Course Syllabus

RNSG 1262 Clinical to:

Common Concepts of Adult Health

Revision Date: 5-15

Catalog Description: Students are provided detailed education, training and work-based experience in direct patient/client care, generally at a clinical site. On-site clinical instruction, supervision, evaluation and placement are the responsibility of the college faculty. Clinical experiences are unpaid external learning experiences. Lecture hours = 0, Lab hours = 8

Prerequisites: RNSG 1201, 1205, 1309, 1362

Co-Requisites:RNSG 1441

Semester Credit Hours: 2 Lecture Hours per Week: 0 Lab Hours per Week: 8 Contact Hours per Semester: 128

State Approval Code: CIP 51.3801

Instructional Goals and Purposes: The purpose of this course is to prepare students to use the

nursing process in providing preventive, restorative, and maintenance/supportive care for adult clients and their families. Nursing care will be provided for specific adult health disorders working from the framework of the nurse as a Member of the Profession, Provider of Patient-Centered Care, Patient Safety Advocate, and Member of the Health Care Team.

Specific Course Objectives (includes SCANS):

THE NURSE AS A MEMBER OF THE PROFESSION:

At the end of the course using classroom application, the student will be able to:

Course Objective I : Differentiate between activities that are and are not within scope of nursing practice. SCANS I A i,iv,v, B ii,iii,v, C v; II B iii,C i

PO# 1 DEC# I, A

Course Objective 2 : Use reflection and feedback to improve practice. SCANS I A i,iv,v, B iii,iv, C I,iv,v; II Bv,Ci,iii

PO# 2 DEC# I, B,C,D

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THE NURSE AS PROVIDER OF PATIENT-CENTERED CARE:

At the end of the course using classroom application, the student will be able to:

Course Objective 3 : Use systematic holistic approach to meet healthcare needs of patients with common healthcare needs. SCANS I Ai, iv,v,B i,ii,iii,iv,v, C i, iii iv,v; II Ai,iii,iv, B,I,ii,iii,v,vi, C i,ii,iii, E ii,iii

PO# 3 DEC# II, A,B,C

Course Objective 4 : Plan and implement individualized teaching plans for adults with common healthcare needs to facilitate health promotion, maintenance and restoration. SCANS I A i, iv,v,B i,ii,iii,iv,v, C i, iii, iv,v; II A i,iii,iv, B,I,ii,iii,v,vi, C i,ii,iii, E ii,iii

PO# 4 DEC# II, G

Course Objective 5 : Provide nursing care to patients with common healthcare needs based on evidence-based practice and available resources. SCANS I A i, iv,v,B i,ii,iii,iv,v, C i, iii iv,v; II A i,iii,iv, B,i,ii,iii,v,vi, C i,ii,iii, E ii,iii

PO# 5 DEC# II,D,E,F,H

THE NURSE AS PATIENT SAFETY ADVOCATE:

At the end of the course using classroom application, the student will be able to:

Course Objective 6 : Administer medications and treatments to patients with common healthcare needs safely, with supervision. SCANS I A I,ii,iii,iv,v, B ii,iii,iv, C I,iii,iv,v; II A i, iii,iv, B i,iii,vi, C iii

PO# 6 DEC# III, A,B,D

Course Objective 7 : Formulate goals and outcomes using evidence-based data to reduce patient risks. SCANS I A, i,ii,iv,v, B i,ii,iii,iv,v, C i,iii,v; II A i, ii,iii,iv, B i, ii,iii,iv,vi, C i, ii, iii

PO# 7 DEC# III, C,E,F

THE NURSE AS A MEMBER OF THE HEALTH CARE TEAM:

At the end of the course using classroom application, the student will be able to:

Course Objective 8 : Practice confidential interaction with patients and Health Care Team members to meet needs of patients. SCANS I A,I,ii,iv,v,B ii,C i, iii,iv,v; II B i, iii,vi, C iii

PO# 8 DEC# IV, A,D

Course Objective 9 : Anticipate resources needed in order to provide access to quality care for patients. SCANS I A i,ii,iv, B i, ii,iv, C i,v; II A iii,iv, B iii, iv,v, vi, C iii

PO# 9 DEC# IV, B,C

Course Objective 10 : Demonstrate ability to use technology systems and skills including EHR. SCANS I A, i, ii,; II A i,ii, iii,iv, E i,ii

PO# 10 DEC# IV, E

Course Objective 11 : Differentiate between activities that can and cannot be delegated and how and to whom they can be delegated. SCANS I A, i, ii, C i,iv,v; II A iv, B i,iv,vi, C iii

PO# 11 DEC# IV, F,G

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Methods of Instruction/Course Format/Delivery:

Clinical assignments Student-Teacher conferences

Client care assignments Computer Assisted Instruction

Clinical conferences, pre/post Return demonstration

Group discussion

Observation Service learning project

Students are expected to be self-directed independent learners throughout the semester. All learning resources listed may include testable information. Students are responsible for material that is updated from the Evolve website for their current textbook. Students are expected to login to the following website for use of web resources: http://evolve.elsevier.com/staticPages/index.html and register as a student for the free learning resources accompanying this textbook.

Core Competencies: Students are expected to demonstrate basic competency in reading, writing, oral communication, math and computer skills. Students are expected to be active learning participants by assuming accountability in preparing for each class by completing required readings and/or other learning activities as listed in each unit assignment. Proficiency will be measured by examination scores, oral discussions, and computer assisted instruction (CAI) participation. Course Requirements: 1. Regular class attendance within current attendance policies. 2. An average of 75% or better on nursing process work. 3. Preparation and active participation in class discussions. 4. Outside individualized research in texts, videos, case studies and journals. 5. Completion of assignments outlined in syllabus. 6. Compliance with all rules and regulations as outlined in current Department of Nursing Student

Handbook and Panola College Catalog. 7. Current American Heart Association, Health Care Provider, Basic Life Support (BLS) certification. 8. Demonstration of college-level skills following American Psychological Association (APA)

guidelines. MEDICATION ADMINISTRATION EXAM: Students are required to demonstrate calculating dosages and solutions by achieving a score of 100% on a Medication Administration Exam given before the first clinical day. The student will have three opportunities to achieve a score of 100%. If the student does not achieve 100%, he/she must withdraw from the course with a grade of an “F”.

Assessment: Each student will be evaluated on e-value at the mid and endpoint of this clinical course. Individual conferences will be set up upon request. The evaluation will be based on observation of the student’s performance and behaviors in the clinical setting and all required written assignments. The student is expected to complete the student mid-term and final self-evaluations in e-value. Care plans, CIS client forms, and other written assignments are due at the beginning of the next clinical day**. For example, if clinical day is Monday, the care plan and/or CIS are due the next Monday at the beginning of the day. If you will not be at the hospital clinical site that day, you will upload your assignment to the assignment in the Canvas gradebook. Written care plans are one of the primary means for the instructor to evaluate the student’s ability to apply the nursing process in the clinical setting. **Late work will not be accepted unless there are serious extenuating circumstances. Prior permission must be obtained from the instructor, and the instructor will make the determination. If written

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work is turned in after the assigned deadline with instructor approval, 80% is the highest grade possible. Students who do not submit work by the assigned due date and time will receive a zero for the assigned work. The following items will be assigned during the semester and used to calculate the student’s final grade: Final grades will consist of the following: Clinical Evaluation tool 90% Case Studies 10% Clinical Evaluation (90%) consists of the following:

Nursing Care Plans for each med-surg hospital patient and dialysis clinical experience (one of two patients when two assigned) to meet syllabus requirements. (No care plan required for ED rotation, OR rotation or clinic time, however a clinical log should be turned in). A care plan and CIS should be done for your patient during the dialysis rotation, if you have not already scored above 90% on two care plans. No grades will be dropped.

Completion and submission of Client Information Sheets on all patients assigned in hospital and dialysis (not required for ED rotation, OR rotation or clinic visit.)

Completion and submission of two (2) Braden Scale Assessments during semester (for appropriate patients).

Observed Patient Assessment

Completion and submission of clinical log for specialty areas assigned (ED, OR, clinic)

Oral presentation of current nursing journal article from Nursing (year), American Journal of Nursing or RN. Articles from other journals must be approved by the instructor.

Completion and submission of 2 clinical teaching worksheets.

Completion of Home Health Agency Summary following assignment instructions.

Participation in pre-and/or post-clinical conference

Faculty observations

Other written assignments as assigned by faculty

Logging of skills in the e-value system each clinical day.

1. Students will be assigned clients for the clinical experience during report. Completion of the Client Information Sheet (which incorporates the Medication Information Sheet) is required on each client. Students will be expected to be knowledgeable of the medications their client(s) is (are) on. Note: Students arriving late to clinical will be sent home.

2. Nursing Care Plans: For each client care plan the student must have two nursing

diagnoses, one goal per diagnosis, and a minimum of 3 interventions per diagnosis.

On each CIS form, the student must list at least three (3) nursing diagnoses in priority order. The two diagnoses the student works up must be the top two unless directed otherwise by clinical instructor.

The course requires a minimum of 5 care plans for the semester. Students may complete two (2) additional care plans to allow the instructor to substitute for the 2 lowest grades. You must pick an additional hospital patient for each care plan and notify the instructor.

The rationales for each intervention must be supported by current references, to include the listed textbooks. At least one reference must be a current journal article (not the abstract), which the student must attach to the care plan. The journal must be a professional journal, not an article/website meant for patient teaching or layperson use. Ackley, as well as other care plan books are not considered textbooks for reference purpose and may not be used as a cited reference for rationales.

3. Medication Sheets: Must include all fields completed. Class of drug refers to

pharmaceutical class. Must include action (how the drug works) and why this client is receiving this drug at this time.

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4. Oral Presentation: Must be from a nursing journal and addresses the nursing care of a client with the selected topic. If the student desires to use a different nursing journal, he/she must clear the selection with the instructor. The topic is not to address the medical entity but the nursing care of the client. The student is expected to present the material, not read the article to the class.

5. Clinical Teaching Worksheet: The student must complete the clinical teaching

worksheet for two (2) of the patients they are assigned. Students will turn in the teaching worksheets to his/her clinical instructor for grading purposes.

6. Home Health Agency: Each student will complete a one-two page summary of their

experience at the home health agency. Include: 1) the role of the agency in the community,2) your personal experience that day, 3) compare and contrast the role of the home care nurse with that of the hospital nurse. This report must be typed using APA format.

7. Skills Checklist: Students are to maintain their skills checklist and enter skills performed

in the “E-value” system at the end of each clinical day. It is the student’s responsibility to maintain the forms appropriately. If the e-value portion is not completed, a grade of “F” will be recorded for the course. While it is not expected each student will be able to complete every item on the checklist, it is to the student’s benefit to complete as many as possible during this semester.

Achievement examinations will be administered throughout the nursing program. In addition to fulfilling the academic requirements of Panola College, all students must successfully pass a comprehensive achievement examination in the final semester of the nursing program in order to be eligible to graduate. This is the capstone experience. Please refer to the Student Handbook for further information about scores required on each specialty HESI and the policy on the comprehensive achievement examination. In preparation for these examinations and the NCLEX for licensure after graduation, students are advised to increase their exposure to multiple-choice questions similar to those they will see on NCLEX. This can be accomplished by completing periodic self-evaluation review exams as found in NCLEX Review texts. Case Studies/Patient reviews Students are required to complete assigned lessons on the evolve website by the date and time posted on the calendar. The first attempt score will be recorded as the grade for the activity. Students will be given one clinical day (8 hrs) as computer lab time for the above assignments. Failure to complete the assigned lessons on the date posted will result in 1 hour clinical absence for each lesson not turned in.

Course Grade: The student must have an average grade of 75 or above on all graded assignments in order to successfully pass this course. The Associate Degree Nursing Program, in accordance with policy, uses the following numerical scale in

computing final course grades: (see Grading Policy) A = 90-100 B = 80-89 C = 75-79 F = 74.99 and below

CLINICAL ASSIGNMENTS: THE NURSE AS A MEMBER OF THE PROFESSION: At the end of the course the student will be able to:

1. Differentiate between activities that are, and are not, with the scope of nursing practice. (PO #1)

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a. Adhere to laws governing the practice of nursing. b. Discuss situations and discuss what the nurse may legally do.

2. Use reflection and feedback to improve practice. (PO#2). a. Complete and review student evaluations. b. Participate in post-clinical discussions/activities. c. Review submitted work for opportunities to improve.

THE NURSE AS PROVIDER OF PATIENT-CENTERED CARE: At the end of the course the student will be able to:

3. Use systematic holistic approach to meet healthcare needs of patients with common healthcare needs. (PO#3) a. Analyze data accurately finding relationships among data. b. Prioritize the assessed needs of assigned clients. c. Classify client needs according to Maslow’s hierarchy. d. Formulate prioritized nursing diagnoses based on client assessment and need analysis. e. Formulate expected client outcomes accurately. f. Identify the role of the home care nurse.

4. Plan and implement individualized teaching plans for adults with common healthcare need to facilitate health promotion, maintenance, and restoration.(PO#4) a. Assess the client’s need for teaching and learning based on objective and subjective data.

b. Use a systematic approach in holistic care plan development. c. Implement appropriate teaching plans to meet the client’s need with consideration of age,

culture, educational level, and other areas of diversity. d. Evaluate effectiveness of teaching.

5. Provide nursing care to patients with common healthcare needs based on evidence-based practice and available resources.(PO#5) a. Reflect assessment of cultural influences, spiritual/religious beliefs and available support

systems in provision of care. b. Use non-judgmental caring behaviors. c. Implement appropriate interventions to restore optimal health and independence. d. Provide for clients’ comfort and pain management using holistic methods as wells as

conventional pharmacological interventions. e. Evaluate expected outcomes/goals accurately. f. Document client responses and rationale for termination of care. g. Use knowledge base, scientific rationale and supportive data in care delivery.

THE NURSE AS A PATIENT SAFETY ADVOCATE: At the end of the course the student will be able to:

6. Administer medications and treatments to patients with common healthcare needs safely and with supervision.(PO#6) a. Utilize five rights in administration. b. Verbalize action/purpose of medication prior to administration. c. Describe treatment and expected outcomes prior to performance.

7. Formulate goals and outcomes using evidence-based data to reduce patient risks.(PO#7) a. Take action to assure a safe care environment. b. Familiarize self with equipment/supplies prior to client usage.

THE NURSE AS A MEMBER OF THE HEALTHCARE TEAM: At the end of the course the student will be able to:

8. Practice confidential interaction with patients and health care team members to meet the needs of patients.(PO#8) a. Communicate verbally and in writing with other team members.

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b. Provide patient report to appropriate individual prior to departure from unit. c. Demonstrate client advocacy by protecting the client’s autonomy dignity, and rights. d. Maintain client confidentiality by the appropriate use of client information and disposal of

confidential information.

9. Anticipate resources needed in order to provide access to quality care for patients with common healthcare needs.(PO#9)

a. Provide discharge teaching to optimize self-care, restoration of health, and promote wellness behaviors for the client in the home environment.

b. Apply resources to assist client in meeting goals. c. Suggest appropriate referrals to meet client’s health care needs.

10. Demonstrate ability to use technology systems and skills including electronic health record

(EHR).(PO#10) a. Utilize computerized documentation when available in clinical site. b. Assess and utilize EHR in simulation activities.

11. Differentiate between activities that can and cannot be delegated and how and to whom they can be delegated.(PO#11) a. Discuss aspects of client care that may be delegated to support staff.

Texts, Materials, and Supplies:

The textbooks listed for RNSG 1441 will be used for this clinical course. Uniform, stethoscope, blood pressure cuff, penlight, hemostats, pen.

Other:

For testing services, use the following link: http://www.panola.edu/elearning/testing.html

If any student in this class has special classroom or testing needs because of a physical learning or emotional condition, please contact the ADA Student Coordinator in Support Services located in the Administration Building or go to http://www.panola.edu/student-success/disability-support-services/ for more information.

Withdrawing from a course is the student’s responsibility. Students who do not attend class and who do not withdraw will receive the grade earned for the course.

Student Handbook, The Pathfinder: http://www.panola.edu/student-success/documents/pathfinder.pdf

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SCANS CRITERIA

1) Foundation skills are defined in three areas: basic skills, thinking skills, and personal qualities.

a) Basic Skills: A worker must read, write, perform arithmetic and mathematical operations, listen, and speak effectively. These skills include: i) Reading: locate, understand, and interpret written information in prose and in documents such

as manuals, graphs, and schedules. ii) Writing: communicate thoughts, ideas, information, and messages in writing, and create

documents such as letters, directions, manuals, reports, graphs, and flow charts. iii) Arithmetic and Mathematical Operations: perform basic computations and approach practical

problems by choosing appropriately from a variety of mathematical techniques. iv) Listening: receive, attend to, interpret, and respond to verbal messages and other cues. v) Speaking: Organize ideas and communicate orally.

b) Thinking Skills: A worker must think creatively, make decisions, solve problems, visualize, know how to learn, and reason effectively. These skills include: i) Creative Thinking: generate new ideas. ii) Decision Making: specify goals and constraints generate alternatives, consider risks, and

evaluate and choose the best alternative. iii) Problem Solving: recognize problems and devise and implement plan of action. iv) Visualize ("Seeing Things in the Mind's Eye"): organize and process symbols, pictures, graphs,

objects, and other information. v) Knowing How to Learn: use efficient learning techniques to acquire and apply new knowledge

and skills. vi) Reasoning: discover a rule or principle underlying the relationship between two or more objects

and apply it when solving a problem.

c) Personal Qualities: A worker must display responsibility, self-esteem, sociability, self-management, integrity, and honesty. i) Responsibility: exert a high level of effort and persevere toward goal attainment. ii) Self-Esteem: believe in one's own self-worth and maintain a positive view of oneself. iii) Sociability: demonstrate understanding, friendliness, adaptability, empathy, and politeness in

group settings. iv) Self-Management: assess oneself accurately, set personal goals, monitor progress, and exhibit

self-control. v) Integrity and Honesty: choose ethical courses of action.

2) Workplace competencies are defined in five areas: resources, interpersonal skills, information, systems, and technology.

a) Resources: A worker must identify, organize, plan, and allocate resources effectively.

i) Time: select goal-relevant activities, rank them, allocate time, and prepare and follow schedules.

ii) Money: Use or prepare budgets, make forecasts, keep records, and make adjustments to meet objectives.

iii) Material and Facilities: Acquire, store, allocate, and use materials or space efficiently. Examples: construct a decision time line chart; use computer software to plan a project; prepare a budget; conduct a cost/benefits analysis; design an RFP process; write a job description; develop a staffing plan.

b) Interpersonal Skills: A worker must work with others effectively. i) Participate as a Member of a Team: contribute to group effort. ii) Teach Others New Skills. iii) Serve Clients/Customers: work to satisfy customer's expectations. iv) Exercise Leadership: communicate ideas to justify position, persuade and convince others,

responsibly challenge existing procedures and policies. v) Negotiate: work toward agreements involving exchange of resources, resolve divergent

interests.

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vi) Work with Diversity: work well with men and women from diverse backgrounds. Examples: collaborate with a group member to solve a problem; work through a group conflict situation, train a colleague; deal with a dissatisfied customer in person; select and use appropriate leadership styles; use effective delegation techniques; conduct an individual or team negotiation; demonstrate an understanding of how people from different cultural backgrounds might behave in various situations.

c) Information: A worker must be able to acquire and use information. i) Acquire and Evaluate Information. ii) Organize and Maintain Information. iii) Interpret and Communicate Information. iv) Use Computers to Process Information. Examples: research and collect data from various sources; develop a form to collect data; develop an inventory record-keeping system; produce a report using graphics; make an oral presentation using various media; use on-line computer data bases to research a report; use a computer spreadsheet to develop a budget.

d) Systems: A worker must understand complex interrelationships. i) Understand Systems: know how social, organizational, and technological systems work and

operate effectively with them. ii) Monitor and Correct Performance: distinguish trends, predict impacts on system operations,

diagnose deviations in systems' performance and correct malfunctions. iii) Improve or Design Systems: suggest modifications to existing systems and develop new or

alternative systems to improve performance. Examples: draw and interpret an organizational chart; develop a monitoring process; choose a situation needing improvement, break it down, examine it, propose an improvement, and implement it.

e) Technology: A worker must be able to work with a variety of technologies. i) Select Technology: choose procedures, tools or equipment including computers and related

technologies. ii) Apply Technologies to Task: understand overall intent and proper procedures for setup and

operation of equipment. iii) Maintain and Troubleshoot Equipment: Prevent, identify, or solve problems with equipment,

including computers and other technologies. Examples: read equipment descriptions and technical specifications to select equipment to meet needs; set up and assemble appropriate equipment from instructions; read and follow directions for troubleshooting and repairing equipment.

Secretary of Labor’s Commission on Achieving Necessary Skills (SCANS)

BASIC SKILLS in RNSG 1262: i, ii, iii, iv, v THINKING SKILLS in RNSG 1262: i, ii, iii, iv, v PERSONAL QUALITIES in RNSG 1262: i, ii, iii, iv, v RESOURCES in RNSG 1262: i, iii INTERPERSONAL SKILLS in RNSG 1262: i, ii, iii, vi INFORMATION in RNSG1262: i, ii, iii SYSTEMS in RNSG 1262: i EQUIPMENT in RNSG 1262: ii

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STUDENT ACKNOWLEDGMENT

I have read the Panola College Associate Degree Nursing program syllabus for

RNSG 1262 Clinical to Common Concepts of Adult Health. The items in the

syllabus have been explained to me. I understand that it is my responsibility to

seek any additional clarification that I may need from the instructor.

I will comply with the syllabus requirements as delineated. In addition, I will

comply with the current ADN Student Handbook as found on the ADN web

page. It is my understanding that this form will become part of my permanent

file.

_________________________ ______________________________

Student Name (print) Student Signature

_________________________

Date

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CARE PLAN GRADING CRITERIA

Student Name_______________________________

Date__________________________________

Possible Points

Points Earned

Assessment 20 _______ Includes only defining characteristics

for selected nursing diagnosis and

data to support related to organized by

subjective and objective data

Nursing Diagnosis 20 _______ -Appropriate for patient’s medical dx

& reason for hospitalization (top two)

-Appropriately worded to include: problem,

related to and AEB (if necessary)

Client Objectives 20 _______ -Related to nursing diagnosis

-Client centered

-Observable, measurable, specific

-Time limited

- Realistic

Nursing Interventions 20 _______ -Apply to R/T statement of nursing dx

-Individualized/specific

-Feasible/realistic

Rationale 10 _______ -Support each intervention

-Use one journal article per care plan

Evaluation 10 _______ -States how each outcome was

met during the clinical day.

Total _______

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Observed Physical Assessment Grading Criteria

Possible Points

Points Earned

A. General Survey: Overall appearance: skin color, posture,

Check IV lines, tubes, note site appearance,

IV fluid type, character of drainage from

all tubes. 5 _________

B. Mental Status: LOC, orientation, affect. 5 _________

C. Head/Face: Head: shape, hair; facial features; eyes:

drainage, equal movement, pupils, nose:

patency/drainage, mouth: mucous membranes,

condition of teeth,etc 5 _________

D. Neck: ROM; lymph nodes; carotid pulses;

JVD, listen for bruits. 5 _________

E. Anterior Chest: Inspection: resp effort (rate/depth), symmetry

Breasts, skin

Auscultation: listen lung sounds all fields

Listen for heart sounds at 5 points 5 __________

F. Posterior Chest: Inspection: above plus ROM

Auscultation: listen lung sounds all fields 5 __________

G. Abdomen: Inspection: shape, contour, pulsations skin.

Auscultation: BS all 4 quadrants; bruits.

Palpation: light palpation all 4 quadrants 5 __________

H. Extremities: ROM all extremities; symmetry present;

Muscle strength; quality/presence of pulses;

Hair distribution; capillary refill; skin;

Presence of edema; sensation in all 4 extremities 5 ___________

TOTAL 40 ___________

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NAME: __________________________________________ DATE: _______________________________

DO NOT LEAVE ANY BLANKS

Panola College ASSOCIATE DEGREE NURSING

RNSG 1262

Student: Clinical Date: Instructor:

CLIENT INFORMATION SHEET (CIS)

*Background Information

Pt. Initials: Date of Adm: Admitting Medical Diagnosis:

Admission

Vital signs:

T P Surgery type and Post-Op day

(If applicable)

R BP

Age: Allergies (all types):

Pertinent Past Medical History

Sex: Chief Complaint on admission

Height Weight BMI

Ethnicity: Dentures Upper Lower Fluid Restriction

Religion: Hearing Loss: Rt: Lt: Diet:

Marital Status:

Glasses Y N Diet Rationale:

(why)

Contacts Y N

Activity: Reason

Code Status: Advance Directive?

Occupation: Previous Occupation:

Safety Considerations:

Braden Scale:

Hx tobacco use: pack year history

Hx. Alcohol or substance abuse:

Fall Risk: Aspiration Risk: Other:

Treatment and Special Orders: (include all such as TCDB, incentive spirometry, resp Tx, telemetry,FSBS,,your nsg

interventions, etc)

Treatment/ Procedure Frequency Rationale for Treatment/Procedure

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Nursing Assessment

Area Findings Points General Survey: Overall

appearance: skin color,

posture; IV type, site

appearance; IV fluid

type; character of

drainage from all tubes

(type); VS

/5

Mental Status

LOC, orientation, affect

/5

Head/Face

Head: shape, hair; facial

features, eyes: drainage,

equal movement, pupils

Nose: patency/drainage

Mouth: mucous

membranes, condition of

teeth

/5

Neck

ROM; lymph nodes;

carotid pulses; JVD,

listen for bruits

/5

Anterior Chest

Inspection: resp effort

(rate/depth), symmetry

Auscultation: listen for

lung sounds in all fields

Listen for heart sounds

@ 5 points

/5

Posterior Chest

Inspection: as above

Auscultation: lung

sounds in all fields

/5

Abdomen

Inspection: shape,

contour, pulsations

Auscultation: BS in all 4

quadrants

Palpation: light palpation

in all 4 quads

/5

Extremities

ROM; symmetry; muscle

strength;

quality/presence of

pulses; capillary refill;

skin; presence of edema

Sensation

/5

Genitalia/perineum:

Skin, urinary catheter; as

applicable

/0

/40

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List ALL Current Routine and PRN Medications with dosages: Use medication sheet from RNSG 1262 syllabus. Attach to this assessment sheet.

VOLUME (PRIMARY) INTRAVENOUS (IV) THERAPY

IV/Additive

Solution Tonicity Ordered

rate

Rationale for use

specific to your client

Nursing Considerations

specific to your client

Lab Data:

Lab Test Result (s) & Date (s) D: = date

Normal Range

Brief Rationale for Abnormalities

CBC D: D: D:

WBC

RBC

Hgb

HCT

Platelets

Coagulation

PT

PTT

INR

Chemistries

Na+

K+

Cl-

CO2

BUN

Glucose

Creatinine

Ca

Protien, total

Albumin,serum

Bilirubin, total

Alkaline phos

ALT

AST

UA

Color

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Appearance

Sp Gr

pH

Protein

UA D: D: D: Normal Rationale

Glucose

Ketone

Urobilinogen

Blood

Leukocyte

Nitrate

Epith Cell

Mucus

WBC

RBC

Bacteria

Other labs:

Amylase

Lipase

Cholesterol

HDL

LDL

Triglycerides

CK

CKMB

Troponin

D-dimer

BNP

Diagnostic tests: (x-rays, MRI, EKG, EGD, etc) (continue on back, if necessary)

Date Diagnostic Test Results Rationale for test Nursing Implications

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Chief Complaint and Brief History of Present Illness:

Pathophysiology of current illness and major medical diagnosis: Focus on current admission plus medical problems covered in this semester (RNSG 1441) (use back if necessary) Nursing considerations for significant medical diagnoses: what do you need to know to take care of this patient this clinical day?

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Time Table (organize your activities for the day ):

Time: Assessment Medications Treatments and

Procedures Activities ADLS

0700

0730

0800

0830

0900

0930

1000

1030

1100

1130

1200

1230

Prioritized List of Nursing Diagnoses for this Patient: (include R/T and AEB for each) 1. 2. 3.

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CLINICAL EVALUATION TOOL and GRADING SHEET *This form is used to score the student during the clinical evaluation. It includes all the unit learning

objectives

Student Name: _______________________ Semester: ____________________

CRITERIA POINTS

MID-TERM END OF SEMESTER

THE NURSE AS A MEMBER OF THE

PROFESSION

1. 1.Differentiate between activities that are and are

not within the scope of nursing practice. (PO #1)

Follows legal, ethical, and professional standards

of nursing practice, advocating for clients, and

acting responsibly within limits of nursing

knowledge and scope of practice. Follows

faculty’s instructions. (10 points).

2. Use reflection and feedback to improve practice.

(PO#2).

Appropriately dressed with name tag, equipment

and on time. (5 points).

Complete and review student evaluations (5

points).

Seeks input to improve practice. (5 points)

Seeks learning experiences that enhance student

development and improve practice. Participates in

pre- and post-conference. (5 points).

Fill out completely & submit all written

assignments on time. (5 points).

THE NURSE AS PROVIDER OF PATIENT-

CENTERED CARE

3. Use systematic holistic approach to meet

healthcare needs of patients with common healthcare

needs (PO3).

a. Braden Scale Assessment (5 points each)

1.

2.

b. Patient Assessment – observed (40 points) *

1.

c. Client Information Sheet (5 points each) minimum

of 5

1.

2.

3.

4.

5.

d. Care Plans (100 points each) 5 required *

1.

2.

3.

4.

5.

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6.

7.

*If score of 90 or above, only two will be required.

4. Plan and implement individualized teaching plans

for adults with common healthcare needs to

facilitate health promotion, maintenance, and

restoration (PO4)

a. Teaching plans (10 pts each) 2 required.

1.

2.

b. Submit written summary of experience of home

health agency to include role of the agency. (5

points) or participation in health fair.

c. Completes clinical log for all specialty areas (5pts

each)

1.

2.

3.

4.

5. Provide nursing care to patients with common

healthcare needs based on evidence-based practice

and available resources (PO5).

a. Provide for client’s comfort and pain

management using alternative methods as well as

conventional pharmacological interventions.

(5pts)

b. Documents client’s responses and provision of

care appropriate to the facility. ( 10 pts).

c. Summarizes and shares current journal article as

assigned. (10 points)

THE NURSE AS A PATIENT SAFETY

ADVOCATE:

6.Administer medications and treatment to patients

with common healthcare needs safely and with

supervision.(PO#6)

Utilizes five rights for medication administration

(20 points).(Must have a minimum of 15 points

to pass course)

Verbalizes action/purpose of medication prior to

admin (5 points).

7. Formulate goals and outcomes using evidence

based data to reduce patient risks.(PO#7)

Takes appropriate action to assure a safe care

environment. (5 points)

Familiarizes self with equipment/supplies prior

to usage. (5 points).

THE NURSE AS A MEMBER OF THE

HEALTHCARE TEAM

8. Practice confidential interaction with

patients and health care team members to

meet the needs of patients (PO8)

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Communicate with other team members and

classmates to provide optimum care and

promptly correct violations of client care

standards. Follow appropriate lines of authority

within organization and follows faculty’s

instructions. (10 points)

Provide client report to appropriate nursing staff

prior to departing. (5 points) *

9. Anticipate resources needed in order to provide

access to quality care for patients with common

healthcare needs (PO9)

Suggest appropriate referrals to meet client’s

health care needs (5 points).

Organize assigned tasks and resources to

complete care in designated time frame. Apply

resources within agency. (10 points)

10. Demonstrate ability to use technology systems

and skills including electronic health record

(PO10).

Locate and apply data from EHR to prioritize

care (simulation lab if unavailable in clinical

site) (5 points)

11. Differentiate between activities that can and

cannot be delegated and how and to whom they

can be delegated (PO 11).

Give examples of skills and patient-centered

tasks that may legally and ethically be delegated

to non-professional personnel (5 points).

items considered critical indicators

Max points: 755 points *

TOTAL

*Point total to be adjusted if < 5 care plans or no

home health experience.

Your total/possible points

GRADE

COMMENTS:

PANOLA COLLEGE NURSING PROGRAM

CLINICAL EVALUATION

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Grades for the clinical component of Common Adult Health Problems are derived by observing the student’s

performance and by evaluating the student in the role of a Member of the Profession, Provider of Patient-

Centered Care, Patient Safety Advocate, and Member of the Health Care Team . Grades will be calculated as

follows: 10% will be the grade for the Case Studies/Patient reviews and 90% will be all other clinical

assignments and faculty observations.

The points for these items are the student’s scores on those assignments and

faculty observations.

MID END COMMENTS

Case Studies

All other clinical

assignments and faculty

observations reflected in

comments on previous tool.

Mid-course grade

Student signature: Date:

Faculty Signature: Date:

End-of-Course Grade:

Student Signature: Date:

Faculty Signature: Date:

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Log for Clinical Nursing Experience

Student Name: ______________________ Clinical Area_____________________________

Instructor: __________________________ Date of Clinical___________________________

Date Pt Initials Nursing Diagnosis

Skills Performed Student Comments *

COMMENTS : *( address how your experience met course objectives)(i.e. Obj #6-

administered IM injection with supervision)

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Student’s Self-evaluation of Clinical Performance

Directions: This self-evaluation form is to be completed at mid-term and at the end of semester. For each

objective give specific examples of way/s the objective was met.

Mid-term Evaluation End of Semester Evaluation

Course Objective I:

Differentiate between

activities that are and are

not within scope of nursing

practice.

Course Objective 2: Use

reflection and feedback to

improve practice.

Course Objective 3: Use

systematic holistic approach

to meet healthcare needs of

patients with common

healthcare needs.

Course Objective 4: Plan

and implement

individualized teaching plans

for adults with common

healthcare needs to facilitate

health promotion,

maintenance and

restoration.

Course Objective 5: Provide

nursing care to patients with

common healthcare needs

based on evidence-based

practice and available

resources.

Course Objective 6:

Administer medications and

treatments to patients with

common healthcare needs

safely, with supervision.

Course Objective 7:

Formulate goals and

outcomes using evidence-

based data to reduce patient

risks.

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Course Objective 8: Practice

confidential interaction with

patients and Health Care

Team members to meet

needs of patients.

Course Objective 9:

Anticipate resources needed

in order to provide access to

quality care for patients.

Course Objective 10:

Demonstrate ability to use

technology systems and skills

including EHR.

Course Objective 11:

Differentiate between

activities that can and cannot

be delegated and how and to

whom they can be delegated.

Use additional paper as needed

Mid-Term Evaluation

List two areas you feel you need to work on:

1.

2.

List two specific goals for yourself for the remainder of the semester:

1.

2.

___________________________________ ___________________________

Student Signature Date Instructor Signature Date

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Final Evaluation

List 3 specific areas you feel you have improved in this semester:

1.

2.

3.

State whether you met the goals you listed above this semester. If so, how, if not, why not.

1.

2.

___________________________________ ___________________________

Student Signature Date Instructor Signature Date

MEDICATION LIST

Brand Name

Generic Name Pharmaceutical Class

& Actions

Applicable Indication

Why pt uses this drug

Dosage Route Frequency Possible Side-Effects Applicable Nursing

Implications/Actions

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NURSING 1262 - CLIENT CARE PLAN GUIDELINES

Assessment Nursing Diagnosis Client Objectives Nursing Intervention Rationale for Nursing

Interventions

Evaluation

Assessment requires:

Nursing Diagnosis * (NANDA approved)

followed by “related

to”phrase (what is

causing the problem)

followed by

Must be: Give scientific rationale for Show data that

1. Communication

with the client via

the client interview

and nursing history.

-related to the nursing

diagnosis. (stem)

-client centered

-action oriented

-mutually exclusive

-realistic

-measurable

-behaviorally stated

Need to include

condition, projected

time, and date for client

to achieve goal. (The

date and time will be

for this clinical day)

Need to include short

term goal.

i.e., Client will have

improved gas exchange

by 1300 1/30/05 as

indicated by:

1. Sp02 > 95% on

room air

2. Dyspnea < 3, etc.

Nurse Directed contain

action verb stated

clearly should include:

-What is to be done or

given.

each nursing intervention.

State why nursing intervention

was developed or selected.

supports eval-

uation of client

objectives.

State whether or

not each

objective was

met & the

client’s overall

response.

State reason(s)

why objectives

not met were not

met.

State any needed

revisions in

objectives or

nursing orders.

2. Data: Physical

Intellectual

Emotional

Social

Spiritual

(Subjective Data:) What

the client says.

(Objective data:)

Observable,

measurable data i.e.,

laboratory reports,

your assessment of the

client for this dx

and related to data

3. Medical Dx

“as evidenced by” …

signs/symptoms of the

label (nsg dx)

-How the behavior is to

be performed.

-Frequency & specific

time for order to be

done.

-Should include:

comfort measures,

treatments,

medications,

observations, and

teaching.

-Directed towards the

“related to” and

problem

-Be specifically

designed for THIS

patient.

List reference & page number

following APA format.

(One journal article per care

plan)

* North American Nursing Diagnosis Association

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CLIENT CARE PLAN (ADPIE SHEET)

Student Name: ____________________________________Pt’s Initials _______ M or F ________ Pt’s Age _______Date of Clinical_____________

Clinical Section: __________________________________Date of Admission/Surgery _______________________(Include both if applicable and specify)

Health Agency Unit: ________________________________Diagnosis or Surgery __________________________________(match RNSG 1441 material)

Assessment Nursing Diagnosis Client Objectives Nursing Intervention Rationale for Nursing

Interventions

Evaluation

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Sample Teaching Plan Format Purpose: To provide patient with information necessary for self-administration of insulin as prescribed

Goal: The patient will be able to perform insulin injections independently according to treatment regimen

Objectives

Content Outline Method of

Presentation

Time

Allotted

(in min.)

Resources Method of

Evaluation

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Following a 20-

minute teaching

session, the

patient will be

able to :

Identify the five

sites for insulin

injection with

100% accuracy

(cognitive)

Demonstrate

techniques

according to

procedure for

drawing up insulin

from a multidose

vial

(psychomotor)

Give insulin to

self in thigh area

with 100%

accuracy

(psychomotor)

Express any

concerns about

self-administration

of insulin

(affective)

Location of five

anatomical sites.

(Specify sites)

Rotation of sites

Accepted

technique

according to

procedure.

(Describe steps)

Reading syringe

unit dose

markings

Procedure for

injecting insulin

SQ at 90-degree

angle using

aseptic

technique

(Describe steps)

Summarize

common

concerns

1:1 instruction

Demonstration

Demonstration

Discussion

2

5

10

3

Anatomical

chart

Alcohol sponges

Sterile SQ

needles and

insulin syringes

Multidose vial

of sterile water

Human model

SQ needle and

syringe

Multidose vial

of sterile water

Alcohol sponges

Video Written

handouts

Circle 5 anatomical

locations on an

anatomical chart

Return demonstration

Return demonstration

Question and answer

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HEALTH TEACHING PLAN FORM

Patient Learning

Objectives

C - (Cognitive)

P - (Psychomotor)

A - (Affective)

Content Teaching Learning Activities/

Method of Presentation

Resources Time Allotment Evaluation Method

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Index

BASIC SCANS___________________________________________________________9 CARE PLAN GRADING CRITERIA____________________________________________11 CLIENT CARE PLAN GUIDELINES____________________________________________28 CLIENT CARE PLAN______________________________________________________29 CLIENT INFORMATION SHEET (CIS)__________________________________________13 CLINICAL EVALUATION TOOL /GRADING SHEET________________________________19 COURSE OUTCOMES______________________________________________________1 COURSE OVERVIEW_______________________________________________________1 GRADING_______________________________________________________________4 HEALTH TEACHING PLAN FORM____________________________________________31 LOG FOR CLINICAL NURSING EXPERIENCE_____________________________________23 MEDICATION LIST________________________________________________________27 OBSERVED PHYSICAL ASSESSMENT GRADING CRITERIA__________________________12 SECRETARY OF LABOR’S COMMISSION OF ACHIEVING NECESSARY SKILLS (SCANS)______8 STUDENT ACKNOWLEDGEMENT_____________________________________________10 STUDENT’S SELF-EVALUATION OF CLINICAL PERFORMANCE_______________________24 TEXTBOOK/REFERENCES____________________________________________________7 THE NURSE AS A MEMBER OF THE PROFESSION_________________________________2 THE NURSE AS A MEMBER OF THE HEALTH CARE TEAM___________________________3 THE NURSE AS PROVIDER OF PATIENT-CENTERED CARE___________________________2 WORKPLACE COMPETENCIES________________________________________________9