379 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 Creation of a remote clinical practice curriculum for first year nursing students: Reflections and lessons learned Original Research Diane MacEachern1, Joyal Miranda2, Shari Cherney,3 1School of Community and Health Studies, Centennial College, Toronto, Canada; 2Daphne Cockwell School of Nursing, Ryerson University, Toronto, Canada; 3Sally Horsfall Eaton School of Nursing, George Brown College, Toronto, Canada Corresponding author: D. MacEachern (dmaceachern@centennialcollege.ca) ABSTRACT Introduction: A problem-based learning approach using intentionally created client profiles and nursing care summaries formed the foundation of a remote clinical experience for first year undergraduate nursing students. Methods: Using carefully designed client scenarios, care summaries and active learning strategies, students were introduced to the nursing profession and provided the opportunity to develop skills in collaboration, critical thinking, clinical reasoning, and clinical judgement. Results: Based on discussion with students, the remote experience assisted in the development of several skills addressing communication, theoretical foundation, and critical thinking. As well, this experience allowed for the integration and application of newly acquired nursing knowledge, and an enhanced understanding of the role of the professional nurse. Implications: Significant lessons learned may serve other nursing programs around the world as we continue to navigate both current and future public health mandates while managing competing demands for in-person clinical practice sites. Conclusion: Face- to-face clinical experiences remain a critical component of comprehensive nursing education, however, given today’s climate and continued restrictions, a hybrid model, utilizing a remote platform, is worthy of further exploration. KEYWORDS Baccalaureate, Clinical Judgement, Clinical Reasoning, Critical Thinking; Education, Nursing, Problem-Based Learning INTRODUCTION Schools of nursing in Canada and around the world have been creatively responding to the COVID-19 pandemic as we continue to educate another generation of front-line healthcare providers. A loss of clinical nursing placement opportunities forced academia to swiftly pivot to remote learning. Few schools in Ontario offer a first-year clinical practicum for nursing students; and although our collaborative undergraduate nursing program, which takes place across three urban sites, faced the loss of this valuable educational learning opportunity; preserving the experience was essential. Despite the loss of in-person practicums, students remain eager to learn about the practical application of nursing theory, employ a variety of newly learned therapeutic communications skills, demonstrate foundational practical skills, integrate, and apply developing skills in critical thinking and problem-solving, develop routines of performance and acquire reflective skills (Henderson et al., 2012; Papastavrou et al., 2016; Yazdankhahfard et al., 2020). The aim of this paper is to describe the key features and lessons learned during the development of a remote clinical practice curriculum for first year nursing students. Specifically, a course revision intentionally designed to support year one undergraduate nursing students who, due to the pandemic, had their in-person first year clinical practicum transformed to a remote clinical practicum was undertaken. To provide additional context, the first-year clinical practice course was revised and approved by the Canadian Association of Schools of Nursing (CASN) for implementation during the Winter 2021 semester. In its pre-pandemic format, this course was 380 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 designed as a 48 hour in-person clinical practicum, 8 hours per week, every other week, for 6 weeks, in a long-term care home (LTCH) or hospital rehabilitation unit. This practicum provided students an opportunity to begin to develop their entry-to- practice competencies including the development of skills necessary to create therapeutic relationships, assist patients with activities of daily living and utilize principles of infection prevention and control. Students were currently engaged in both focused and comprehensive health assessments. As well, they began to learn about the need to provide safe, competent, compassionate, and ethical nursing care (College of Nurses of Ontario [CNO], 2018). METHODS Procedure To maintain the integrity of the remote clinical practice, the planning of this foundational practicum for first year nursing students had to address program outcomes, course outcomes, weekly learning goals/objectives and clinical competencies. Purposeful connections to other requisite coursework and consideration of both delivery and student engagement was necessary. Due to the Pandemic, incoming students who had completed grade 12 remotely, had very limited exposure to practical nursing labs in the first semester. They attended all first semester nursing courses virtually and did not have an opportunity to engage with one another in-person. Many had also never been inside an Ontario hospital or long-term care home. This newly designed remote clinical practicum would occur weekly in a four-hour time block in groups with a ratio of one clinical instructor to 10 to 16 students. Weekly objectives were modified from those created for the in-person practicum as students would no longer be able to “perform” or “demonstrate” psychomotor skills. Bloom’s Taxonomy of Educational Objectives was utilized for development of all learning objectives (Bloom et al., 1956). Consideration of the College of Nurses of Ontario (CNO) Professional Standards throughout course development was essential in ensuring alignment with entry-to-practice standards. (CNO, 2018). Learning goals were contextualized to the new remote platform and a backward course design methodology was helpful in clarifying our focus in identifying and creating relevant and meaningful learning experiences and assessment/evaluation strategies that would be appropriate for year one students with limited experiences and exposure to the healthcare environment. This constructivist approach is learner-centred and begins with goal identification, proceeds to development of measurements of achievement and ends with selection of learning activities and strategies that will support learner acquisition of knowledge, skills, and judgement. (Wiggins, 1998; Fink, 2013; Wiggins & McTighe, 2005). Keeping the needs of our learners at the centre of the design of this remote practicum was critical for success. Considering the current global health crisis and the immediate priority in ensuring that students understood the relevance of infection prevention and control (IPAC) to their ongoing professional practice and personal safety, IPAC education was reinforced at the outset. Learning modules addressing personal risk assessment in both long-term care and acute care, control of the environment, chain of transmission, engagement with a virtual gaming simulation based on SARS-CoV-2, and proper use of personal protective equipment (PPE) remained in the evaluation of student learning. These content areas played an important role in mimicking a more realistic orientation to clinical practice. An existing reflective activity using the LEARN framework was also embedded into the student evaluation methods (College of Nurses of Ontario, 1996). LEARN (Look back, Elaborate, Analyze, Revise, New perspective) emphasizes thoughtful deliberation, critical thinking, change theory and aesthetic expression all of which support students in their development as reflective practitioners. Video vignettes depicting interactions between nurses, interprofessional teams, patients, families and significant others were used as a basis for the assignment. Students were asked to reflect and critically analyze the behaviours and best practices of the registered nurse in the vignette and consider areas of personal and professional development. In absence of real-life patient interactions, we hoped that this third- party reflection would provide some foundation for future reflective practice. To mimic inter-collaboration between healthcare providers, individualized nursing care planning was also included as a student evaluation measure. Two student assessments, one group and one individual, involved the creation of comprehensive nursing care plans based on a given “client profile” and were guided by the components of the Clinical Judgement Model (CJM) - recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes. (Sherrill, 2020; 381 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 Tanner, 2006). To honour the principles of Universal Design for Learning (UDL) the nursing care plans were created as oral presentations, with an accompanying informal written component (Center for Applied Special Technology, 2018). The final and most challenging element of this backward design approach was creating relevant, rigorous, and engaging curriculum content. Relying on the organic nature of a typical clinical placement, those experiences that naturally unfold in a real-life setting, was not possible. Instead, a comparable and relatable experience for students needed to be created. The first step in this process included brainstorming, researching, and vetting any available resources. Widely available and accessible external learning modules, videos, learning tools and virtual gaming simulations were explored by a team of faculty across the collaborative nursing program. It became apparent that most commercial learning suites were not suitable for a year one nursing student with limited nursing knowledge; most case studies and simulations were too detailed and required a certain level of prerequisite knowledge of which first year students do not have. Eventually several appropriate interactive online modules with supporting resources and relevant YouTube videos to support curriculum and keep students interested and engaged were identified. A selection of freely accessible Virtual Gaming Simulations also proved to be valuable learning activities. Client profiles: The main component of the practicum It was essential that intentional and integrated clinical experiences be generated for students. Clinical experiences would have to be brought to students, as very little was going to occur naturally or spontaneously as it normally would in a face-to- face clinical placement. The decision was made to move forward with a case study-based, problem-based learning (PBL) approach where students could work cooperatively together in the remote setting and learn from real-world scenarios. PBL helps foster strong communication, critical thinking, and self-directed learning skills, promotes teamwork and leadership and a development of lifelong learning skills all of which are essential to the nursing profession (Cartwright et al, 2017; Kong et al., 2014). Sixteen “client profiles” of varying levels of difficulty; scenarios that could unfold with instructor support and serve to address a myriad of issues that students would commonly encounter in a typical initial clinical placement, were created. Appendix 1 and Appendix 2 for an example of a client profile case study and nursing care summary, respectively. Course learning outcomes addressed during the first semester nursing courses were used when creating client case profiles and care summaries, with an aim to give opportunities for novice students to focus on communication skills necessary for building both therapeutic nurse-client relationships and foundational nursing skills. Profiles were carefully crafted with consideration of principles of equity, inclusion, and diversity. Each nursing care summary included relevant history and nursing care needs. Profiles were introduced weekly with increasing complexity, to include comorbidities, additional psychosocial elements, and family dynamics. In addition, students examined advancing aspects of health assessment, communication skills and application of other theoretical knowledge. The introduction of each new weekly client profile was intentional and supported with other relevant theoretical concepts including caregiver support, patient-centred language, dementia care, equity, diversity, and inclusion in patient care. These client profiles became the main component of our remote clinical experience and together with detailed nursing care summaries, guided students in their critical thinking and development of clinical judgement. Application of the CJM, using a guided template/worksheet and creation of comprehensive and individualized care plans, was emphasized (Sherrill, 2020; Tanner, 2006). This guided worksheet outlined the core elements of the CJM: recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes. The goal was to introduce students to a diverse group of “patients” and “long-term care residents”; individuals requiring both physical and psychosocial support, with accompanying opportunities to support novice students as they built skills in personal organizational management, health assessment, critical thinking, problem-solving, clinical reasoning, and clinical judgement skills. Clinical instructors would be instrumental in facilitating movement through each scenario and supporting application of the CJM. Maintaining students’ focus and attention to course content required clarity and structure; it also demanded that clinical instructors who were responsible for supporting this learning think intentionally about how to motivate and engage students, prompt interaction, support students in their questioning and assess student learning. To enhance consistency and continuity in course 382 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 delivery, “Road Maps'' or prescriptive daily outlines were designed to support clinical instructors in facilitating a PBL approach, managing time in the four-hour block and in providing guidance in covering concepts/content designed to meet weekly learning objectives and overall practicum objectives. Suggestions for supporting student learning were provided to the instructors on a weekly basis, including recommendations for introducing the client profiles and facilitating supportive learning activities, but room for flexibility and academic freedom existed. Client profiles and unfolding case studies actively engaged our learners by providing opportunities for applying newly acquired concepts to scenarios, supporting knowledge transfer and increasing confidence (Cleveland et al, 2015). Narrative approaches, instructional storytelling and the sharing of real-life examples was also useful in the absence of actual clinical context (Timbrell, 2017). Clinical instructors, who are current practitioners, drew upon their clinical expertise to facilitate group discussion through the use of the CJM. Data Collection A course evaluation of the remote clinical practice using a Google survey link took place on the last clinical day (week 12 of the students’ academic calendar). An announcement was posted on the student learning management system (Blackboard/D2L/Brightspace) to participate in the course evaluation. Within the announcement a Google survey link was provided. Students were also notified that the survey was anonymous. The course evaluation was purposefully completed in week 12 after all student evaluations for the course had been completed. A limitation with the use of online surveys is that students may respond in a manner that is favorable as they may perceive their participation to reflect their course grade. Hence, the course evaluation was deliberately delivered at the end of the course when all evaluations had been completed. The evaluation consisted of 5 sections using a 5- point Likert scale (strongly agree, agree, neutral, disagree, strongly disagree). The first section contained 8 questions inquiring about students’ experiences with the delivery of remote clinical practice; the second section consisted of 9 questions reflecting on students’ experiences with the content covered throughout the practicum; the third section consisted of 5 questions inquiring about students’ experiences with the various course evaluations, the fourth section inquired about the students’ evaluation of their clinical instructor using 10 questions. The last component of the course evaluation contained open-ended questions regarding what students would have liked to see more of or less of in either the content or delivery of the remote clinical course. Research Ethics Board Research Ethics Board (REB) approval was sought but not needed on the basis that course evaluations designed to evaluate student learning and/or assess the effectiveness of remote teaching modules to inform future course development are exempt from review and do not require REB approval. RESULTS A total of 368 students out of 490, resulting in a response rate of 75%, completed course evaluations. The overall results indicated that majority of students (88%, n=322) strongly agreed/agreed that the remote clinical course successfully introduced students to the profession of nursing as a practice discipline and 99% (n=344) indicated that the learning activities supported the course learning outcomes and fostered different types of interaction (i.e., instructor-student, content-student, student- student). In relation to the course content, students also strongly agreed/agreed that the course content allowed students to 1) develop an understanding of the role of the nurse within an interdisciplinary team (93%, n=340); 2) apply theoretical caring nursing skills (91%, n= 332 ), 3) apply communication strategies (91%, n= 333 ), 4) develop critical thinking strategies (89%, n= 327), and 5) apply theoretical foundational nursing skills (87%, n=320) to support client’s health and well-being. Lastly, students strongly agreed/agreed that the client profiles and care summaries used throughout the course allowed students to integrate and apply knowledge from each of the first-year courses to their nursing practice (97%, n= 353). Open-ended questions surveyed students on what they would have liked to see more or less of in either the content or delivery of the remote clinical course. Overwhelmingly, students indicated that they would have preferred a shorter class duration rather than the 4-hour class time. Students also indicated that they would have liked to see more interactive virtual simulations where they could “practice making clinical decisions regarding patients as well as videos that portray a day in the life of a nursing student” in order to really get a grasp of what nursing students do throughout a clinical shift in clinical practice year 383 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 1. For instance, one student indicated, “I would like to see more VGSs [virtual gaming simulations] that simulate the real clinical experience more. With remote clinical, the main thing you want to see is what the actual clinical experience is like, especially if you haven't experienced it before”. Overall, the results of the course evaluation indicated that the students perceived their remote clinical practice to have been a positive and enjoyable learning experience. Students also indicated that in future revisions of the course, they would like to see more of a hybrid; in-person clinical practice linked to remote content delivery. This hybrid model would allow students to meet remotely to think through, review and build links from content to clinical experience. Frequently in clinical practice there is not enough time set aside to discuss, reflect, and link content to the students' experiences in clinical as they occur. Environments are usually fast-paced, and students are scattered among the unit assigned to different patients. Clinical instructors were also provided with a course evaluation at the end of week 12 of the academic calendar. Results aligned with student responses but remain beyond the scope of this paper as the aim of this paper is to describe the key features and lessons learned during the development of a remote clinical practice curriculum for first year nursing students with a focus on students' experiences. DISCUSSION Lessons Learned Although students responded very favorably to this remote clinical experience, there were several important lessons learned. Clear, frequent communication with both students and clinical instructors, comfort with technology and an ability to remain flexible and genuine with students is essential. Students indicated that a four-hour block of time spent in a remote setting was too long. Even though instructors used break out rooms, provided nutrient and other breaks as well as other techniques to engage and energize students, ‘zoom fatigue’ was identified as an ongoing challenge throughout the course and within the course evaluation. The student course evaluation suggested that the clinical profiles and accompanying nursing care plan summaries were valuable to this experience. Using problem-based learning we hoped to support the development of clinical reasoning and critical thinking skills in our novice learners. Development of sound clinical judgement skills takes time to cultivate; being able to critically think and carefully work through the various nursing scenarios and receive support from both instructors and peers in the development of comprehensive and individualized care plans using a problem-based learning approach demonstrates a promising benefit to students. Dedicated time to support the client profiles with supportive concepts and the intentional integration of both prerequisite and corequisite nursing coursework was an advantage. IMPLICATIONS The COVID-19 pandemic forced schools of nursing and allied health care programs in Canada and around the world to find alternative delivery formats as in- person student practicums were prohibited. Lessons learned through our experience are highlighted in this paper and may provide key points when considering alternative student learning opportunities. As the COVID-19 pandemic continues and the demand for remote curriculum delivery increases, the need for an alternative or hybrid format for learning will persist. The significant lessons learned and highlighted may serve to meet these ongoing challenges while maintaining academic program standards, and manage the competing demands for in-person practicum placements for students in health-related professional programs. CONCLUSION Although a remote clinical practicum is possible to create and may be beneficial to novice students, it will not take the place of a face-to-face clinical experience where students can interact with and care for real patients. Feedback from the course evaluation suggests that a hybrid model that involves clinical time online to thoughtfully work through carefully and intentionally designed case studies combined with an opportunity to practically apply this learning in a face-to-face clinical environment holds promise for novice nursing students. Additional research in the use of a hybrid model for early clinical learning is still needed. REFERENCES Bloom, B. S., Englehart, M. D., Furst, E. J., Hill, W. H., & Krathwohl, D. R. (1956). Taxonomy of educational objectives: Handbook 1. Cognitive domain. Longmans Green. Cartwright, P., Bruce, J., & McInerney, P. (2017). 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Journal of Education and Health Promotion, 9:311. https://doi: 10.4103/jehp.jehp_438_20 https://www.cno.org/globalassets/docs/reg/41037-entry-to-practice-competencies-2020.pdf https://www.cno.org/globalassets/docs/reg/41037-entry-to-practice-competencies-2020.pdf https://www.cno.org/globalassets/docs/reg/41037-entry-to-practice-competencies-2020.pdf https://www.cno.org/globalassets/docs/prac/41006_profstds.pdf https://www.cno.org/globalassets/docs/prac/41006_profstds.pdf 385 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 Appendix 1. Client Profiles Client Profile - Aki Stevens Aki lives at home in a small-town reserve just north of Mississauga, Ontario. She is a member of the Mississaugas of the Credit First Nations. She was admitted to the city hospital 5 days ago to have surgery for her fractured left femur after a fall at home. She has type 2 diabetes and is supposed to follow a prescribed diet to keep her blood sugar levels stable. She does not like taking analgesics for her leg pain or going to physiotherapy. She is anxious to return home to her family. You are assigned to Aki Stevens today (0700 – 1200) Aki Stevens is a 66-year-old Ojibwe woman. She speaks both Anishinaabemowin and English. Prior to hospitalization she was living with her family of 2 adult children and their spouses and 3 grandchildren. She has a close-knit community of friends, spiritual leaders, and other extended family. Her family have brought in food for her since the surgery; however, they have been discouraged in doing this for Aki to achieve stable blood sugar levels. Aki tells you that she is not eating the food her family provides anymore and instead follows the hospital diet, but you notice her meals are largely left unfinished. Although her family tells you that Aki is normally a very social person at home, Aki refuses to go to her rehabilitation classes now and keeps to herself. She does not seem to want to talk much. Although she does not want any analgesics and says she is not in pain, you see her flinching and limping her way to the washroom. Due to her surgery, she has a trapeze bar, trochanter roles, and a raised toilet seat to assist her positioning. She tends to lie on her back avoiding interactions with others and a small red area has begun to form over her sacrum. She can wash herself if brought a basin to the bedside. When you talk with her family, they share that Aki feels out of place here. She knows that others stereotype Indigenous persons as alcoholics and fears being labelled. She is not used to the food here yet is being pressured to eat it and according to her daughter is experiencing Post Traumatic Stress Disorder (PTSD). Aki’s eldest daughter has also shared that Aki is a residential school survivor and has told her family that she was often forced to eat unpleasant foods while attending the residential school. She feels stressed and admits to her family that she has pain, both physical and spiritual, with which smudging would normally help. She is anxious to go home; however, she will not be discharged until she can ambulate safely and has stable blood sugars. Nursing Care Considerations: Cultural values/beliefs - care requires sensitivity to background and Indigenous culture/cultural values/ceremonies eg. smudging practice for pain and stress while hospitalized. PTSD – residential school survivor Social engagement with family, friends, spiritual leaders, and elders. Interprofessional Team - collaboration with dietician re: culturally therapeutic meal plans that client will follow that also allows family to provide food; include family in all aspects of care. Assisting with ADLs in hospital/encouraging independence where possible (set up Aki with basin to wash her face/oral hygiene). Encourage and assist bedside mobility; address potential issues re: skin care Exercise/risk of deconditioning - continuing PT/OT in the community. Other community supports within the reserve. 386 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 Appendix 2. Client Care Summary Patient Name: Aki Stevens Age: 66 Sex: Female Gender: identifies female Primary Diagnosis: Left Femur fracture Admit/Transfer Date: February 5, 2021 Secondary Diagnosis: Type 2 Diabetes From: Home Date Completed: Feb 5, 2021 MRSA/VRE Screening: Completed – negative for MRSA and VRE COVID-19: Completed - negative Allergies: No known allergies Active Infection: none Isolation Precautions (SPECIFY): (X) No ( ) Yes – Contact Precautions Medication Reconciliation: (X) Yes ( ) N/A Date Ordere d Laboratory Tests/Diagnostic Procedures: Date Done MD/NP Notified to Complete: Marion laRoc, NP Date Notified: Feb 5, 2021 Feb 5, 2021 CBC, Cr, eGFR, Platelet count, clotting time, A1C, FBS, TRIG Feb 5,6,7, 2021 (RN to complete if not completed by MD/NP) History/Previous Surgery ORIF Left Femur February 5, 2021 Living Environment Lives with extended family at home. Mississaugas of the Credit First Nations, Brantford, ON Next of Kin/Relationship/Contact Number 387 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 Sally Stevens 716-444-1234 (sister) Communication (specify) Speech: Fluid, no deficits – understands and speaks English clearly Hearing: Intact, no deficits Visual: Requires glasses for reading Language: Anishinaabemowin, English Nursing Diagnoses for Consideration 1) Alteration in comfort, acute pain r/t post-operative status as evidence by non-verbal cues, physical behaviour (reluctance to participate in rehabilitation) 2) Impaired physical mobility r/t post-operative pain and discomfort as evidenced by facial grimacing and slow movement 3) Potential for ineffective individual coping r/t hospitalization, loss of independence and spiritual distress 4) Potential impairment of skin integrity r/t immobility, poor positioning, and pressure 5) Potential for impaired nutritional intake r/t lack of preferred foods 6) Risk for falls r/t muscle weakness and deconditioning 7) Knowledge deficit (e.g. diet) r/t lack of exposure to relevant resources Date Vital Signs 02/13/20 T. P. R. &BP: q 4 hours CSM: q shift O2 Saturation: q 4hours CBGM: before meals tid or as ordered Pain Assessment: prn Date Nutrition/Hydration 02/13/20 Type: 1800kcal diet, high fibre Specific Concerns: N/A Food Allergies: None identified Swallowing Difficulties: None (X) Self ( ) Feed with Assistance Set Up: none Supplements: Oral: N/A Other (Specify): N/A () Tube Feeds ( ) IV Hydration () NPO 02/13/20 Interventions: • Independent, diabetic and CFG meal planning (family teaching required) • Encourage client to follow prescribed diet/consult with dietitian re: cultural preferences, PTSD may be triggered due to experience in residential schools Date Hygiene 02/13/20 (X) Self Care () Bath with assistance () Complete bed bath/shower () Special Mouth Care: N/A, own teeth Specific Concerns: • Assist with mouth care at bathroom sink after breakfast & at bedtime Interventions: 388 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 • Shower planned for postop day 5-protect incision and brace • Assess ability to perform own ADL's with am & pm care Date Skin Integrity / Skin Care 02/13/20 ( ) Special Mattress (specify): Specific Concerns: • Wash incision gently with soap and water • Small stage 1 pressure ulcer on sacrum • Sutures to be removed Day 10 by visiting nurse ( ) Turn: q2-3h (X) Sutures Wound location: left femur Dressing Type: dry Frequency: daily 02/13/20 Interventions: • Assess skin integrity and record any significant findings or alterations • Monitor sacral ulcer; Braden Scale: complete weekly and encourage turning and mobility • Cleanse incision gently with soap and water daily, cover with dry dressing Date Mobility 02/13/20 (X) AAT no strenuous exercise ( ) Specify: limited ambulation, see interventions (X) Assistive Devices: • Crutches • Brace • Trapeze bar () Hoyer/Total lift • impaired posture & balance from stroke • weakness on left side (X) ROM: TID 02/13/20 Interventions: • Encourage client to do active ROM of left leg • Observe gait when using crutches • Educate client about the importance of movement and exercise; use trapeze bar; brace to be kept on • Encourage orthopedic physiotherapy classes • Place trochanter in supine and Fowler’s position • Consult with family re: cultural interventions (e.g., Smudging for pain relief) Elimination 389 IHTP, 1(3), 379-389, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 02/13/20 Intake/Output: () Toilet with assistance Specify: () Constant supervision/incontinence () Ostomy: Type & Location of stoma NG tube to: () STD () Intermittent suction *Raised toilet seat Specific Concerns: () Constipation () Diarrhea () Prostate Problems Date of last BM: see Intake/Output record Foley Catheter: N/A Size: _________ Balloon: _________cc Date inserted: Date to be changed: Date to be removed: Drains & Irrigation needs (specify): () Foley () Condom Catheter () Silastic () CBI () Other (specify): 02/13/20 Interventions: Independent Safety & Security 02/13/20 Hearing: Intact Visual: presbyopia - glasses Specific Concerns: () Confusion /Agitation (Specify Concern): () Deficit (specify): Hearing: Visual: difficulty seeing near Interventions: • Needs glasses when reading. • Continue to support and encourage patient. She is firm in her goal to return home • Support family participation in care • Cultural preferences re: care must be explored both in hospital and in planning for discharge home