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I INTRODUCE YOURSELF YourName: Your Title: Reason for Being There: Patient: Age: History of Current Problem: Gender: S SITUATION Height/Weight: Allergies: Code status: Privacy Code: Time: Attending Physician: Patient Chief Complaint: Chief Informant: Family History: B BACKGROUND Past Medical History: Current Medications: Social History: A ASSESSMENT VITAL SIGNS: B/P HR RR TEMP SP02 PAIN FALLS RISK Y N IV Site: Accu check: IV Fluids: ISOLATION Isolation Precautions: Y N Contact Air Droplet HEENT RESPIRATORY CARDIOVASCULAR NEUROLOGICAL GI/GU I & O MUSCULOSKELETAL INTEGUMENTARY LYMPHATIC ENDOCRINE PSYCHOLOGICAL FAMILY – SUPPORT SAFETY LABS/TEST Abnormal: Pending: Ordered R REQUEST/ RECOMMENDATION Hand off report to: From: ©2016 Chamberlain College of Nursing LLC. All rights reserved.
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NR442 Community Health Clinical teaching plan Instructions: This is intended as an individual assignment that replaces the care plan requirement. Please be thorough in your work. Successful completion of this assignment is a required element of success in the NR442 Clinical Learning experience. Complete an SBAR on one of your patients. Use your course textbook and other course materials to review the concepts of Social Determinants of Health (SDoH), Cultural Assessment, and Health Literacy. Visit the CDC website to learn more about SDoH, cultural awareness in health care, and the importance of understanding patient’s health literacy needs. Then, select one area of need for further education, or possibly re-education for your patient. Answer the questions below in the teaching plan section. Submit your SBAR and Teaching Plan to your Clinical Instructor for feedback by their indicated deadline. Make corrections or answer further questions based on their feedback and submit your final work by the end of week 7 to your Canvas course Drop Box. Be sure to include citations and references in APA format where used. This assignment should include a minimum of two scholarly resources. SBAR Situation: Reason for visit and primary medical diagnosis/problem. Background: medical history and comorbidities, current medications, history of present illness/primary medical diagnosis and related medication history, perceived/stated issues, or concerns with management of present illness and treatments (medicinal and non-medicinal) that have worked well. Assessment: Assess patient for social determinants of health and cultural assessment. Determine health literacy needs and potential or actual barriers to learning. Recommendation: Based on the information above develop a teaching plan that will meet the patient needs. (see next section) Teaching Plan What will you be teaching this patient and why? What is your expected outcome following the teaching session? What is your SMART goal? What social determinants of health impact your education of this patient? How will you adjust your educational information to accommodate this need? What cultural needs exist and how does you teaching plan meet the cultural needs of your patient? What is your patient’s health literacy and ability to understand information being given? Are there potential barriers to learning? How will you accommodate your patient and what type of learning materials will be provided to help them learn and retain the information provided?

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