSG 2361 Traditional and Simulation, Level III
Lesson Title: Constructing the Nursing Narrative
Bridge: (intro) With the advent of computers, you’d think paper charting would be a thing of the past but not so. You will experience times when
you are not able to chart on the computer and must revert back to paper charting. This class will show you how to create a nurse narrative on
paper.

Read Chapter 1 & 2 in Nursing Documentation: Quick and Easy. Download these three documents (see attached). Using the examples provided,
create a 7AM “head to toe” assessment on a patient using the blank narrative above and bring it to class. Be prepared to discuss what to include
and not include in your narrative.
Estimated Time: 30 min. non classroom time

Course Student Learning Outcome: The student will be able to demonstrate legal and ethical behavior, safe practices, interpersonal and
teamwork skills and appropriate written and verbal communication skills using the terminology of the occupation and business/industry.

Learning Objectives (these should be the ones you wrote in Module 1): By the end of this lesson, students should be able to:
1. compile assessment data for documentation in the clinical setting (Blooms Level: Synthesize)
2. demonstrate correct computer usage and documentation in the clinical setting (Blooms Level: application )

Pre-Assessment: How will you assess learning prior knowledge of the topic?
1. Create 7am head to toe assessment using sample data and blank form. Download and bring to class
2. In class, complete concept map prior to lecture (handout).

Participatory Learning: Learner Activities Lesson Materials
Time Instructor Activities
10 min PPT presentation Explains importance of good nurse documentation Handout of PPT slides
and narrative. Pause for clarification and questions Blank narrative handout
15 min Watch patient YouTube video throughout presentation
Provide Youtube video at end of slide presentation.
Using video, allow students to practice creating a
Head to Toe narrative assessment

10 min CAT concept map Have students complete original concept map a Concept map
15 min Discussion of Examples/ask questions second time using newly acquired information.
Compare difference in both.
Review concept map and H2T assessments. Clarify
material with the following questions:

20 min Create groups of 3 students each and create a Question 1: How would you ensure that your Handout of sample
nurse narrative narrative is in chronological order? (Blooms patient info
application) Blank narrative handout
Question 2: How would you prevent cluster or
double charting? (Blooms synthesis)
Question 3: Should everyone’s charting look the
same? Why or why not? (Blooms evaluation)
Question 4: What should you include or not include
in your narrative? (Blooms analysis)
Students strategize on writing nurse narrative and
evaluate each other

Post Assessment:

1. Nurse narrative grading rubric (see attached)
2. New Technology: Socrative Nursing Documentation quiz

Estimated time: 10 min

Summary: how will you close the lesson?

1. Verbal content review
2. Recognition to top performers (hopefully everyone)
3. Group roundtable on practical application and potential future use

Estimated Time: 10 min

Attachments:

(1) Introduction
(2) nurse narrative examples
(3) Blank Nurse narrative form
(4) Sample Patient information
(5) Nurse narrative grading rubric

RNSG 2361
Transition and Simulation

Level III

Deania Hoffpauir MS RN Adjunct Faculty

Written evidence of:

 The interactions between and among health care
professionals, clients, their families, and health care
organizations.

 The administration of tests, procedures, treatments,
and client education.

 The results of, or client’s response to, diagnostic tests
and interventions

 Professional  Research
responsibility
 Satisfaction of
 Accountability Legal and Practice
 Communication standards
 Education
 Reimbursement

 Documentation is a communication method that

confirms the care provided to the client.

 It clearly outlines all important information

regarding the client.

 If it wasn’t documented, it wasn’t done!

 The medical record can be used by health care

students as a teaching tool.

 It is a main source of data for clinical research.

 The medical record is a main source of data for

clinical research.

 Accreditation and reimbursement agencies require

accurate and thorough documentation of the
nursing care rendered and the client’s response to
interventions.

Elements of nursing process needed to
be made evident in documentation include:

 Assessment.  Implementation.
 Evaluation.
 Nursing Diagnosis.  Revisions of

 Planning and planned care.
outcome
identification.

To ensure effective documentation, nurses
should:

 Use a common vocabulary.  Employ factual and time-
sequenced organization.
 Write legibly and neatly.
 Document accurately and
 Use only authorized completely, including any
abbreviations and errors.
symbols.

 Narrative Charting  Focus charting

 Source-oriented  Charting by
charting exception

 Problem-oriented  Computerized
charting documentation

 PIE charting  Critical pathways

 This traditional method of nursing

documentation takes the form of a story written in
paragraphs.

 Before the advent of flow sheets, this was the only

method for documenting care.

 A narrative recording by each member (source) of

the health care team on separate records.

 Focuses on the client’s problem and employs a

structured, logical format called SOAP charting:

 S: Subjective data (what the client states)
 O: Objective data (what is observed/inspected)
 A: Assessment
 P: Plan

PROBLEM
INTERVENTION
EVALUATION

 A documentation method that uses a column

format to chart data, action, and response (DAR).

 A documentation method that requires the nurse

to document only deviations from pre-established
norms.

 A documentation method that requires the nurse

to document only deviations from pre-established
norms.

 Decreased documentation  Statistical analysis of data.
time.
 Enhanced implementation
 Increased legibility and of the nursing process.
accuracy.
 Enhanced decision
 Clear, decisive, and making.
concise words.
 Multidisciplinary
networking.

 A comprehensive, standard plan of care for specific

case situations.

 The pathway is monitored to ensure that

interventions are performed on time and client
outcomes are achieved on time.

 Kardex
 Flow Sheets
 Nurse’s Progress Notes
 Discharge Summary

 A summary worksheet reference of basic
information that traditionally is not part of the
record. Usually contains:

 Client data (name, age, marital status, religious
preference, physician, family contact).

 Medical diagnoses: listed by priority.

 Allergies.

 Medical orders (diet, IV therapy, etc.).

 Activities permitted.

 Vertical or horizontal columns for recording dates
and times and related assessment and intervention
information. Also included are notes on:

 Client teaching.

 Use of special equipment.

 IV Therapy.

 Used to document:

 Client’s condition, problems, and complaints.
 Interventions.
 Client’s response to interventions.
 Achievement of outcomes.

Highlights client’s illness and course of care.
Includes:

 Client’s status at admission and discharge.

 Brief summary of client’s care.

 Intervention and education outcomes.

 Resolved problems and continuing care needs.

 Client instructions regarding medications, diet,
food-drug interactions, activity, treatments, follow-
up and other special needs.

 Nursing Minimum Data Set.
 Nursing Diagnoses.
 Nursing Intervention Classification.
 Nursing Outcomes Classification.

 The elements that should be contained in clinical
records and abstracted for studies on the effectiveness
and costs of nursing care. Focuses on:

 Demographics.

 Service.

 Nursing care.

 A clinical judgment about individual, family, or
community responses to actual or potential health
problems or life processes.

 A comprehensive standardized language for nursing
interventions organized in a three-level taxonomy.

 A classification system that comprises 190 outcome
labels and corresponding definitions, measures,
indicators, and references.

 The outlining of information pertinent to the client’s
needs as identified by the nursing process.

 Commonly given at end-of-shift.

 A reporting method used when the members of the
care team walk to each client’s room and discuss care
and progress with each other and with the client.

 Telephone communications are another way nurses:

 Report transfers.
 Communicate referrals.
 Obtain client data.
 Solve problems.
 Inform a client’s family members regarding a change in

client’s condition.

 The documentation of any unusual occurrence or
accident in the delivery of client care, such as falls or
medication errors.

 Please enter 37607 into your cell phone as the phone
number

 Please enter deaniahoffpa314 in the text box.

 This will enroll you in the Interactive Poll Survey

 https://www.youtube.com/embed/Bkoic2dLFmY"
frameborder="0" allowfullscreen></iframe>

Keep it Succinct

Don't incorporate opinion or try to make your writing beautiful. Narrative notes need to be
succinct and easy for busy medical professionals to quickly read. Focus only on the specific issue
you're charting. For example, a patient with a history of diabetes who also presents a skin
problem does not demand detailed charting of his diabetic history. Instead, you'll only need to
chart information that is or could be relevant to the patient's skin problems.

Make it Comprehensible

Narrative notes should be short, but if you must convey a significant amount of information,
break your narrative into paragraphs for easy scanning. Use only abbreviations that are widely
used and accepted at your hospital or clinic. If abbreviations for two similar conditions or
treatments look very similar, avoid using them altogether and instead write out the full names of
the conditions or treatments. If you write your notes by hand, keep your handwriting clear so that
your reader doesn't inadvertently give an incorrect medication or dosage based on bad
handwriting.

Note Patient Presentation

Your narrative note should clearly identify the presenting problem, as well as any secondary
problems you notice or about which the patient complains. Note objective measures of patient
health, such as blood pressure and heart rate. Next, note any subjective measures, such as skin
color and whether the patient appears anxious.

Note Assessment

Your narrative note should outline any and all assessments you administered, starting with
objective assessments such as blood panels. If you utilized subjective assessments, such as
accounts from family and friends of the patient's state of mind, note these as well. Conclude with
the probable diagnosis and the findings of any assessment measures. If more tests are indicated
or the patient may be suffering from a disorder that has not yet been diagnosed, note this as well.

Note Medication and Treatment

After you or another medical professional have completed the assessment, list any and all
medications your patient has been given, as well as the dosage and mechanism of delivery. If a

doctor prescribes medication, list this medication and the dosage as well as any other
medications the patient regularly takes.

Be Precise
Avoid vague summary statements or general phrases that do not communicate what

actually occurred. Instead, state what happened in specific terms. This will help the reader better
understand the situation and appreciate your actions. For example:
Don’t say: "I analyzed the possible dangers to the patient and took action."

Instead, say: "The blood pressure was dropping and the pulse rate was rising. I sensed the patient
was going into shock. I immediately called the intern."
Don’t say: "I gave emotional support."

Instead, say: "I sat and talked with the patient about how to tell his family about the diagnosis."
Don’t say: "The patient is improving."
Instead, say: “The patient is able to sit independently, transfer out of bed with assistance, and is
progressing with gait activities on the parallel bars and with a walker."

Learning Objectives: By the end of this lesson, students should be able to:
1. compile assessment data for documentation in the clinical setting
2. demonstrate correct computer usage and documentation in the clinical setting

The current CAT trend in nursing is the concept map. Students are expected to construct
at least one concept map per semester. This allows faculty to assess the student’s ability
to synthesize the course materials with the student’s knowledge and skills. It can also
offer insight into how a student views and organizes that knowledge. In nursing, the
concept map utilizes a patient’s problem or diagnosis and its relationship to signs,
symptoms, labs, diagnostic tests, etc.
For this exercise, I would offer a Nursing Documentation “fill in” concept map at the
beginning of the lecture to assess what the students know prior to the presentation. An
example is provided below.

Students would fill in what they think should be included in the initial nurse narrative. I
would then present the power point and nurse narrative examples. Students would use
then make necessary corrections to their concept map. This way, I can assess prior
knowledge plus new knowledge as well as how students use their critical thinking skills.

Lastly, since this will be a new course addition I want to assess students’ reactions to this
module offering. For this I’ve chosen Assignment Assessment. Below are three open-

ended questions about this module and how the student feels about its value. This would
be offered in the last 5 minutes of class and would be anonymous. I plan on using the
information provided to drive any future changes to the learning module.

Module Assessment
Please take this brief survey about the learning module you were given. Your opinions will be used to
evaluate its effectiveness and make any changes to its content or delivery. Your information will remain
anonymous and will be used solely for the purpose the purposes stated above. Thank you in advance!

1. What changes would you make to the learning module (i.e. time limit, delivery method, testing
application, etc.)

2. In what way has this learning module changed your nursing process?
3. What questions were not answered in the learning module?
4. Would you recommend this learning module to your fellow nursing students?

Date:_____________ Faculty: _______________

Sample Nursing Narrative #1

10/05/2015 0800. 86 y.o. male admitted 10/01/09 for left-sided CVA with right-sided
hemiparesis. V/S: T 98.4, HR 97, RR 22, BP 140/76. Alert and oriented to person, place, day/
time, and situation; denies any pain or distress. PERRLA. Responds appropriately to verbal
stimuli; no slurring of speech. At risk for aspiration related to dysphagia; on thickened
dysphagia diet. Pt eats with assistance. Skin pink with loose turgor, mucous membranes moist
and pink. Negative JVD. Respirations even, unlabored, on room air. Breath sounds clear to
auscultation throughout all lung fields. Apical pulse regular rate and rhythm; s1, s2 noted.
Abdomen soft & non-distended with bowel sounds active in all 4 quadrants. Pink nailbeds with
capillary refill less than 2 seconds in all extremities. Peripheral pulses palpable in all
extremities. Pt moves all extremities, hand grips unequal: strong on left, weak on right. Right
arm has limited mobility due to weakness secondary to CVA. 20 gauge IV saline lock to left
lateral forearm, site is free from redness or drainage, with tegaderm dressing intact. (if your
patient has an infusing iv, make sure you record the fluid and rate in your assessment). Uses
urinal, has occasional episodes of incontinence. Urine clear yellow. No skin breakdown noted.
Ted hose on bilaterally. Homan’s sign negative bilaterally. Feet cool, dry, intact, with thick
toenails bilaterally. Side rails up x 3, bed in low position, call bell within easy reach of left hand.
PT instructed to call for any needs or to request assistance before attempting to get up. Pt
verbalized understanding. Will continue to monitor closely. ………… S. Johnson, student nurse

Sample Nursing Narrative #2

7-3 shift-Received pt lying on bed asleep and not in respiratory distress. Pupil size 3mm,
equally round and briskly reactive to light and accommodation. O2 inhalation @ 2L via nasal
cannula, with NGT at left nare, patent and intact; distal end closed for feeding and medication-
with endotracheal tube attached to mechanical ventilator with the following set-up: FiO2= ;
TV;= . Symmetrical chest wall expansion-with clear breath sounds in all lung fields noted-with
pink nailbeds noted and good capillary refill time. Good skin turgor-with IVF of @ 125cc/hr
infusing well @ left AC vein, 18 gauge. Foley catheter attached to left leg via leg strap, clear
yellow urine, complete bed rest with bathroom privileges. Fecalysis/ sputum AFB not yet
collected. Pt instructed and provided with containers @ bedside. CBC/FBS/lipid profile/serum
creatinine/SUA at lab pending results. CT scan of brain scheduled for 4pm today. New order
for 2 units PRBC, type and transfuse asap. Paracetamol 500mg 1 tab PO given as ordered.
Bedside care done; linen changed. Oral care done after meal served. Pt able le to consume of
the meal served. Health teachings rendered with emphasis on diet and blood transfusion signs
and symptoms to report……………………………………………..S. Johnson, student nurse

Sample Nursing Narrative #3

7:30am Received pt from ER via transportation, lying on stretcher, awake, conscious;
coherent; responsive to stimuli; not in respiratory distress. VS: BP 135/75, HR 70, RR, 26,
Temp 99.1 Pupils equally round and brisk, reactive to light stimulation; 4mm pupil size. O2 at 5
LPM via face mask. NGT to left nare, patent and intact; distal end closed for feeding and
medication. Coarse crackles bilateral upper lung fields noted upon auscultation. 20 gauge LAC
saline locked. 18 Gauge RFA with D5NS at 100 ml/hr and Cipro IVPB at 100 ml/hr. Foley
catheter to gravity drainage with pink tinged urine. Nail beds are pink with <3 sec refill. Good
skin turgor. Diet is heart healthy. Pt is ambulatory with assist. No abnormal AM labs. Bed rails
up x 3, bed in low position, call light and bedside table within reach. Pt acknowledged need to
call for assist with ambulation……………………………………S. Johnson, student nurse

9:00 am. Bedside care done; linens changed. Placed the patient comfortably in bed. Assist
with oral care. Osteorized feeding of 175 ml given; flushed with 50 ml of water; pt tolerated
procedure well. Cipro infusion complete………………………S. Johnson, student nurse

11:15 am Dr Williams bedside to examine pt. New order received for chest xray, 2view, today,
call with results, and Protonix 30 mg IV once every AM……….. S. Johnson, student nurse

12:30 pm Pt having lunch. Ate 50% of meal and drank 250 ml water. PCA ambulate pt to
bathroom. BM x 1, medium size, brown color, soft. VS: BP 125/75 HR 73 RR 26 Temp 99.2

…………………………………………………………………….S. Johnson, student nurse

1:00 pm. Pt taken by wheelchair to XRAY by PCA…………..S. Johnson, student nurse

1:45 pm. Pt returned from XRAY. Pt placed in bed with rails up x 3, bed in low position, call
light and tray table within reach.

3:00 pm Dr Williams called with results of XRAY. New orders received for Albuterol with
nebs, Q 4 hr. New order received for consult with Dr Matthew, pulmonology. Consult called to
Dr Matthew.

7:00 pm Shift change report given to Sally Swimmer RN.

Client initials_______ Room #_________ Student Name___________________________________

Head-to-Toe Assessment Nursing Narrative Note:
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Student signature__________________________________________ Instructor signature _______________________________________

For my technology tool, I chose Poll Everywhere. While working on this module, I knew
I wanted to survey my students to determine if my lesson was effective, did they feel they gained
valuable knowledge and what components were useful or not useful. My original plan was a
Likert Scale but this tool is wonderfully interactive and shows instant results! I also took my
lesson test and converted it to an interactive quiz using Socrative.

While neither of these tools directly accomplishes my objective tools, they indirectly
measure the effectiveness of the learning tools in connection with the objectives and can be used
to drive any changes to the learning module. It’s possible that a different technology tool would
directly impact the learning objectives but I’m more of a big picture kind of teacher and that is
what drives my thought process in choosing the tools I opted to utilize.

There were several challenges in making these two technology tools come to life. First
and foremost was MY learning curve. I consider myself fairly technologically savvy but these
two tools put me through my paces. I had to work through the help section of each to learn to
use them. Secondly, I encountered some issues imbedding them into my power point
presentation but that may be more of an equipment compatibility issue on my end than a problem
with the software. The university software-equipment may not experience this but I’ll be giving
this presentation on my personal computer so I’ll need to address those issues.

I would absolutely use these tools again, and many of the other tools we looked at. I was
amazed at the depth and breadth of learning technology available on the internet. I had hoped
that this class would show me much of what I don’t know or wasn’t aware of, and it certainly
has! I’m looking forward to exploring the vast array of learning opportunities available on the
Internet.

Socrative Test:

https://b.socrative.com/login/student/ Room name: SMYN72BS

Poll Everywhere:

Pollev.com/deaniahoffpa314 or text to 37607 and put DEANIAHOFFPA314 in the text
msg box and hit send