rnsg 1263 syllabus spring 2010 - panola collegeoral presentation, silvestri’s, 15% teaching plan,...

1

Course Syllabus

RNSG 1263 – Clinical to Complex Concepts of Adult Health

Revision Date: 5/28/2015

Catalog Description: A health-related work-based learning experience that enables the student to apply specialized occupational theory, skills, and concepts. Direct supervision is provided by the clinical professional. Lecture hours = 0, Lab hours = 2

Prerequisites: RNSG 1205, 1309, 1362, 1441, 1262

Semester Credit Hours: 2

Lecture Hours per Week: 0

Lab Hours per Week: 9

Contact Hours per Semester: 128

State Approval Code: 51.3801

Instructional Goals and Purposes: Students will use the nursing process in providing preventive, restorative, and maintenance/supportive care for adult patients and their families. Nursing care will be provided for specific adult health disorders working from the framework of the nurse as member of the profession, provider of patient-centered care, patient safety advocate, and member of the health care team. Students will also apply concepts of nursing, environment, person and health throughout the course.

2

TABLE OF CONTENTS Core Competencies: …………………………………………………………………… 3

Course Outcomes…………………………………………………………………… 3

Teaching Learning Strategies/ Dress Code/ Medication Administration exam Grading ………………………………………………

4

Grading/Nursing Care Plan Guidelines ………………………………………………………..

5

Bedside Assessment Guidelines …………………………………… Assignment………………………………….

6

Silvestri’s/ Oral Presentation Project/Textbook/References………………………………

7 Teaching Plan/ Health Fair Assignment

Objectives……………………………………………………………………. 8

Textbook/ References/ Learning Objectives SCANS………………………………………………………………………………..

9

Student Acknowledgement…………………………………………………………… 15

Appendices:

A. Patient Care Plan Grading Criteria…………………………………………….. 16

B. Bedside Assessment Grading Criteria…………………………………………. 17

C. Client information sheet template……………………………………………… 18

D. Alternative CIS………………………………………………………………… 22

E. Medication List Template……………………………………………………… 23

F. Log for Clinical Nursing Experience………………………………………….. 24

G. Care Plan Guidelines ………………………………………………………….. 25 H. Care Plan Template……………………………………………………………. 26

I. Patient Assessment Form (Teaching Plan)……….……………………………. 27

J. Teaching Plan Grading Criteria ………………………………………………. 28

K. Teaching Plan Form…………………………………………………………… 29

L. Sample Teaching Plan…………………………………………………………. 30

M. Oral Presentation Grading Criteria ……………………………………………. 32

N. Clinical Evaluation Grading Sheet…………………………………………….. 33

O. Midterm Evaluation……………………………………………………………. 38

P. Clinical evaluation tool Summary…………………………………………….. 39

3

Panola College

Associate Degree Nursing Program Core Competencies: Students are expected to demonstrate basic competency in reading,

writing, oral communication, math, and computer skills. Students are expected to be an active

learning participant by assuming accountability in preparing for each clinical day by

completing required readings and/or other learning activities as listed in the syllabus.

Proficiency will be measured by clinical participation, skills assessment, documentation, and

interaction as a team member.

Course Requirements:

1. Regular clinical attendance within current attendance policies.

2. Acceptable documentation of current immunization status 3. A minimum score of 75% on the clinical evaluation tool.

4. A minimum average score of 75% on nursing care plans is required.

5. Preparation and active participation in clinical conferences

6. Outside individualized readings and assignments

7. Compliance with all rules and regulations as outlined in the current Department of Nursing

Student Handbook and Panola College Catalog.

8. Current Basic Life Support (BLS) certification.

9. Demonstration of college-level skills following American Psychological Association (APA)

guidelines.

COURSE OUTCOMES with Clinical Activities

MEMBER OF THE PROFESSION: At the end of the course the student will be able to:

1. Assume responsibility and accountability for the practice of

professional nursing within the scope of nursing (Scans I B,C II B,C)

PO# 1

DEC# IA,B,D

2. Participate in activities that promote the development of

Professional nursing practice (Scans I C II B)

PO# 2

DEC# IC

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

3. Assimilate knowledge from the humanities and sciences in

developing and providing safe and holistic care within the

legal and ethical scope of practice (Scans I A,B II B,C)

PO# 3

DEC# II A,B,C,D

4. Plan and implement teaching plans for complex patients

through the innovative use of multimedia (Scans I B,C II B,C,E)

PO# 4

DEC# II A,G,H

5. Initiate the plan of care using clinical reasoning and evidence- PO# 5

4

based literature for clinical judgment and decision making (Scans I B,C II B,C)

DEC# II A,B,C,E,F

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

6. Advocate for complex patients and their families by reporting

pertinent information to members of the interdisciplinary care

team (Scans I A, B,C; II B,C)

PO# 6

DEC# III A,B,C,D,E

7. Obtain instruction, supervision, or training as needed when

implementing nursing procedures or practices(Scans I A,B,C; II B,C,E)

PO#7

DEC#III A,B,C,D

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

8. Demonstrate collaboration with peers, patients, families, and

health care teams in the process of planning, delegating,

implementing, and evaluating patient-centered care (Scans I B,C IIC)

PO# 8

DEC# IV A,B,D

9. Advocate for patients and families to ensure access to quality

health care (Scans I B,C; II A, B,C,E)

PO# 9

DEC# IV B,C

10. Communicate and utilize electronic data and technology to

support decision making in patient care (Scans I B,C II B,C,E)

PO# 10

DEC#IV B,C,D,E

11. Employ clinical reasoning and evidence based findings to make

decisions about task that may be delegated appropriately (Scans I B,C

II A,B,C,E)

PO# 11

DEC# IV F,G

TEACHING/LEARNING STRATEGIES: Clinical assignments Student-Teacher

conferences Patient care assignment

Computer Assisted Instruction Observation Group discussion Return demonstration

Clinical conferences, pre/post Simulation lab

PERSONAL APPEARANCE AND DRESS CODE Please review your Student Handbook policy for proper dress code. You will be sent home

if you do not meet these criteria.

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”.

CONCURRENT ENROLLMENT Concurrent enrollment in RNSG 1343 is required. Successful completion of both theory and

5

clinical courses is required for progression. If a student is not successful in either course

(RNSG 1343 or 1263), the student MUST repeat BOTH courses.

GRADING Each student will be evaluated in a clinical conference at the mid and endpoint of this clinical

course. The evaluation will be based on observation of the student’s performance and

behaviors in the clinical setting and all required written assignments (see pg 39).

The Associate Degree Nursing Program, in accordance with policy, uses the following

numerical scale in computing final course grades: (see Policy 5.1)

A = 90-100

B = 80-89

C = 75-79

F = 74.99 and below

Final grades will consist of the following:

Clinical evaluation 85% (using the attached grading tool)

Oral Presentation, Silvestri’s, 15%

Teaching plan, Bedside assessment,

and 3 care plans

NURSING CARE PLANS

GUIDELINES:

1. A client information sheet and care plan is required for three (3) patient care situations.

2. The student will use the assessment tool and care plan tool provided in the syllabus. The

grading criteria are provided in the syllabus.

3. All nursing assessments and care plans will be typed according to APA format to include a

cover page and a reference page. Please include the date you were assigned to the patient and

NOT the date that you submit the care plan for a grade.

4. All care plans must be typed and consist of the following:

a. Minimum – Two (2) Nursing Diagnosis are required, (one psychosocial and one physical)

b. Maximum – One (1) goal per each diagnosis. (Must be measurable)

c. Minimum- Three (3) interventions per related to or AEB statement.

d. Rationale for each intervention- Include citations using proper APA format

include copies of articles used with referred sections highlighted.

e. Evaluation of each goal. (Must be measurable)

6

5. Care plans must include a CIS. All pertinent diagnostic reports and rationales for

abnormal results as it relates to the patient’s nursing and medical diagnoses should be

included.

6. Include medications in the care plans (see medication list for formatting).

7. Care Plans will NOT be accepted if they are:

a. Submitted late.

b. Handwritten.

c. Not in APA format. 8. Care plans are due as assigned. SIM lab care plan will be the only care plan done by hand

and turned in by the end of the day. All other care plans will be submitted on line.

9. Alternative critical thinking tools (Alternative CIS) will be required on all patients unless

care plan to be done (see #5 above). All CIS and alternative CIS must be typed and have a

medication sheet turned in with them.

NURSING BEDSIDE ASSESSMENT

1. Each student will perform one (1) graded bedside assessment. The bedside

assessment will be scheduled and posted under announcements on the canvas

course. It is the students’ responsibility to notify the instructor prior to the

graded assessment if they need individualized help or instruction on bedside

assessment.

2. The bedside assessment criterion is to be followed for each assessment. The student

is expected to be able to perform the assessment from memory. No books, charts or

grading criteria will be allowed in the room for student use during the observed

examination.

3. The assessment will then be charted in a narrative format on a form provided by the

instructor. Please review narrative charting before this assignment.

7

Silvestri Assignment

Units to be covered in Silvestri from CD are:

Renal

Nervous

Musculoskeletal

GI

Endocrine

1. Four quizzes and one exam must be done. A score sheet showing a minimum grade of 90%

must be turned in through Canvas to get credit for the assignment. Each unit must be done

but the student can choose which 4 to do as quizzes and which one to do as an exam. One

subject per quiz or exam, no mix and match.

2. The student’s name and date must be printed on the results sheet. If not printed on

the sheet the assignment will not be accepted.

Oral Presentation

1. Present a 15 – 20 minute Oral presentation identifying a disease process, clinical issue or

trend, or problem that is critical to nursing, health, or healthcare delivery.

2. Select topics from the units of med-surg covered in RNSG 1343 or other current issues or

trends.

3. Presentation should include the reason topic was chosen, role of nursing in addressing

the issue, trend, or problem, the topic is described and a description of what was

learned. (See grading criteria).

4. You must cite at least three articles from current literature (no older than 5 years). Attach

a reference sheet and cover sheet with the grading sheet.

5. A visual aid developed by the student is required for this assignment included but not

limited to a poster, skit, handouts, or power point.

6. The presentation will be recorded.

8

Teaching Plan

1. Select an individual/family or group who demonstrates a knowledge deficit

2. Complete a brief nursing history to validate the need for intervention. (see page 26)

3. Identify the clients’ strengths and limitations in meeting the need.

4. Develop a teaching plan

5. Implement the teaching plan. Teaching plan must be used to instruct a real patient no SIM

patients or make believe.

6. Develop a PowerPoint to accompany the teaching plan. Patient is the audience for the

PowerPoint. Do not include the powerpoint as a teaching strategy in the teaching plan.

7. Evaluate the effectiveness of the teaching plan in meeting its learning objectives and

the evaluation strategies used.

8. Attach a copy of the PowerPoint, assessment sheet (pg 26), and teaching plan (pg 28), and

any references used with the grading sheet (pg 27).

Health Fair Assignment 1. This is a group assignment

2. Each Clinical section will be divided into groups.

3. Select a topic from the list provided by the instructor and create a community focused

poster display.

4. Each student is responsible for a section on the poster and must identify the section done.

5. You must cite at least three articles from current literature (no older than 5 years)

9

TEXTBOOK/REFERENCES: The textbooks listed for RNSG 1343 will be used for this clinical course.

Learning Objectives:

1. Assume responsibility and accountability for the practice of

professional nursing within the scope of nursing.

a. Act responsibly within the limits of nursing knowledge.

i. Solicits supervision from the instructor when needed.

ii. States own limitations

iii. Provides interventions with respect for human dignity and

rights unrestricted by considerations of social or economic

status, personal attributes, or the nature of health problems.

CO# 1

b. Apply principles inherent in the laws and standards governing

the nursing practice to the care of patients in diverse settings.

i. Adheres to Panola College student handbook policies and

clinical agency policies when providing care for culturally

diverse patients.

ii. Arrives at the clinical setting on time.

iii. Perform within legal and ethical guidelines of the nursing

practice act.

CO# 1

c. Demonstrates the principles of the “Code of Ethics” for nurses

i. Maintains patient confidentiality.

ii. Provides patient privacy.

iii. Seeks help from others when needed.

CO#1

2. Participate in activities that promote the development of professional

nursing practice .

a. Participates in clinical self evaluation.

i. Documents skills and relevant behaviors on e-value.

ii. Complete self-evaluation

iii. Identifies areas of needed improvement

CO# 2

b. Participates in self directed learning.

i. Demonstrates the initiative to seek new learning experiences.

ii. Seeks opportunities to learn new skills or to practice skills.

iii. Accepts responsibility for clinical assignments without excuse.

iv. Participates in Health Fair

CO#2

c. Participate in or discuss the benefits of the available professional

organizations.

CO# 2

10

3. Assimilate knowledge from the humanities and sciences in

developing

and providing safe and holistic care within the legal and ethical scope

of

practice.

a. Perform comprehensive assessment to identify health needs and

obtain patient and family history to determine patient needs in

areas of physical, spiritual, cultural, and psychological.

CO# 3

b. Apply information from evidenced based literature and nursing

science to assist in planning and providing safe and holistic

patient

care.

CO# 3

c. Interpret and analyze health data using knowledge of anatomy

and

physiology, pathophysiology, and signs and symptoms of disease

processes to assist in planning safe holistic care for the adult with

complex health issues.

CO# 3

4. Formulate teaching plans for complex patients through the innovative

use of multimedia.

a. Assess learning needs of adult patients with complex health

issues and their families.

CO# 4

b. Develop and implement teaching plan with the use of multimedia

and best practice standards and include consideration of age,

culture, educational level and other areas of diversity.

CO# 4

c. Evaluate learning outcomes of adult patients and their families. CO# 4

d. Revise teaching plan if needed. CO# 4

5. Initiate the plan of care using clinical reasoning and evidenced-based

literature for clinical judgment and decision making.

a. Relate clinical reasoning to adult patient needs in planning care. CO# 5

b. Prioritize nursing diagnoses and develop goals for adult patients

with complex health issues.

CO# 5

c. Devise interventions with cultural aspects taken into

consideration derived from evidence based information for adult

patients.

CO# 5

d. Evaluate interventions for effectiveness and modify plan of care

for adult patients with complex health issues.

CO# 5

e. Evaluate patients’ responses to medication, treatment, or

procedures and be able to prioritize problems and respond

appropriately.

CO# 5

6. Advocate for complex patients and families by reporting pertinent

information to members of the interdisciplinary care team.

a. Consult with interdisciplinary care team members when planning CO# 6

11

and providing care to adult patients with complex health issues.

b. Report and document pertinent information to appropriate

interdisciplinary care team members.

CO# 6

c. Document and report any adverse reactions to medications,

procedures, or treatment that may occur in adult patients with


CO# 6

d. Evaluate care administered to adults with complex health issues

by

members of the interdisciplinary care team.

CO# 6

7. Obtain instruction, supervision, or training as needed when

implementing procedures or practice.

a. Arrange instruction, supervision, and education associated with

the

implementation of a new or previously observed nursing

procedure.

CO#7

b. Identify potential safety risk for adult patients with complex

health issues.

CO# 7

c. Formulate a plan to decrease safety risks by using guidelines in

the Texas Nursing Practice Act.

CO# 7

d. Apply standards of nursing practice and evidenced based

information to provide and evaluate nursing care of adults with


CO# 7

8. Demonstrate collaboration with peers, patients, families, and health

care teams in the process of planning, delegating, implementing, and

evaluating patient centered care.

a. Utilize patient and family input when planning care for the adult

patient with complex health issues.

CO# 8

b. Construct plan to include care provided to adult patients by

other

members of the interdisciplinary team.

CO# 8

c. Maintain timely communication and collaboration with

members

of the interdisciplinary care team for optimal patient health

status.

CO# 8

d. Evaluate patient care through collaboration with

interdisciplinary

care team by using evidence based information and patient

evaluation data.

CO# 8

9. Advocate for patients and families to ensure access to quality health

care.

a. Coordinate resources available in the health care setting to

optimize patient centered care.

CO# 9

b. Serve as a patient advocate in promoting quality care and access

to resources for adult patients and their families.

CO# 9

12

c. Teach patients and families about access to reliable and valid

resources including health information.

CO# 9

d. Refer adult patients to appropriate outpatient services in the

community to provide them with access to quality health care.

CO# 9

10. Communicate and utilize electronic data and technology to support

decision making in patient care.

a. Employ technology as a means of communication and

management of patient information to improve delivery of care.

CO# 10

b. Participate in simulation lab using electronic data to improve

patient care.

CO# 10

11. Employ clinical reasoning and evidenced based findings to make

decisions about tasks that may be delegated appropriately.

a. Compare the needs of the patient with the knowledge, skills, and

abilities of the assistive personnel prior to delegating task.

CO# 11

b. Participate in decision making related to delegation to improve

clinical reasoning.

CO# 11

c. Evaluate nursing care provided by unlicensed personnel by using

evidenced-based nursing information

CO# 11

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

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.

13

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 one-self. 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. 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.

14

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.

15

Panola College

Associate Degree Nursing

Student Acknowledgment

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

RNSG 1263 Clinical Nursing and I understand the policies as discussed.

I will comply with the requirements as delineated. It is my understanding that this form will

become part of my permanent file.

Student Name (Printed)

Student Signature Date

16

Patient Care Plan Grading Criteria

Points

Possible

Points

Earned Assessment Pertinent history and physical assessment finding related to

Admission. (Including, but not limited to, allergies,

medications, diet, statement of presenting problem,

physical assessment findings which support the nursing

diagnosis.)

20

Nursing Diagnoses Identify two (2) high priority nursing diagnoses supported

by the assessment data. (1physical and 1 psychosocial)

20

Patient

Objectives

(Goals)

directly related

to the nursing

diagnoses

Patient centered Observable

Measurable and Specific

Time limited

20

Nursing

Interventions

Individualized/Comprehensive Appropriate/

Specific

Feasible/Realistic

Time related

20

Rationale State rationale behind each nursing intervention. Literature must be used to support each

intervention. At least one journal article must be

used per care plan.

*If no journal article is used, you will receive a 0 in

this category.

5

Evaluation State if the patient outcome was met or not met.

State how you evaluated each patient goal.

10

APA Cover page, citations, and bibliography follow the APA guidelines

5

Total

Comments:

Student Name:

Instructor:

Date of Patient Care

17

Bedside Assessment Grading Criteria

The bedside assessment will be observed by the instructor and charted by the student.

Both components will be graded. Provide the grading criteria to the instructor during

the observed assessment. Assessment will be charted and turned end before the end of

the clinical day.

Assessment Criteria Possible

Points

Points

Earned

Comments

Vital Statistics: *Height, *Weight, *Temperature, *Pulse, *Respirations, *Blood

Pressure, *Pain, *Allergies

5

Neurological *Level of consciousness, *orientation, *Affect, pupils, speech

characteristics,

*Hand grips and leg strength,

follows commands

10

Respiratory Quality of respirations, depth of respirations, respiratory rate

*Breath sounds in all areas (anterior

and posterior) , O2 use, *O2

saturation, presence of secretions

5

Cardiovascular Heart sounds, rate and rhythm, *carotid, radial, and pedal pulses,

clubbing , *capillary refill,

*Peripheral edema, JVD

5

Abdomen Scars, nausea/vomiting, *Bowel sounds, tenderness, drains,

NGT location, descriptions &

amount of drainage, drains

*Last BM & characteristics

5

Skin *Temperature, moisture level, *turgor, *color, *Characteristics of

oral mucosa, lesions, dressings

5

Musculoskeletal Ability to sit up, turn gait *ROM 5

Urinary *Foley, voiding, *color and amount of urine

5

Misc. *IV’s, site assessment, Feedings,

dressings

5

Charting 50

Total

* Critical Assessment data

18

Pt. Initials:

Date of Adm: Chief complaint/

Admitting Medical Diagnosis:

Current

Vital

Signs

T P Surgery type and Post-Op

day:

(if applicable)

R BP

Age/

Sex:

Allergies and type of reaction

(all types):

Pertinent Past Medical

History:

O2

Sat

O2

Use

Respiratory Therapy

Treatments

Height: Weight: IV Therapy/

SL:

Solution and

rate

Ethnicity: Dentures: Upper Lower Fluid Restriction:

Hearing Loss: Right Left Diet:

Marital Status:

Impaired vision Code Status:

Advance

Directive?

Safety

Considerations:

Activity: Reason:

Hx

tobacco

use: pack

year

history

Hx. Alcohol or

substance

abuse:

Fall Risk:

Aspiration

Risk:

Other:

Panola College ASSOCIATE

DEGREE NURSING RNSG 1263

Student: Clinical Date: Instructor:

CLIENT INFORMATION SHEET (CIS)

19

*Treatment and Special Orders: (include all such as TCDB, incentive spirometer, Resp.

therapy, nursing interventions, etc.)

Treatment/Procedure Frequency Rationale for Treatment/Procedure

Date Diagnostic Test Results Rationale for test Nursing implications

Chief Complaint and Brief History of Present Illness:

Past Medical History, Including Home Meds:

Pathophysiology of current illness or major medical diagnosis:

20

*Lab Data: ( Not and all inclusive list)

Lab Test Result (s) & Date (s) Normal

Range

Brief Rationale for

Abnormalities (Be sure to

explain all grossly abnormal

labs)

CBC Date Date Date

WBC 4.6 – 10.2

RBC 4.0 – 5.5

Hgb 12.2 – 16.2

HCT 37.7 – 47.9

Platelets 140 - 440

Coagulation

PT 10-12 sec

PTT 30-45 sec

INR 2-3( target)

Electrolytes

Na+ 136 – 145

K+ 3.50 – 5.10

Cl- 98 – 107

CO2 22.0 – 29.0

Magnesium 1.5-2.0

BUN 6.0 – 20.0

Glucose 60 – 105

Creatinine 0.70 – 1.30

Cardiac

Enzymes

CKMB < 7.1U/L

Troponin <1ng/mL

Chemistry

Albumin 3.5-5.0

Protein 6-8.4

Amylase 4-25

UA

Color straw - yellow

Appearance clear - hazy

Specific

Gravity

1.003 – 1.030

pH 5.00 – 9.00

Protein negative

Glucose negative

Ketone negative

21

Lab test Date Date Date Normal Rationale for abnormal

ABG

PH 7.35-7.45

PO2 70-100 mm Hg

PCO2 35-45 mm Hg

HCO3 22-26 mm Hg

B.E. +1 to -2

O2 Sat. 96%-100%

Additional labs

RNSG1263

22

Alternative CIS

Name____________________________ Date_____________________

For each patient answer these questions:

1. What are you on alert for today with this patient?

2. What are the important assessments to make?

3. What complications may occur? What could go wrong?

4. What interventions will prevent complications?

5. Add any abnormal or normal lab pertinent to patient’s condition. Any lab listed on medication sheet must

be listed here.

Lab Test Value Indications specific to patient

RNSG1263

22

RNSG1263

23

Brand Name Generic Name Class &

Actions

Applicable

Indication

why pt is using this

drug

Dosage Route Frequency Possible

Side-Effects

Patient Specific

Nursing

Implications

and Actions

MEDICATION LIST

RNSG1263

24

PANOLA COLLEGE ASSOCIATE DEGREE NURSING

Log for Clinical Nursing Experience

Student Name: Clinical Area:

Instructor:

Date Pt

Initials

Nursing Diagnosis Skills Performed Student Comments

Reflections on experience:

RNSG1263

25

Assessment Nursing Diagnosis Client Objectives Nursing

Intervention Rationale for

Nursing

Interven

tions

Evaluation

Assessment requires:

1. Communication

with the client via

the client interview

and nursing history.

2. Data: Physical

Intellectual

Emotional

Social

Spiritual (Subjective data:)

What the client

says. (Objective data:)

Observable,

measurable data i.e.,

laboratory reports,

nursing

observations, review

of the chart 3. Medical Diagnosis

Nursing Diagnosis *(NANDA approved)

followed by “related

to” phrase followed by

“as evidenced by” …

Contributing factors:

Environmental,

Sociological

Psychological,

Spiritual,

Physiological, or

any other factors

involving health

problems

Must be:

-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. Need to include short

term or long term

objectives.

i.e., Ms. Doe will walk

to the end of the hall &

back QID with the

Assistance of a walker

by 10/12.

Nurse Directed

contain action verb

stated clearly should

include:

-What is to be done

or given?

-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” or “as

evidenced by”

statements.

Must be specific to

patient

Give scientific rationale

for each nursing

intervention.

State why nursing

intervention was

developed or selected.

List citations (Authors

last name, year, and

page number)

i.e.(Smith, 2004,

pp125)

Full reference on

reference page

1 journal article per

care plan

Show data that

supports evaluation

of client objectives.

State whether or

not each objective

was met (met,

partially met, or not

met.)

State Patients

response.

State reason(s) why

objectives were met

or not met.

State any needed

revisions in

objectives or nursing

orders.

Do not include

interventions

NURSING 1263 - CLIENT CARE PLAN GUIDELINES

Student Name: ___________ Pt. Initials

Date of Care Plan: ___ Pt Sex/Age:

Clinical Section: Date of Admission/Surgery Health Agency Unit: Diagnosis/Surgery

RNSG1263

26

PATIENT CARE PLAN

Assessment

Nursing

Diagnosis

Client Objectives

Nursing

Interventions

Rationale for

Nursing

Interventions

Evaluation

Student Name:

RNSG1263

27


PATIENT ASSESSMENT

(to accompany teaching plan)

Students’

Name:

Date:

Client Initials: Age/Sex:

Assessment/Data Collection

Pertinent Client Data/ Brief Nursing History

Subjective

Objective:

Assessment

Nursing diagnosis (knowledge deficit: specify (ex: IS) related to…)

Client Assets and Limitations (relative to knowledge deficit)

ASSETS LIMITATIONS

RNSG1263

28

Grading Criteria Teaching Plan

Points

Possible Points Given

Comments

Identifies Learning Need

a. Communicates learning need/ knowledge deficit to instructor

b. Select an individual, family, or group who

demonstrates a knowledge deficit

5

c. Complete a brief nursing history to substantiate the clients need for educative intervention

10

d. The student followed all directions given 5

Constructs a Teaching Plan

a. Develops a written plan for teaching based on an identified learning need of the

patient/family

b. Develops a topical outline of content material

15

c. Utilizes the nursing process to develop the teaching plan

d. Uses a holistic approach in teaching plan

10

e. Includes preventive measures in teaching plan 5

f. Identifies appropriate resources available 2

g. Develops specific client focused learning objectives

5

h. Identify planned teaching learning activities and time frame for planned activities

5

Presentation

a. Develop a power point presentation to accompany the teaching plan

25

Evaluation

a. Evaluate the effectiveness of the teaching

plan in achieving the learning objectives

5

Conventions/Usage/Sentence Structure

a. The sentences are well constructed, vary in form, and show no major examples of non-

standard sentence formation.

2

b. The grammar, spelling and punctuation are

basically free of error except minor infractions.

2

Format

a. APA format was used throughout paper. 2

b. Reference page is correct 2

c. Cover page in APA

Total 100

RNSG1263

29


HEALTH TEACHING PLAN FORM

Patient Learning Objectives

C - (Cognitive)

P - (Psychomotor)

A - (Affective)

Content Teaching Learning Activities Time Allotment Evaluation of Patient Learning Objectives and evaluation strategies.

RNSG1263

30

Patient Learning Objectives

C - (Cognitive)

P - (Psychomotor)

A - (Affective)

Content Teaching Learning Activities Time Allotment Evaluation of Patient Learning Objectives and evaluation strategies.

By the end of this lesson

the client will be able

to: Select from a list three

benefits of relaxation

(cognitive) Agree to experiment

with walking and

various relaxation

techniques (affective) Count his pulse within

three beats of what the

nurse counts

(psychomotor)

Introductions

Relaxation

Definitions

Balance with

exercise

Benefits

Reduce blood

pressure

Reduce tension

Increase efficiency

Medication

Fears Side effects

Life-style change

Costs

Benefits

Techniques for

Pulse taking

Location of artery

Finger placement

Discussion Question “What

does relaxation mean to you?”

Discuss the relationship

between stress and blood

pressure. Give the patient the

pamphlet: Balancing Relaxation

and Exercise

Discussion fears and mixed

feelings

“Who else in your family has

been diagnosed with

hypertension? What did it do to

control it, and what were the

results?” Demonstrate pulse taking. Have

the client return demonstration

of pulse taking. Develop a

record keeping system

monitoring pulse rate. Read

directions for deep breathing,

10min

10min

10min


SAMPLE TEACHING PLAN FORM

them? What have they done to

RNSG1263

31

Counting Multiplying

Recording method

Technique for

Relaxation

Deep breathing

Yoga

Medication

Imagery

Prayer

Wrap up

yoga, meditation, and imagery.

Obtain a clock with a second

hand. Develop a chart for recordkeeping at home. Obtain

an audio cassette for recording

directions for deep breathing,

yoga, meditation, and imagery.

RNSG1263

32

Grading Criteria Oral Presentation

Points

Possible Points Given

Comments

Introduction

A. Identify the reason the diagnosis or nursing issue, trend, or problem was chosen

10

B. The student followed all directions given 5

Overview of the Content

A. The work addresses effectively the topic B. The main ideas are stated clearly, thoroughly

supported, and developed

C. Description of what was learned

25

A. Describe the perceived impact of the topic on client care or in clinical situations

10

A. Present information in a professional manner

a. Rapport with audience (eye contact)

b. Speaking voice (volume and diction)

c. Confidence (enthusiasm, speaks without

reading every word)

d. Material supporting oral presentation:

skits, power point, handouts, posters,

pamphlets, etc.

10

B. Present information on resources available to

patients and health care providers regarding the

topic

10

C. Interacts with the audience. Discussion generated

by the presentation, stays within the time frame

(15 – 20 minutes)

10

Format

A. Presented on assigned date (10 points deducted if not presented on assigned day)

5

B. The presentation is well constructed.

5

C. The grammar, spelling and punctuation are basically free of error except minor infractions

5

D. Correct APA format: cover and reference page 5

Total: 100

Note : Required 3 references, Must be Peer reviewed and publication within the last 5 years.

RNSG1263

33

CLINICAL EVALUATION GRADING SHEET

CRITERIA POINTS

Possible Points Student

Evaluation

Faculty

Evaluation

MEMBER OF THE PROFESSION

1. Act responsibly within the limits of

nursing knowledge

a. Solicits supervision from the

instructor when needed.

4

b. States own limitations

4

c. Provides interventions with

respect for human dignity and

rights unrestricted by

considerations of social or

economic status, personal

attributes, or the nature of health

problems.

4

2. Apply principles inherent in the

laws and standards governing the

nursing practice to the care of

patients in diverse settings.

a. Adheres to Panola College student

handbook policies and clinical

agency policies when providing

care for culturally diverse patients.

4

b. Arrives at the clinical setting on

time.

4

c. Perform within legal and ethical

guidelines of the nursing practice

act

4

3. Demonstrates the principles of the

“Code of Ethics” for nurses

a. Maintains patient confidentiality 4

b. Provides patient privacy. 4

c. Seeks help from others when

needed.

4

4. Participates in clinical self-

evaluation.

a. Documents skills and relevant

behaviors on e-value.

4

b. Complete self-evaluation 4

RNSG1263

34

c. Identifies areas of needed

improvement

4

d. Participates in health fair. 4

5. Participates in self-directed

learning.

a. Demonstrates the initiative to seek

new learning experiences.

4

b. Seeks opportunities to learn new

skills or to practice skills.

4

c. Accepts responsibility for clinical

assignments without excuse.

4

6. Participate in or discuss benefits of

the available professional

organizations.

4

PROVIDER OF PATIENT-

CENTERED CARE:

7. Perform comprehensive assessment

to identify health needs and obtain

patient and family history to

determine patient needs in areas of

physical, spiritual, cultural, and

psychological.

4

8. Apply information from evidenced

based literature and nursing science

to assist in planning and providing

safe and holistic patient care.

4

9. Interpret and analyze health data

using knowledge of anatomy and

physiology, pathophysiology, and

signs and symptoms of disease

processes to assist in planning safe

holistic care for the adult with


4

10. Assess learning needs of adult

patients with complex health issues

and their families.

4

11. Develop and implement teaching

plan with the use of multimedia

and best practice standards and

include consideration of age,

culture, educational level and other

areas of diversity

4

12. Evaluate learning outcomes of

adult patients and their families.

4

RNSG1263

35

13. Revise teaching plan if needed. 4

14. Relate clinical reasoning to adult

patient needs in planning care.

4

15. Prioritize nursing diagnoses and

develop goals for adult patients


4

16. Devise interventions with cultural

aspects taken into consideration

derived from evidence based

information for adult patients.

4

17. Evaluate interventions for

effectiveness and modify plan of

care for adult patients with


4

18. Evaluate patients’ responses to

medication, treatment, or

procedures and be able to prioritize

problems and respond

appropriately

4

THE NURSE AS PATIENT SAFETY

ADVOCATE

19. Consult with interdisciplinary care

team members when planning and

providing care to adult patients


4

20. Report and document pertinent

information to appropriate

interdisciplinary care team

members.

4

21. Evaluate care administered to

adults with complex health issues

by members of the interdisciplinary

care team.

4

22. Document and report any adverse

reactions to medications,

procedures, or treatment that may

occur in adult patients with


4

23. Arrange instruction, supervision,

and education associated with the

implementation of a new or

previously observed nursing

procedure.

4

24. Identify potential safety risk for

adult patients with complex health

issues.

4

RNSG1263

36

25. Formulate a plan to decrease safety

risks by using guidelines in the

Texas Nursing Practice Act.

4

26. Apply standards of nursing practice

and evidenced based information to

provide and evaluate nursing care

of adults with complex health

issues.

4

MEMBER OF THE HEALTH CARE

TEAM

27. Utilize patient and family input

when planning care for the adult

patient with complex health issues.

4

28. Construct plan to include care

provided to adult patients by other

members of the interdisciplinary

team.

4

29. Maintain timely communication

and collaboration with members of

the interdisciplinary care team for

optimal patient health status.

4

30. Evaluate patient care through

collaboration with interdisciplinary

care team by using evidence based

information and patient evaluation

data.

4

31. Coordinate resources available in

the health care setting to optimize

patient centered care.

4

32. Serve as a patient advocate in

promoting quality care and access

to resources for adult patients and

their families.

4

33. Teach patients and families about

access to reliable and valid

resources including health

information.

4

34. Refer adult patients to appropriate

outpatient services in the

community to provide them with

access to quality health care.

4

35. Employ technology as a means of

communication and management

of patient information to improve

delivery of care.

4

RNSG1263

37

36. Participate in simulation lab using

electronic data to improve patient

care.

4

37. Compare the needs of the patient

with the knowledge, skills, and

abilities of the assistive personnel

prior to delegating task.

4

38. Participate in decision making

related to delegation to improve

clinical reasoning.

4

39. Evaluate nursing care provided by

unlicensed personnel by using

evidenced-based nursing

information.

4

CIS and Medication Sheet or

Alternative CIS and Medication Sheet

1.

2.

3.

4.

5.

6.

7.

8.

(4 points each)

32

SUBTOTAL 232

85% of subtotal

+

Silvestri’s, care plans, teaching plan,

bedside assessment, and oral

presentation 15%

Total

RNSG1263

38

Mid-Term Evaluation

Student is to fill out the top portion of the evaluation and email to instructor by due date

Student strengths, as identified by student:

Student areas for improvement, as identified by student:

Student strengths, as identified by instructor:

Student areas for improvement, as identified by instructor:

Student Signature Date Instructor Signature Date:

RNSG1263

39

RNSG 1263 CLINICAL EVALUATION TOOL SUMMARY

The clinical evaluation tool is structured along the five major areas of nursing function:

Assessment, Nursing Diagnoses, Planning, Implementation, and Evaluations. The organization

of the objectives/outcomes uses the four major roles of the practicing nurse: Member of the

Profession, Provider of Patient-centered Care, Patient Safety Advocate, and Member of the

Healthcare Team. Grades for RNSG 1263 are derived by observing the student’s performance,

evaluating required assignments and the student in the role of Member of the Profession,

Provider of Patient-centered Care, Patient Safety Advocate, and Member of the Healthcare

Team.

Points will be assigned to each objective/outcome reflecting the level of competence as follows:

4 -- Consistently performs at an independent level. Meets the described objectives with self-

direction. 90-100% on assignments =4 points

3 — Demonstrates consistent performance and improvement. Needs minimal guidance to meet

described objectives. 80-89% = 3points

2 — Satisfactory/safe level of performance. Meets objectives with consistent guidance. 75-79%

on assignments = 2 points

<2 — Unsatisfactory/Unsafe. Level of performance does not meet standards. Unable to meet

objectives without frequent, direct, intensive guidance and instruction to avoid errors. This

includes submitting late assignments, substandard assignments, failure to submit assignments

and inconsistent performances from week to week.

The points for each course outcome are derived from a combination of Nursing Care Plans

(NCP), Assignments (A), and/or Faculty Observations (FO). If a student receives a grade of zero

(0) on any assignment or nursing care plans, the student will also receive a zero (0) on this

clinical evaluation tool for the corresponding assignment.

85% of course grade = Clinical Evaluation

15% of course grade = Care Plans/Bedside Assessment/Teaching Plan/ Oral Presentation

/Silvestri’s