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SUFFOLK COUNTY COMMUNITIY COLLEGE AMMERMAN CAMPUS DEPARTMENT OF NURSING NR 33 CLINICAL FOLDER Revised 8/07 sm 1 Faculty Contact Information Susan McCabe Assistant Professor E-Mail: [email protected] Telephone: (631) 451-4915 Office: Riverhead Building - 343 Location: Ammerman Campus E-Mail: Telephone: Helene Winstanley Assistant Professor [email protected] (631) 451-4565 Office: Riverhead Building - S/R/344 Location: Ammerman Campus E-Mail: Telephone: Office: Location: E-Mail: Telephone: Office: Location: Florence Mullarkey Associate Professor [email protected] (631) 451-4959 Riverhead Building - 343 Ammerman Campus E-Mail: Doreen Coppa Instructor [email protected] Telephone: (631) 451-4673 Office: Location: Riverhead Building - 338 Ammerman Campus Donna L Carra Assistant Professor [email protected] (631) 451-4265 (rm 106) Riverhead Building - S/R/344 Ammerman Campus 2 NR33/40 CLINICAL REQUIREMENTS 1. Arrive and be prepared for clinical pre-conference at shift start 2. Profit from constructive suggestions made to you (i.e. if you are corrected for a procedure error once, it is expected that you will not repeat that mistake a second time. 3. You will be expected to know generic as well as trade names of any medication that you are asked to administer. 4. Communicate with your instructor in a professional manner and maintain all commitments/appointments with yourself and that instructor. Questions/clarifications during clinical practicum are to be directed to your clinical instructor initially not nursing staff. 5. Communicate in a professional manner with clients, peers and nursing staff at all times. Address clients by last name (i.e. Mr. Jones, Ms. James). 6. Structure your clinical experience according to assignment, being guided by priorities, time management and organization. 7. The client's chart is a legal document, therefore all entries must be correct, professionally stated and reviewed by your instructor before entry into the record. Have sample charting ready for review at least one hour before time to leave the unit. 8. Contact and utilize the teaching/learning center, computer center, for individual and additional support and assistance if needed or assigned. 9. Use the nursing lab on your own time to practice and reinforce skills. You may be asked by your instructor to make a video of a skill you are having difficulty with. 10. Clinical assignments must be submitted on the dates specified by the clinical instructor. A clinical failure will be recorded for assignments received after the designated date. Course failure will result unless all assignments are submitted. Submit assignments in a large envelope to your clinical instructor. List materials enclosed 11. If you anticipate being absent, please call the nursing unit no later than two hours before clinical practicum starts. 3 SUFFOLK COUNTY COMMUNITY COLLEGE SCHOOL OF NURSING Medication Administration for a Client/Group of Clients NR33/40 Bring drug book/drug card file to clinical Check all doctors medication orders with MAR If you can’t find order dates in doctors orders, check MAR or kardex, if this is the hospital’s standard Obtain a separate med cart (if possible) to put your assigned client’s med boxes in Obtain separate 3 ring binder, place MAR’s in book for those clients assigned Check med boxes early to determine if all meds are there. If missing meds, call/fax pharmacy to send – or give to the unit clerk to fax. You will administer morning meds (5 hr day) and morning and afternoon meds (10 hr day), check with instructor for specific times Remember military time – 10:00 am = 1000 12:00 = 1200 2:00 pm = 1400 etc. Administer IVPB’s first. Review drop factor formula and IV pump method of delivery. Check for change date of tubings, etc. check patency of site. Remove IVPB’s from refrigerator at least 30 minutes before administering. Review method of giving meds through central lines and through saline locks when there is no maintenance IV Check allergy status, found on MAR and on client’s armband Make sure you have cups, alcohol sponges, tubings, applesauce, pill crushers, spoons, straws, etc. on your med cart before you proceed from room to room Know the five rights of all medications, plus therapeutic and adverse actions Know automatic stop dates, hospital policy regarding renewals Know parameters, eg BP’s, apical pulses, electrolyte levels, digoxin levels, etc. before administering meds Assemble unit dose meds in med cups without removing wrappers, pour liquids with instructor present. Be alert to meds that cannot be crushed and/or removed from capsules – there are many When all of the above actions are completed, it is time to have your instructor check your meds and supervise you as you administer them Do not give any med at any time unless supervised by instructor Remember 2 forms of ID of client – failure to do so will result in failed clinical day, this is a critical element Ensure that client has safely swallowed all meds and is comfortable before leaving the room/ensure IVPB is infusing correctly Document with instructor present Monitor client at intervals for therapeutic or adverse effects of medications Enter fluid type and volumes for all IVPB’s on fluid balance sheet F. Mullarkey 4 PERIOPERATIVE OBJECTIVES NR 33 students will rotate for 4.5 hours in to perioperative area during their clinical rotation. A second rotation into the perioperative area may be assigned at the discretion of the clinical instructor. The OR experience should not exceed 9 hours in the perioperative area. 1. Identify risk factors (present illness/history) that increase the potential for client complications during the perioperative experience 2. Review the client plan of care and preoperative check list to determine factors that may alter the client’s response to the surgical experience 3. Identify any special preoperative procedures prescribed prior to surgery and determine the rationale for use of these 4. Determine if preoperative teaching has been done 5. Differentiate among the various types and purposes of surgery 6. Describe principles, protocols and rules of surgical asepsis 7. Explain procedures used to identify client and accuracy of the planned surgical procedure 8. Describe roles of the interdisciplinary team in the operating room environment 9. Describe approaches to ensure prioritization of care during the operation 10. Identify interventions used to maintain client safety and dignity in the operating room 11. Discuss potential adverse reactions and complications of anesthetic agents 12. Describe fluid management protocols utilized during an operation 13. Prioritize plan of care for the client in the post-anesthesia care unit (PACU) 14. Describe approaches to pain management after surgery 15. Discuss criteria used to determine discharge from the PACU EXPECTATIONS OF STUDENTS IN THE PERIOPERATIVE ROTATION 1. Receive and position clients in the holding area 2. In the holding area, assist with assessment and skills already learned in Fundamentals 3. Review client record to determine that all parameters related to the planned surgical procedure are in place 4. Assess client’s level of anxiety and implement interventions to reduce anxiety 5. Comply with instructions for role of observer in the operating room 6. Participate in plan of care for client in the PACU 7. STUDENTS ARE NOT PERMITTED TO ADMINISTER ANY MEDICATIONS, DRAW BLOOD, OR INSERT PERIPHERAL IV ACESS DURING THE PERIOPERATIVE 8. Perioperative care plan is to be submitted one week after the rotation. 5 NR 33 ACTIVITY FOR FIRST CLINICAL DAY (PAGE 1) 1. Identify your best resources and references for clarifying knowledge gaps in preconference. (Consider which of the following references would be needed) MED/SURG textbook or handbook Drug reference Lab test reference Nursing diagnosis handbook Hospital procedure manual Clinician 2. Develop tentative nursing diagnoses and identify what s/o data you would need to collect to support its existence before leaving preconference. 3. Perform initial client assessment: After report, perform an initial assessment on your client. Complete the following information to present to your peers in mid-conference. LOC: A: B: C: I/O: Wound: Pain: Safety: 4. After performing the initial assessment, gather any additional information you need from the chart and seek clarification with your clinical instructor to get direction for focused physical exam. Check for labs tests released and pending. Labs released: Labs pending: Check for orders written in last 24-48 hours: New orders/changes: Check last 24 hours of progress notes (MD, NURSING, CONSULTS) MD plan Nursing plan Consults 6 NR 33 ACTIVITY FOR FIRST CLINICAL DAY page 2 5. Perform the focused physical exam and then develop actual nursing diagnoses and priorities of care in consultation with your clinical instructor. Set outcomes (What do you expect the client to achieve?) Design interventions (What will assess for, perform, monitor, consult?) Apply a prioritizing framework (life threatening, safety, patient concern, nursing concern) * * * * * * * * * * * * * * * * * 7 Initial Assessment Tool AIRWAY 1. 2. 3. 4. 5. YES NO NA YES NO Does the client manifest an altered level of consciousness? Is the client maintaining their own airway? Is there an adjunct airway such as a Trach tube or oral airway in use that is ineffective? Is the client making any airway noises consistent with obstruction; snoring, barking, stridor? Does client require any emergency assistant to establish/maintain an airway? BREATHING 6. 7. 8. 9. Does your client exhibit a normal breathing pattern and rate? Is there evidence of excessive chest wall movement? Is there evidence of use of accessory muscles? Is the client making audible sounds when breathing that are cause for alarm? CIRCULATION 10. Does your client complain of chest pain, shortness of breath, diaphoresis, and evidence of bleeding or hemorrhage? 11. Does your client have a pulse? 12. Does your client exhibit and abnormal skin color patterns consistent with an alteration in circulation; pallor, cyanosis, rubor, erythema or mottling? 13. Does the client have malaise, fever, and/ or chills? I/O 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Does your client have an IV infusing or a Normal saline lock that is patent? Is the dressing loose or is there redness, swelling, warmth or edema at the site? Is the correct solution infusing at the correct rate and the tubing unexpired? Does your client have a Foley catheter in place that is draining clear amber urine? If the client is on daily weights, has the weight been done before breakfast? If your client has BRP on I/O does the client state understanding of compliance? If the client is NPO, does the client state understanding? If the client is on aspiration precautions, is the bed positioned appropriately and prescribed diet followed? If the client is a diabetic, did they have their blood sugar checked yet? Are drainage tubes present, patent and set to appropriate levels of suction as ordered? Is the client receiving a gastric feeding to a patent gastric tube without leakage? If so, is the rate, product correct and tubing unexpired? WOUND 26. Is the dressing dry and intact, dated and timed? 27. Is there evidence of decubitus at areas of pressure or bony prominence? 28. Should you initiate decubitus precautions? PAIN 29. Is the client meeting their goals for pain management? 30. Does the client need their pain medications now? 31. If the client has a pump, are the settings accurate the pump working correctly? SAFETY 32. 33. 34. 35. 36. If restraints are in use, is a monitoring protocol to prevent harm in place? Is the bed low and the call bell in reach? Should the side rails be up? Are skid proof slippers provided for ambulatory patients? Are their internal or external factors that indicate that your client is at risk for falls? References Fitspatrick J. B. & Shinners M.C. (1996, August). How to make assessment as easy as A, B, C. Nursing 1996. page 51. Katz, M. (2006) Save time! Do a 5-minute initial assessment, RN, originally published: March 1, 2006 Retrieved 8 http://mediwire.skyscape.com/main/Default.aspx?P=Content&ArticleID=310565 STEPS TO CREATING A PRIORITY LIST A. Use a systematic approach to create a list of diagnoses and collaborative problems 1) Review the admitting diagnosis in textbook or scientific reference 2) Review the co-morbidities in the history of illness, hospitalizations and surgeries a) What is the client’s prior medical and surgical history that requires tertiary prevention? 3) Research what are the probable nursing diagnoses/collaborative problems in a current med/surg text a) These will likely be your highest priorities (1) Create diagnoses in PES format for each nursing diagnosis and collaborative problem 4) Review medication profile prior to hospitalization a) Ensure that the client continues to get the medication during hospitalization or there is a reasonable explanation for its discontinuation (1) Medication that has been discontinued can lead to a collaborative problem for the medical problem it is used to manage. (a) Create diagnoses in PES format for each nursing diagnosis and collaborative problem. b) Ensure that the past medical history reflects the disorders that the client has been prescribed medication prior to hospitalization. (1) Refer to a current drug guide for collaborative care (a) Create diagnoses in PES format for each nursing diagnosis and collaborative problem or add to a data cluster for a previously identified diagnosis. (i) Carpenito has several example PC statements for commonly used drugs that can be used as a template for other PCs 5) Review each health pattern in the assessment database a) Create diagnoses in PES format for each deviation from normal value where a data cluster exists that supports its use. 6) Review lab/diagnostics a) Ensure that your daily nursing process plan has the pertinent lab/diagnostics for the medical problems. (1) Indicate what lab data was not obtained on that sheet b) Create diagnoses in PES format for each deviation from normal value where a data cluster exists that supports its use or add to a data cluster for a diagnosis already developed. 7) Review medication profile a) Refer to a current drug guide for collaborative care or add to a data cluster for a diagnosis already developed. (1) Create diagnoses in PES format for each nursing diagnosis and collaborative problem as done in medications prior to admission. 8) Review your nurse’s note a) These words shed light onto the context of what your client is experiencing immediately during the time that you are providing care. (1) Improve your note writing skills by showing it to your clinical instructor before the end of the clinical day. (a) Begin to list diagnoses and collaborative problems (i) Constantly confirm structure, format and appropriate data of labels with Nursing care plan book (ii) All PC diagnoses are not in nursing care plan bookso 1. Refer to med/surg text for labels under collaborative care 9) After completing the list, number diagnoses and collaborative problems in order of priority. 9 HISTORY OF PRESENT ILLNESS VITAL SIGN MEASUREMENT Description of the circumstances describing the chief compliant Expanding on the client’s chief complaint or positive response in the review of systems, develop questions to obtain information about the following: Location/Radiation, Quality, Quantity, severity (1-10), onset and duration, Frequency, Aggravating Factors, Relieving Factors, Associated Symptoms, Effect on client’s functional status in own words. BLOOD PRESSURE PULSE RESPIRATIONS TEMPERATURE REVIEW OF SYSTEMS PHYSICAL ASSESSMENT Neurologic/Psychiatric Convulsions, seizures, stroke, syncope, paralyses, tremor, incoordination, parathesias, difficulties with memory or speech, sensory or motor disturbances, or muscular coordination (ataxia, tremor), Predominant mood "nervousness" (define), emotional problems, anxiety, depression, previous psychiatric care, unusual perceptions, hallucinations. Head/Eyes/Ears/Nose/Mouth/Throat Headaches (location, time of onset, duration, precipitating factors), vertigo, lightheadedness, injury Blurred vision, double vision, tearing, blind spots, pain, hearing loss, ear pain, tinnitus. Nose bleeding, colds, obstruction, discharge, Dental difficulties, gingival bleeding, dentures, sore throat. Neck stiffness, pain, tenderness, masses in thyroid or other areas. Intolerance to extremes of hot and cold. Neurologic/Psychiatric Alert and oriented to person, place, time. Cooperative. Speech clear, appropriate, posture relaxed. Recent/remote memory intact. Cranial nerves II-XII intact. Sensation to pinprick, light touch intact. Motor: no atrophy, weakness or tremors bilaterally. Ambulates with steady gait. Negative Romberg’s sign. Performs alternating movement. DTR’s intact. Note if falls precaution is in effect and restraints in use. Head/Eyes/Ears/Nose/Mouth/Throat Normocephalic, atraumatic. Facies symmetric, no weakness or involuntary movements noted. Visual acuity intact.20/20/ OD, OS. Full visual fields intact by confrontation. No ptosis, no lidlag, discharge PERRLA. Corneal reflex symmetric no strabismus. Conjunctive clear, sclera white. Pinna no masses, lesions, tenderness, drainage. Whispered words heard bilaterally. Rhinne: AC>BC. Weber: no lateralization. Nares patent, no tenderness, lesions, discharge. Pharynx pink, no lesions, dentition in good repair, uvula rises on midline, positive gag reflex. Cardiovascular No JVD. No heaves, no thrills. Heart sounds: S1, S2 no S3 S4 gallop or murmurs. Regular rate and rhythm. Indicate cardiac rhythm on continuous cardiac monitoring. If murmur note grade, timing, location, quality and radiation. Record weight and I/O. Peripheral vascular Color pink, no lesions, varicosities, symmetric bilaterally. Hair present. No edema, calf tenderness, all perpheral pulses present (Grade +), no changes in temperature. Capillary refill < 3 seconds. Note use of antithrombotics devices. Respiratory Respirations even and unlabored, no use of accessory muscles. Trachea midline. Chest symmetric, AP diameter not increased. No tenderness on palpation. Lung fields resonant. Diaphragmatic excursion (47 cm) and = bilaterally. Lungs clear to auscultation, no adventitious sounds. Record presence of adjunct oxygen therapy, use of pulse oximetry and presence of thoracic tubes. Gastrointestinal Abdomen flat, symmetric. No lesions, herniations, gas patterns, venous patterns or pulsations. Normoactive bowel sounds in all quadrants. Tympanitic to percussion. Abdomen soft nontender. Liver span (7cm). Murphy’s sign negative. No organomegaly. No rebound tenderness, McBurney’s point negative. Femoral pulses present bilaterally. No lymphadenopathy. No CVA tendern4ess. Record bowel elimination pattern. Note presence of gastrointestinal tubes, drains, and dressings. Indicate tolerance to diet type and use of capillary blood sugar measurements Genitourinary External genitalia no lesions or discharge. Describe urinary pattern: continence, frequency, volume, color, odor clarity. Document presence of indwelling catheter noting size, type and if irrigation is in progress. RELEVANT READINGS FROM INTERMITTENT AND CONTINUOUS MONITORS Cardiovascular Chest pain, substernal distress, palpitations, syncope, dyspnea on exertion, orthopnea, nocturnal paroxysmal dyspnea, edema, cyanosis, hypertension, heart murmurs, anemia, bleeding problems, history of heart disease Peripheral vascular Pain, numbness, swelling in extremities, temperature changes, discoloration or changes in color, varicose veins, infections, or ulcers. Claudication, asymmetry. Respiratory History of lung disease, pain (location, quality, relation to respiration), shortness of breath, wheezing, stridor, cough (time of day, of productive, amount in tablespoons or cups per day and color of sputum), hemoptysis, respiratory infections, tuberculosis (or exposure to tuberculosis), fever or night sweats. Gastrointestinal Changes in appetite, dysphagia, indigestion, food intolerances, abdominal pain, heartburn, nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul smelling), flatulence, hemorrhoids, recent changes in bowel habits, use of laxatives, surgical incisions, presence of drains. History of ulcers, cirrhosis, gallbladder disease, appendicitis. Genitourinary Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine, stones, infections, nephritis, hesitancy, change in size of stream, dribbling, acute retention or incontinence, change in libido, potency, genital lesions, discharge, venereal disease, presence of indwelling catheters, stents. (Female) Age of onset of menses, regularity, last period, dysmenorrhea, menorrhagia, vaginal discharge, post-menopausal bleeding, dyspareunia, number and results of pregnancies (gravida, para) Musculoskeletal Pain, swelling, redness or heat of muscles or joints, limitation, of motion, muscular weakness, atrophy, cramps. History of arthritis, osteoporosis, calcium supplementation, fractures, strains, sprains. Skin/Breast Rash, itching, change in pigmentation, excessive moisture or dryness, presence of wounds, presence of invasive devices, alterations in texture, changes in hair growth , texture or loss, nail changes. Breast lumps, tenderness, swelling, nipple discharge Note if menses is in progress, date of menstrual flow, quality and quantity of bleeding. Musculoskeletal (TMJ, Neck, shoulders, elbows, wrists, hands, spine, hips, knees, ankle, feet) No joint pain, tenderness, FROM. Extremities symmetric, no tenderness, weakness, discoloration, or swelling. Maintains flexion against resistance. Vertebra nontender, no curvature, no deformity. Skin/Breast Skin pink warm dry to touch. No lesions, hyper/hypopigmentation. Hair even distribution, texture, no pest inhabitants. Nails no clubbing, cyanosis, and discoloration. Breasts symmetric: no lesions, lumps, changes in pigmentation or nipple discharge. No lymphadenopathy. 10 SUFFOLK COUNTY COMMUNITY COLLEGE DEPARTMENT OF NURSING DAILY NURSING PROCESS PLAN NR 20, 33, 36, 40 Student Name: Date of Care _______Patient Initials _______ Room # _______ Chronological Age _________Code Status_________________ Weight _______ Height _______ Diet __________________Isolation__________________Glasses/Lenses_________________ Hearing Aid______Oriented_________Disoriented________Admitting Diagnosis______________________________________ ________________________________________________________________________________________________________ Surgical Procedure_________________________________________________________________________________________ PMH/PSH________________________________________________________________________________________________ ________________________________________________________________________________________________________ _______________________________________________________________________________________________________ Social History/Family History________________________________________________________________________________ ________________________________________________________________________________________________________ Allergy to drugs, food, or environment ______________________________________Activity____________________________ Vital signs: T______________(route) Pulse: A_______ R _______ RR _______ B/P ______________________ (L, R) SaO2 _______________ Pain Scale:_________ IV ___________________________________________________________________( Solution, Rate, Site, Gauge, Date, Time) Intake __________ Output __________ Tubes/ Drains/Appliances _______________________________________ Assessment Data: Place your initials in the box if the descriptors match your client, otherwise (*) and write a nurses note. SAFETY: Call bell within reach. Bed in low position. INTEGUMENTARY: Skin color pink. Skin warm, Environment clutter free. Fall precautions:___YES ___NO dry and intact. Mucous membranes pink and moist. Restraints:___YES___NO Suicide Risk___YES___NO No skin breakdown. HYGIENE: ___Complete ___Partial ___Self WOUND/INCISION: No redness or increased ORAL CARE: ___Complete ___Self temperature in surrounding tissues. No drainage. Wound edges well approximated. Sutures/staples/steri strips intact. PSYCHOSOCIAL: Stress:__________________________ MUSCULOSKELETAL: No joint swelling or Ways of Handling Sress:_____________________________ tenderness. Full ROJM. No muscle weakness. Emotional Status:___________________________________ Surrounding tissue without inflammation. Steady Problems Related to Illness/Condition__________________ balance and gait. NEUROLOGICAL: A & O X 3. PERRLA. Appropriate SKIN RISK ASSESSMENT: 2 points for each behaviors. Verbalization clear and understandable. No positive answer:___poor physical condition, dysphasia. Active ROJM all extremities. No numbness or ___inactive, ___lethargic, ___poor nutrition, tingling. ___incontinent, __poor mobility (over 6 = risk) RESPIRATORY: Respirations regular and unlabored. No FALL RISK ASSESSMENT: 1 point for each SOB. No cough. Nailbeds and mucous membranes pink. positive answer: ___confused, ___seizure disorder, Breath sounds clear bilateral. No dyspnea on exertion. No ___weak, ___sedated, ___poor judgment, ___poor nightsweats. O2 therapy: specify_______________________ sight, ___combative, ___unsteady, ___lang.barrier, CDB/IS_______ Suction_________ ___incontinent, ___poor hearing (over 5 = risk) CARDIOVASCULAR: No chest pain. Pulse regular. No PAIN ASSESSMENT: Pain Intensity (1-10)______ edema of extremities. Vital Signs Stable.. Extremities warm. Pain tolerable:___yes, ___no Brisk capillary refill. ___alert, ___sedated FLACC Score____ GI: Abdomen soft, non-tender. Audible bowel sounds. INTRAVENOUS LINES: IV site is clear, without Passing flatus. Stools within own normal pattern and redness, swelling or pain. PIV___Date Inserted, consistency. ___Tubing Change. Central Line___Date Inserted, Tubes___________________Ostomy__________________ ___Tubing Change, ___Dsg Change. GU: Empties bladder independently and without difficulty. ACTIVITY: BR, OOB, Dangle, BRP, Ambulate Urine clear and yellow to amber. Catheter____________ Independent____Assist______________________ Ostomy_______________________________________ Sleep Pattern______________________________ NUTRITION: Diet:_______________________ CLIENT ED/DISCHARGE PLANNING: Appetite:__Good>75% of meal__Fair50-75%___Poor <50% ___Needs Identified ___Self___Assist Diet Supplement___________________ ___Client Education Started DAILY NURSING PROCESS PLAN Complete Drug Order Safe Dose? Add additional pages as necessary. Labs Client Expected Values Values RBC 4.7-6.1 M 4.2-5.4 F Hgb 14-18 M 12-16 F Hct 42-52 M 37-47 F Platelets 150,000400,000 WBC 5,000-10,000 Sodium 135-145 Potassium 3.5-5 Chloride 95-105 Glucose 70-110 (FBS) CO2 35-45 Calcium 8.5-10.5 1.8 to 2.4 Magnesium Classification Generic/Trade Labs Major Therapeutic Effect/ Major Adverse Effect Client Values Labs BUN Expected Values 10-20 Creatinine 0.6-1.2 ABG Nursing Responsibilities Client Values Expected Values CMP Cardiac Enzymes Troponin I U/A PH Color Sp. Gravity Protein Glucose 4.6-8 Amber 1.010-1.025 None None Ketones Blood None 0-2 RBCs Drug Levels PT/PTT INR Other mg/dL Add additional pages as necessary with interpretation of abnormal values. Diagnostic Tests; Procedures; Treatments; Dressings: Client/Family Teaching: (include health education/ prevention based on cognition and culture) DIAGNOSES/COLLABORATIVE PROBLEMS Nursing Diagnoses Interventions Evaluations Nursing Note: Consider the Subjective and Objective Data that records the Client’s response to the interventions for the Actual Diagnoses/Collaborative Problems (Add additional pages as necessary) 12 Nursing Assessment Student Name: Key + pt has this Ø pt does not have this * unable to assess and requires explanation DO NOT LEAVE BLANK SPACES ________________________ Patient Initials: ________________________ SECTION 1: GENERAL INFORMATION Admission date __________ Assessment date __________ Source of information: _______________________________Reliability (1-4 with 4 being very reliable)____________ Advance Directives: No Yes – if yes: DNR health care proxy living will Copy on chart Yes No: if no: comment __________________________________________ Arm bands: ID Mastectomy Allergy Latex Other Isolation precautions ___________________________________________________________________ Oriented: call bell, bathroom, activity level, meal times, visiting, no smoking policy Yes No _______________________________________________________________________________________________ If no: comment ________________________________________________________________________________ SECTION 2: PATIENT HISTORY (In patient’s own words) Medications taken prior to admission (include Rx, OTC drugs, sleep aids, herbs & alternative medicines) Name Dose & Frequency Reason for taking Chief Complaint/Reason for Admission: ____________________________________________________________ Past Surgical History (year/procedure): _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ____________________________________________________________________________________ Past Medical History: (indicate date of onset of all health stressors) Medical Condition Onset Medical Condition Pacemaker Arthritis Peripheral vascular Back/neck disorder Valve disease/murmur Bleeding disorder Diabetes: Type 1 2 Blood transfusion No Yes Reaction? No Yes Eye: Cataract/Glaucoma Transfusion in last 3 mos? No Yes Cancer (location) Cardiovascular: MI Automatic internal cardiac defibrillator Dysrhythmias GI: Hepatitis/jaundice Hiatal hernia/GERD Ulcer/divertic/polyps GU: ESRD/Dialysis UTI Hypertension Prostate/BPH Onset Medical Condition Mental health disorder Substance use treatment Suicide attempts Pulmonary: Asthma Bronchitis/Pneumonia Emphysema/COPD Sleep apnea Seizures Stroke CVA/TIA Thyroid HypoHyperOther: Developed 5/06 13 Onset Anesthesia: Have you had anesthesia in the past? No Yes If “yes”, did you have any serious complications? No Yes If “yes”, describe _________________________________________________________________________________________________ Body Piercing No Yes, site: ____________ Advised to remove before surgery Tattoos No Yes, site ____________ History of Violence No Yes Social History: Occupation(s) (If retired, indicate what occupation was): _______________________________________________________________________________________________ Lives with: alone spouse family parents other ________________________________________________________________________________________________ Help upon discharge: none spouse family parents other ________________________________________________________________________________________________ Substance use: None Type Tobacco: Alcohol: Drugs: IV Drugs: __________ __________ __________ __________ Frequency/Duration Last Use ________________ ________________ ________________ ________________ ___________ ___________ ___________ ___________ Adult immunizations & vaccines (if yes indicate date last received) No known allergies Adult flu vaccine No Yes __________ Patient does not know Pneumonia vaccine / Pneumovax No Yes __________ Patient does not know Tetanus No Yes __________ Patient does not know PPD No Yes __________ Patient does not know RESPIRATION Subjective (Reports) Objective (Exhibits) Dyspnea/related to: Cough/sputum: History of Bronchitis: Asthma: Emphysema: Tuberculosis: Recurrent pneumonia: Exposure to noxious fumes: Smoker: Pack/day: No. of pack years: Use of respiratory aids: ____________________ Oxygen: ___________________________ Respiratory: Rate: ___________ Depth: _____________ Pulse Oximetry: _________________________________ Symmetry: _____________________________________ Use of accessory muscles: __________________________ Nasal flaring: ___________________________________ Fremitus: ___________________________________ Breath sounds: ______________ Egophony: __________ Cyanosis: ___________________________________ Clubbing of fingers: _______________________________ Cough: nonproductive: ___________________________ Cough: productive: _______________________________ Sputum characteristics: ____________________________ Restlessness: ____________________________________ Nursing diagnosis: 14 CIRCULATION Subjective (Reports) Objective (Exhibits) History of: Hypertension: _____ Heart trouble: _______ Rheumatic fever: _____ Ankle/leg edema: __________ Phlebitis: ______ Slow healing: _________________ Claudication: ___________________________________ Bleeding tendencies/episodes: _____________________ Palpitations: ____________ Syncope: ______________ Extremities: Numbness: ________ Tingling: __________ Cough/hemoptysis: _______________________________ Fatigue: ________________________________________ Change in frequency/amount of urine: ________________ BP: R and L: Lying/sit/stand: ______________________ Pulse pressure: _______ Auscultatory gap: __________ Pulses (palpation): ______ Temporal: _______________ Carotid: ______ Apical: ______ Brachial: ________ Radial: _______ Femoral: ______________________ Post.tibial: _______ Dorsalis pedis: ________________ Cardiac (palpation): Thrill: ______ Heaves: __________ Heart sounds: Rate: _______ Rhythm: _____________ Quality: ____________ Friction rub: _______________ Murmur: _______________________________________ Vascular bruit: ___________________________________ Jugular vein distention (JVD): _______________________ Breath sounds: ___________________________________ Extremities: Temperature: ________ Color: __________ Capillary refill: _____ _____________________________ Varicosities: _______ Nail abnormalities: ____________ Edema: ________________________________________ Distribution/quality of hair: ________________________ Trophic skin changes: ____________________________ Color: General: __________________________________ Mucous membranes: _________ Lips: ______________ Nailbeds: _________ Conjunctiva: _________________ Sclera: ________________________________________ Diaphoresis: _____________________________________ Nursing Diagnosis: ________________________________ NEUROSENSORY Subjective (Reports) Objective (Exhibits) Fainting spells/dizziness: ___________________________ Headaches: Location: __________ Frequency: ________ Tingling/numbness/weakness (location): _______________ Stroke/brain injury (residual effects): _________________ Seizures: _____ Type: ___________ Aura: __________ Frequency: __________ Postictal state: _____________ How controlled: _________________________________ Eyes: Vision loss: __________ Last exam: ___________ Glaucoma: _______________ Cataract: ____________ Ears: Hearing loss: _________ Last exam: ___________ Sense of smell: ____________ Epistaxis: ____________ Mental status (Note duration of change): Oriented/disoriented: Person: _____________________ Place: _______ Time: _______ Situation: __________ Alert: _____ Drowsy: ______ Lethargic: ___________ Stuporous: ______________ Comatose: ____________ Cooperative: _____________ Combative: ____________ Delusions: ____________ Hallucinations: ___________ Affect (describe) _________________________________ Memory: Recent __________ Remote: ______________ Glasses: _______ Contacts: _____ Hearing aids: ______ Pupil: Shape: _______ Size/reaction: R/L: ____________ Facial droop: ________ Swallowing: _________________ Handgrasp/release: R/L: __________________________ Deep tendon reflexes: _____________________________ Posturing: ________________ Paralysis: _____________ Nursing diagnosis: ________________________________ 15 PAIN/DISCOMFORT Subjective (Reports) Objective (Exhibits) Primary focus: __________ Location: _______________ Intensity (0-10 with 10 being most severe): __________ Frequency: ____________ Quality: _________________ Duration: _____________ Radiation: _______________ Precipitating/aggravating factors: ____________________ How relieved: ___________________________________ Associated symptoms: _____________________________ Effect on activities: __________ Relationships: ________ Additional focus: _________________________________ Facial grimacing: _________________________________ Guarding affected area: ____________________________ Emotional response: ______________________________ Narrowed focus: __________________________________ Change in Blood Pressure: __________ Pulse: ________ FLACC Pain Scale Score: ___________________________ Nursing diagnosis: ________________________________ SAFETY AND INTEGUMENTARY Subjective (Reports) Objective (Exhibits) Allergies/sensitivity: ________ Reaction: _____________ Exposure to infectious diseases: _____________________ Previous alteration of immune system: ________________ Cause: ________________________________________ History of sexually transmitted disease: (Date/type): _______________ Testing: ____________ High-risk behaviors: _____________________________ Blood transfusion/number: ________ When: _________ Geographic areas lived in/visited: ____________________ Seat belt/helmet use: ______________________________ Workplace safety/health issues: _____________________ History of accidental injuries: _______________________ Fractures/dislocations: ____________________________ Arthritis/unstable joints: ___________________________ Back problems: __________________________________ Changes in moles: ________ Enlarged nodes: _________ Delayed healing: _________________________________ Cognitive limitations: ______________________________ Impaired vision/hearing: ___________________________ Prosthesis: ___________ Ambulatory devices: __________ Temperature: _______ Diaphoresis: ________________ Skin integrity: Scars: __________ Rashes: ___________ Tattoos: _______________ Piercings: ______________ Lacerations: ___________ Ulcerations: _____________ Ecchymosis: ____________ Blisters: ________________ Eschar: _______________ Burns: _________________ (Degree/percent): ________ Drainage: ______________ Dressing type: ___________ Wound size: ___________ Tubes/appliances ________________________________ Mark location of the above on diagram: Nursing diagnosis: _______________________________ General strength: _________________________________ Muscle tone: ___________________________________ Gait: ________________ ROM: ___________________ Balance: ______________________________________ Paresthesia/paralysis: ____________________________ Results of cultures: _______________________________ Immune system testing: __________________________ Tuberculosis testing: _____________________________ 16 FOOD/FLUID Subjective (Reports) Objective (Exhibits) Usual diet (type): _________________________________ Cultural/religious restrictions: _______________________ Number of meals daily: ____________________________ Vitamin/food supplement use: ______________________ Loss of appetite: __________ Nausea/vomiting: _______ Heartburn/indigestion: ______ Related to: ___________ Relieved by: ____________________________________ Food preferences: _______ Food prohibitions: ________ Allergy/food intolerance: ___________________________ Mastication/swallowing problems: ____________________ Dentures: ______________________________________ Usual weight: __________ Changes in weight: ________ Diuretic use: _____________________________________ Current weight: ______ Height: ______ BMI: ________ Body build: _____________ Skin turgor: _____________ Mucous membranes: Moist/dry: _____________________ Edema: General: _________ Dependent: ____________ Periorbital: ______________ Ascites: _______________ Anasarca: _____________________________________ Condition of teeth/gums: __________________________ Appearance of tongue: ___________________________ Mucous membranes: ___________ Halitosis: ________ Dysphasia: _____________________________________ Bowel sounds: ___________________________________ Serum glucose (Glucometer) ________________________ Nursing Diagnosis: ________________________________ Satisfaction with body weight: ________________________ ELIMINATION Subjective (Reports) Objective (Exhibits) Usual bowel pattern: ______________________________ Laxative use: ____________________________________ Character of stool: _____________ Last BM: __________ Constipation: ________________ Diarrhea: __________ History of bleeding: __________ Hemorrhoids: ________ Usual voiding pattern: _____________________________ Frequency: ____________ Retention: ______________ Character of urine: ________________________________ Pain/burning/difficulty voiding: ______________________ History of kidney/bladder disease: ___________________ Diuretic use: _____________________________________ Incontinence/when: ___________ Urgency: __________ Abdomen: Tender: _________ Soft/firm: ____________ Palpable mass: ___________ Size/girth: ____________ Bowel sounds: Location/type: _____________________ Hemorrhoids: ____________ Stool guaiac: ___________ Bladder palpable: _________________________________ Overflow voiding: _________________________________ CVA tenderness: _________________________________ Tubes: Ostomies: ______________________________________ Character of stool: ________________________________ Character of urine: ________________________________ Incontinence: ____________________________________ Nursing Diagnosis: ________________________________ 17 EGO INTEGRITY Subjective (Reports) Stress factors: ___________________________________ Ways of handling stress: ___________________________ Financial concerns: _______________________________ Relationship status: _______________________________ Recent losses: __________________________________ Cultural factors/ethnic ties: _________________________ Religion: _______________ Practicing: ______________ Lifestyle: _____________ Recent changes: ___________ Sense of connectedness/harmony with self: ____________ Feeling of: Helplessness: _________________________ Hopelessness: ____________ Powerlessness: ________ Suicidal ideation: _________________________________ Suicidal plan: ____________________________________ Objective (Exhibits) Emotional status: Calm: _________ Anxious: _______ Angry: ________ Withdrawn/Fearful: ________ Irritable: _____________ Apprehensive: ____________ Euphoric: ____________ Other: __________________ Observed physiological response(s): __________________ Nursing Diagnosis: ________________________________ ACTIVITY Subjective (Reports) Objective (Exhibits) Occupation: ___________ Usual activities: ___________ Leisure time activities/hobbies: ______________________ Limitations imposed by condition: ____________________ Sleep: Hours: _______ Naps: _______ Aids: ________ Insomnia: ______________ Related to: ____________ Rested on awakening: ____________________________ Excessive grogginess: ____________________________ Feelings of boredom/dissatisfaction: __________________ Observed response to activity: Cardiovascular: _________ Respiratory: ____________ Neuromuscular Assessment: Muscle mass/tone: ___________ Posture: __________ ROM: _______ Strength: _______ Tremors: ________ Deformity: _____________________________________ Other: __________________________________________ Nursing diagnosis: ________________________________ HYGIENE Subjective (Reports) Objective (Exhibits) Activities of daily living: Independent/dependent (level): Mobility: ____________ Feeding: __________________ Hygiene: ____________ Oral Hygiene: _____________ Dressing/grooming: __________ Toileting: __________ Preferred time of personal care/bath: _________________ Equipment/prosthetic devices required: _______________ Assistance provided by: ____________________________ General appearance: ______________________________ Manner of dress: _________________________________ Personal habits: __________________________________ Body odor: _____________________________________ Condition of scalp: _______________________________ Presence of vermin: ______________________________ Nursing diagnosis: ________________________________ 18 SEXUALITY Subjective (Reports) Sexually active: ________ Use of condoms: ___________ Birth control method: ______________________________ Sexual concerns/difficulties: ________________________ Recent change in frequency/interest: _________________ Female Subjective (Reports) Age of menarche: __________ Length of cycle: _______ Duration: ____ Number of pads/tampons used/day ____ Last menstrual period: _______ Pregnant now: ______ Number of pregnancies (gravida) ____________________ Number of live births (para) ________________________ Bleeding between periods: _________________________ Menopause: ________ Vaginal lubrication: ___________ Vaginal discharge: ________________________________ Surgeries: _______________________________________ Hormonal therapy/calcium use: ______________________ Practices breast self-exam: _________________________ Last mammogram: ________ PAP smear: ___________ Male: Subjective (Reports) Penile discharge: _______ Prostate disorder: _________ Circumcised: ___________ Vasectomy: _______________ Practice self-exam: Breast: _______ Testicles: ________ Last proctoscopic/prostate exam: ____________________ Objective (Exhibits) Comfort level with subject matter: ___________________ Objective (Exhibits) Breast: _________________________________________ Genital warts/lesions: _____________________________ Discharge: ______________________________________ Objective (Exhibits) Breast: ______________ Testicles: _________________ Genital warts/lesions: _____________________________ Discharge: ______________________________________ Nursing diagnosis: ________________________________ SOCIAL INTERACTIONS Subjective (Reports) Objective (Exhibits) Marital status: _______ Years in relationship: _________ Living with: ________ Concerns/stresses: ___________ Extended family: _________________________________ Other support person(s): __________________________ Role within family structure: ________________________ Perception of relationships with family members: _______ Ethnic affiliation: _________________________________ Strength of ethnic identify: ________________________ Feelings of: Mistrust: _________ Rejection: __________ Happiness: _____________ Anxiety: _______________ Unhappiness: ___________ Depression: ____________ Loneliness/isolation: _____________________________ Embarrassment:____________ Other: ______________ Problems related to illness/condition: _________________ Problems with communication: ______________________ Speech: Clear: _________ Slurred: _________________ Unintelligible: __________ Aphasic: ________________ Usual speech pattern/impairment: __________________ Use of speech/communication aids: _________________ Laryngectomy present: ___________________________ Verbal/nonverbal communication with family/significant other: ________________________________________________ Family interaction (behavioral pattern): ________________________________________________ Nursing diagnosis: ________________________________ 19 TEACHING/LEARNING Subjective (Reports) Dominant language (specify): _______________________ Second language: _______________________________ Interpreter needed: ______________________________ Literate: ________ Education level: ________________ Learning disabilities: (specify): ____________________ Cognitive limitations: ____________________________ Where born: _______________ If immigrant how long in this country: __________________________________ Health and illness beliefs/practices (e.g., complementary therapies) customs: ______________________________ Which family member makes healthcare decisions/is spokesperson: __________________________________ Presence of Advance Directives/Durable Medical Power of Attorney: ______________________________ Special healthcare concerns (e.g., impact of religious/ cultural practices): _______________________________ Health goals: ____________________________________ Familial risk factors (indicate relationship): Diabetes: ____________ Thyroid (specify): _________ Tuberculosis: _________ Heart disease: ____________ Strokes: ________ High BP: ______ Epilepsy: ______ Kidney disease: ____________ Cancer: _____________ Mental illness: _____________ Other: ______________ Identifies prescribed medications: Yes _____ No _____ Purpose: Yes _____ No _____ Side effects/problems: Yes _____ No _____ Nonprescription drugs: OTC drugs: _________________ Herbal supplements (specify): _____________________ Street drugs: _____________ Tobacco: ____________ Smokeless tobacco: _____________________________ Alcohol (amount/frequency): _______________________ Admitting diagnosis per health care provider: __________ Reason for admission per client: _____________________ History of current complaint: ________________________ Client expectations of care: _________________________ Previous illnesses and/or hospitalizations/surgeries: _______________________________________________ Last complete physical exam: _______________________ Nursing diagnosis: ________________________________ DISCHARGE PLAN CONSIDERATIONS DRG projected mean length of stay: __________________ Date information obtained: _________________________ Anticipated date of discharge: _______________________ Resources available: Persons: ______________________ Financial: ___________ Community: ________________ Support groups: _________________________________ Socialization: ___________________________________ Areas that may require alteration/assistance: Food preparation: ________ Shopping: _____________ Transportation: __________ Ambulation: ___________ Medication/IV therapy: ___________________________ Treatments: ____________ Wound care: ___________ Supplies: ___________ Self-care (specify): __________ Homemaker/maintenance (specify): _________________ Physical layout of home (specify): __________________ Anticipated changes in living situation after discharge: _______________________________________________ Living facility other than home (specify): _______________________________________________ Referrals (date, source, services): Social Services: _________________________________ Rehabilitation services: ___________________________ Dietary: ___________ Home care: _________________ Resp/O2: ___________ Equipment: ________________ Supplies: ______________________________________ Other: ________________________________________ Nursing diagnosis: ________________________________ 20 SUFFOLK COUNTY COMMUNITY COLLEGE NURSING CARE PLAN STUDENT’S NAME: DATE: SURGICAL PROCEDURE: PATIENT’S INITIALS: AGE: DATE OF CARE: DEFINITION OF SURIGICAL PROCEDURE: MEDICAL DIAGNOSIS: ASSESSMENT DATA FOR NURSING DIAGNOSIS NURSING DIAGNOSIS COLLABORATIVE PROBLEMS EXPECTED OUTCOMES WITH INDICATORS NURSING INTERVENTIONS SCIENTIFIC RATIONALE FOR NURSING INTERVENTIONS REALISTIC EVALUATION Effectiveness of Nursing Interventions Revised 5/06 21 Attainment of Expected Outcomes ASSESSMENT DATA FOR NURSING DIAGNOSIS NURSING DIAGNOSIS COLLABORATIVE PROBLEMS EXPECTED OUTCOMES WITH INDICATORS NURSING INTERVENTIONS SCIENTIFIC RATIONALE FOR NURSING INTERVENTIONS REALISTIC EVALUATION Effectiveness of Nursing Interventions 22 Attainment of Expected Outcomes Complete Drug Order ……………………… Usual Dose Generic ……………………… Classification Action of Drug ……………………… Therapeutic Effects ……………………… Adverse Effects 23 Why is This Client Receiving the Drug? Nursing Responsibilities Patient Education CRITICAL THINKING RUBRIC TO ANALYZE THE APPLICATION OF NURSING PROCESS IN STUDENT NURSING CARE PLANS PURPOSE OF THE RUBRIC This critical thinking rubric is designed to analyze the application of nursing process in student nursing care plans and can be used by both faculty and students. COMPONENTS OF THE RUBRIC Each criterion contains performance criteria to demonstrate critical thinking for each step of the nursing process used in the development of a nursing care plan. The performance criteria describe behaviors and traits that are linked to a level of performance. There are four levels of performance. The levels of performance represent the degrees in which critical thinking is applied to accomplish the step in care planning. Level one is a beginner level of performance that reflects an absence of critical thinking whereas level four represents well developed critical thinking skills that reflect the students ability to perform higher-ordered learning. USING THE RUBRIC Students Students can use the rubric to facilitate nursing care plan preparation and development. The emphasis on systematicity and truth seeking behaviors will facilitate college level students progress in critical thinking skills. Prior to submission for faculty review, the student will be able to perform a self-assessment to identify levels of performance in each of the steps of nursing process and identify areas for future development. The student's ability to identify with level three and level four performances will enhance their self-confidence in the reasoning abilities and develop their disposition to critical thinking. Grading of Care Plan: The care plan is only graded in whole numbers. The minimum acceptable score is 28/40. The student will be asked to resubmit or remediate the care plan if any section on the rubric receives a score of less than 2. The care plan will be remediated until an acceptable score is achieved. Rev. 5/05, 6/07 24 CRITICAL THINKING RUBRIC TO ANALYZE THE APPLICATION OF NURSING PROCESS IN NURSING CARE PLANS ASSESSMENT FORM 4: All subjective and objective data is collected and is recorded using the appropriate terminology. Any data that is not collected is adequately explained in the blank spaces. Additional data is collected through the use of inquiry flawlessly, applying knowledge about the individual's disease and the patient's circumstances. 3: Most subjective and objective data is collected and is recorded using the appropriate terminology. Any data that that is not collected is adequately explained in the blank spaces. Additional data is collected through the use of inquiry most of the time, applying basic knowledge about the individual's disease and the patient's circumstances. 2: Some subjective and objective data is collected. Blank spaces in the form are not explained adequately. There is incomplete use of inquiry to collect information. 1: Some subjective and objective data is collected. Blank spaces in the form are not explained. There is an absence of the use of inquiry to collect information relevant to the individual's disease and circumstances. MEDICATION SHEET 4: All current medications are written on a separate piece of paper or index card and contain the required information. The information is complete. The student identifies potential problems and teaching needs individualized to the patient being cared for that is incorporated into the plan of care. 3: Most or all current medications are written on a separate piece of paper or index card and contain most or all of the required. The information is complete. The student identifies some potential problems/teaching needs. 2: Some or all current medications are written on a separate piece of paper or index card and contain most or all of the required information. The information is incomplete with some omissions noted. 1: Some or all current medications are written on a separate piece of paper or index card and contain most or all of the required information. The information is incomplete with many omissions noted. The medications are not integrated into the plan of care. 25 LAB DATA/DIAGNOSTIC TESTS 4: Pertinent lab data and diagnostic test results are recorded. Analysis of data recorded helps to confirm, clarify and direct patient care and is incorporated into the plan of care. 3: Most pertinent lab data and diagnostic test results are recorded. Some data that is irrelevant may be recorded but does not negatively impact patient outcome. Most data recorded helps to confirm, clarify and direct patient care. 2: Some pertinent lab data and diagnostic test results are recorded. Most data that is irrelevant may be recorded but does not negatively impact patient outcome. Absence of pertinent data is not explained. 1: Lab data and diagnostic test results may or may not be recorded. Significant omissions are noted that could lead to a negative impact on patient outcome. REFERENCES 4: References are recorded in the appropriate space. Varied and appropriate references reflect the student's pursuit of the best knowledge in preparing the plan of care for the patient. APA format is used to list references. 3: References are recorded in the appropriate space. References reflect the student's pursuit of the basic knowledge in preparing the plan of care for the patient. 2: References are recorded in the appropriate space. References reflect the student's inability to identify resources that can provide the appropriate knowledge to guide the plan of care. 1: References are recorded in the appropriate space. References are omitted/limited or irrelevant to aid the student's attainment of the appropriate knowledge to guide the plan of care. PRIORITIZATION 4: The nursing diagnoses are evaluated individually and are ranked in priority order to best reflect the coordination of care appropriate to the patient. 3: The nursing diagnoses are evaluated individually and are ranked in priority order and reflect a significant amount of coordination of care appropriate to the patient. 2: The nursing diagnoses are evaluated individually and are ranked in a priority order that indicates flawed decision making. 1: The nursing diagnoses are evaluated individually against a framework that does not facilitate prioritization of nursing diagnoses. 26 DIAGNOSES 4: The nursing diagnoses/collaborative problems selected reflect the accurate interpretation of the subjective and objective data analyzed. Subjective and objective data are listed appropriately as supporting data for the nursing diagnosis. All nursing diagnoses use NANDA terminology. All actual nursing diagnoses use 3 part statements (PES format). Risk nursing diagnosis use 2 part statements and syndrome diagnoses use 1 part statements. 3: The nursing diagnoses selected reflect the adequate interpretation of the subjective and objective data analyzed but are not always the best choice from the possible diagnoses that could be interpreted from the data. PES format is used correctly. 2: The nursing diagnoses selected reflect the inadequate interpretation of the subjective and objective data analyzed and result in a flawed plan of care. PES format is not always complete or used correctly. 1: The nursing diagnoses selected reflect that no effort to interpret information was applied resulting in a flawed plan of care. PES format is usually not complete or used correctly. THE FOLLOWING CRITERIA ARE SUBSETS OF CRITERIA ESTABLISHED IN THE NURSING DIAGNOSIS OF THE RUBRIC. IF THE CARE PLAN RECEIVES A SCORE OF "2" OR BELOW, THE NEXT FOUR CRITERIA (OUTCOME CRITERIA, INTERVENTIONS, RATIONALE, EVALUATION) SHOULD NOT BE SCORED. OUTCOME CRITERIA 4: Measurable criteria are identified all of the time and contain verb and time element. The criteria identified generally are individualized to the patient and will lead to the control of the related factors that contribute to the nursing diagnosis. 3: Most of the outcome criteria are measurable and are identified to achieve goals will lead to the resolution or control of the related factors that contribute to the nursing diagnosis. 2: Some of the outcome criteria are measurable and are identified to achieve goals will lead to the resolution or control of the related factors that contribute to the nursing diagnosis but are poorly developed. 1: Some of the outcome criteria identified to achieve goals will lead to the resolution or control of the related factors that contribute to the nursing diagnosis purely by coincidence. INTERVENTIONS 4: Specific interventions can easily be linked to specific outcomes. The interventions are realistic and appropriate to the patient's current status. 3: Specific interventions can be linked to specific outcomes. The interventions are realistic and usually appropriate to the patient's current status. 27 2: Interventions developed can be linked to specific outcomes but may be independent. The interventions may not be realistic and appropriate to the patient's current status. 1: Interventions developed are incomplete. Inappropriate interventions may be included in the plan of care. RATIONALE 4: Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected. 3: Rationales for each intervention usually explain the intervention adequately and justify its inclusion. 2: Rationales for each intervention do not explain the intervention adequately and consequently its inclusion can not be justified. 1: Rationales for each intervention when included do not attempt to explain the intervention and consequently its inclusion can not be justified. EVALUATION 4: The appropriate subjective and objective data is selected through review of the interventions related to ongoing assessment. The subjective and objective data that measures the outcome is collected and analyzed correctly. 3: The appropriate subjective and objective data is selected most of the time, through review of the interventions related to ongoing assessment that reflects adequate analysis. 2: The appropriate subjective and objective data is selected some of the time, perhaps through review of the interventions related to ongoing assessment or perhaps the data was collected coincidentally. Subjective and objective data is collected most of the time, but there appears to be no pattern to the data collection and it is rarely with consideration of the outcomes that are required to be measured. 1: Subjective and objective data is selected to reflect evaluation without consideration of the outcome criteria. Subjective and objective data may or may not be collected. Data collection is not subjected to analysis. Revised 6/07 28 ANALYSIS OF APPLICATION OF NURSING PROCESS IN STUDENT NURSING CARE PLANS STUDENT NAME _______________________________________ COURSE _______________________________ ASSESSMENT DATE _____________________________ FACULTY ASSESSOR __________________________ SCORE: PLEASE ENTER THE LEVEL OF PERFORMANCE IDENTIFIED IN THE RUBRIC FOR EACH CRITERION. STRENGTHS: DESCRIBE HOW THE PERFORMANCE WAS OF HIGH QUALITY AND COMMENDABLE. LABEL THE ASSESSMENT, SELECTING FROM THE LIST OF CRITICAL THINKING SKILLS AND BEHAVIORS, THAT DESCRIBES THE PERFORMANCE. AREAS OF IMPROVEMENT: IDENTIFY CHANGES THAT COULD BE MADE TO IMPROVE PERFORMANCE IN THE FUTURE EMPHASIZING THE CRITICAL THINKING BEHAVIORS THAT SHOULD BE DEVELOPED. INSIGHTS: REFLECT ON "NURSE KNOWING", "INTUITIONS", AND PERSONAL EXPERIENCE THAT WILL ENHANCE THE STUDENT UNDERSTANDING OF THE PATIENT SCENARIO AND FACILITATE APPLICATION TO NEW CONTEXTS. 29 Revised 5/05, 6/07 PERFORMANCE CRITERIA ASSESSMENT FORM Include Daily Nursing Process Plan with a Nurse’s Note. SCORE STRENGTHS MEDICATION SHEETS Including IV solutions/PRN medications. LAB/DIAGNOSTIC TESTS Include on Daily Nursing Process Plan and submit an additional sheet with interpretation. PRIORITY SHEET List all relevant diagnoses from systematic analysis that incorporates complete diagnostic statements in PES format. REFERENCE LIST On a separate piece of paper in APA format. Minimum of 4 references plus a summary of an article from a professional journal that is relevant to the client. 30 AREAS FOR IMPROVEMENT PERFORMANCE CRITERIA NURSING DIAGNOSES SCORE STRENGTHS List pertinent subjective and objective data as defining characteristics to support diagnoses. OUTCOME IDENTIFICATION Include short and long term measurable goals. INTERVENTIONS Must be client specific. RATIONALE Scientific rationale for interventions. Cite sources in APA format. EVALU ATION The subjective and objective data that measures the outcome is collected and analyzed correctly. TOTAL SCORE: __________ INSIGHTS: 31 AREAS FOR IMPROVEMENT Nursing Care Plans for Faculty The following guidelines are to assist faculty in assessment of student nursing care plans as well as help clinical faculty reinforce expectations with students. The rubric is used to grade all nursing care plans Rubric grades must be placed on clinical evaluation forms at mid and end of semester. Reference list should be typed and in APA format. Students should use different diagnoses for each care plan within a course. Each scientific rationale must have a reference cited in APA format (author, page #). Each nursing care plan must include a bib card about an article related to the particular patient used in the care plan. The bib card must list the reference in APA format and include a brief summary of the article. Nursing interventions must include the specific medications/IV solutions etc. the patient is receiving. Students may not plagiarize each others care plans. All nursing care plans must be submitted in a large brown envelope with student name and diagnostic sheet on the outside. The care plan fails if the total score is less than 28/40. Only whole numbers are used in grading. If the care plan fails the student receives a clinical failure for the day on the evaluation form. If the care plan fails remediation includes the following: o The student must write up and submit a reflection of what went wrong. o The care plan must be remediated and resubmitted until an acceptable score is achieved. o The clinical instructor should have the student resubmit any section of the care plan that receives a score of less than 2 on the rubric. o All of the above must be reflected on the students clinical evaluation form. Specific Guidelines NR 33 One nursing care plan is required The nursing care plan should have at least 5 nursing diagnoses/collaborative problems Each nursing diagnosis should have a minimum of 5 nursing interventions. 32 PERIOPERATIVE CARE PLAN Student Name:_________________________________________ Date submitted ____________________ PATIENT INITIALS: __________________ Date of Surgery: _______________________ Prior Medical/Surgical History:______________________________________________________________ Preop VS: Temp _________ BP ______________ HR___________ RR_______________ Allergy Profile:__________________________________________________________________________ Preoperative checklist completed: Yes No Consent Signed: Yes No Preoperative lab/diagnostics on the chart: Yes No Abnormal lab/diagnostics: Yes No If yes, Describe:________________________________________ __________________________________________________________________________________________ ____________________________________________________________________________________ NPO: Yes No Since______________(enter time) Preoperative prep/medications ordered: Yes No Administered: Yes No If administered, describe:_____________________________________________________________ _______________________________________________________________________________________ Preoperative teaching given: Yes No If given, describe:__________________________________________________________________ _______________________________________________________________________________________ Surgical Procedure: __________________________________________________________________________________________ ____________________________________________________________________________________ Reason for surgery: Diagnostic Curative Restorative Palliative Cosmetic Urgency of Surgery: Elective Urgent Emergent Assessment of Surgical Risk: Review the medical record and check off the box below if any of the following factors are present. AGE Age greater than 65 years MEDICATIONS Antihypertensive therapy Tricyclic antidepressants Anticoagulants NSAIDS/ASA MEDICAL HISTORY Decreased immunity Diabetes Pulmonary disease Infection Cardiac disease Hemodynamic instability Multisystem disease Hypertension Hypotension PRIOR SURGICAL HX Anesthesia reactions Postoperative complications HEALTH HISTORY Malnutrition Obesity Alcohol use Substance abuse Tobacco use FAMILY HISTORY Malignant hyperthermia Bleeding disorder Cancer SURGERY PLANNED Neck, oral or facial procedure Chest or high abdominal procedure Abdominal surgery 33 Coagulation disorder Anemia Dehydration Any chronic disease Review the Intraoperative Report: Type of Anesthesia: General Conscious Sedation Spinal Epidural Regional Block Local Position: supine prone lithotomy lateral jackknife fracture table other Safety equipment used: ____________________________________________________________________ _______________________________________________________________________________________ Airway maintenance: endotracheal tube modified jaw thrust oral airway none Oxygenation: mechanical ventilator supplemental oxygen, type:________________ none Monitoring Equipment: Cardiac monitoring Pulse Oximetry Arterial monitoring CVP monitoring Non Invasive Blood Pressure monitoring Other ___________________________________________ Estimated blood loss (in ccs) ______________________________ Blood Products administered: Yes No If yes, indicate type:__________________________________ Amount:_________________________________ IV Fluids Given: Yes No If yes, indicate type:____________________________________________ Amount:____________________________________________ Total Intake:___________________cc Total Output: __________________________________cc Dressings: (site/condition)_________________________________________________________________ Drains/Tubes: (site/type of drainage)_________________________________________________________ Postop VS: Temp _________ BP ______________ HR___________ RR_______________ What are two priority collaborative problems in the PACU for this client? Identify three interventions for each. Collaborative Problems Interventions What complications can you anticipate postoperatively based on review of the data recorded and the medical and surgical stressors unique to this client? Explain the rationale for each. Complication Rationale 34 NR 33 SELF ASSESSMENT OF APPLICATION OF NURSING PROCESS IN THE CLINICAL SETTING 1. How well did I perform in preconference? a. Did I identify my knowledge gaps and appropriate references? i. Diagnosis and prior medical history ii. Clinical skills and procedures for treatment plan b. Did I seek clarification appropriately? c. Did I formulate tentative diagnoses? i. Could I identify the s/o data I would need to collect to confirm the diagnosis? d. How would I rate my game plan to approach my client based on this review? i. What would I do differently if the opportunity availed itself? 2. How well did I approach my initial assessment? a. How long did it take? b. Was I systematic and analytic in assessment the following: i. Review of findings: 1. LOC (unexpected change in level of consciousness?) 2. Airway (evidence of obstruction?) 3. Breathing (evidence of respiratory distress?) 4. Circulation (evidence of decreased cardiac output or ineffective tissue perfusion?) a. Did I alert my instructor and primary nurse immediately? 5. In and Out a. What tubes? i. IV 1. right solution 2. Right rate (on a pump?) 3. Right tubing (change date?) 4. Site check (date, gauge, time?) ii. O2 (right flow rate? Respiratory treatment needed?) iii. GI/GU 1. Right diet. (Tolerating PO? Daily weight?) 2. I/O (in progress? Should be initiated?) 3. tubes ( quality of drainage) 6. Wound (dressing check? Active bleeding/drainage? Is that OK?) a. Client at risk for decubitus? Back check?) 7. Pain (present? managed?) 8. Safety (side rails? Restraints? Nonskid slippers? Call bell?) c. How would I rate my to approach my client based on this review? i. What would I do differently if the opportunity availed itself? 3. How well did I assess pertinent information from the medical records? a. How long did it take? b. Was I systematic and analytic in assessment the following: i. Doctors orders for last 24-48 hours ( treatments and medications) ii. Progress notes for last 24-48 hours iii. Lab results ( not released yet? Did you find out when the results will be released? iv. Medications (Did I review them in my med book? Any complications I should be looking for? What time should they be given? Do I know how to administer them? How would I give them to my client? 4. How well did I perform a focused physical exam? 35 a. How long did it take? b. Was I systematic and analytic in assessment the following: i. Identification of appropriate systems ii. Use of IPPA format c. Did I verify my assessment findings? i. Ask my instructor, primary nurse or peer to make sure that the finding was correct? d. Did I compare my findings with previous findings to identify changes in my client? i. Is your client getting better? Worse? 1. If there is a new finding or indication of a decline in the client’s status- who did I alert immediately? 5. How well did I identify priority diagnoses? 6. How well did I implement the plan of care? a. Monitoring and nursing intervention protocols i. Did I institute protocols to monitor for complications? ii. Did I perform independent nursing actions to assist to assist my client? b. Treatments and procedures i. Did I review it in skills book? 1. indications, equipment needed, procedural steps ii. Did I seek clarification with instructor? iii. How well did I do it? 1. What would I do differently in the future? c. Appropriate consultation 1. Did I identify anything with my client that required additional follow-up? a. Consultation with MD, PT, RT, case management, social worker i. How did I manage that? d. Patient teaching 1. Did I identify learning needs for my client? a. Review the patient teaching flowsheet to determine what needed to be done? b. Did I find appropriate references and teaching tools? i. How do I do? ii. What would I do differently in the future? 7. Effective communication a. Verbal communication i. How well did I communicate the assessment finding, plan of care and implementation? 1. To my instructor? 2. To the primary nurse? b. Documentation i. How well did document the assessment findings, client’s progress, and treatment plan in the medical record? 1. Did I get all my assessments on the flow sheet cosigned by the instructor? 2. Did I write a focus note for the client’s problems that included the following: a. Data: subjective and objective data that elicited the problem b. Action: The list of nursing actions that required implementation c. Response: subjective and objective data that indicates the client’s response to the nursing actions. ii. What would I do differently in the future? 36 SUFFOLK COUNTY COMMUNITY COLLEGE NURSING DEPARTMENT GUIDELINES FOR REFLECTIVE JOURNALING Instructions to Faculty and Students: Students are directed to keep a clinical log that can be in electronic form, in a bound journal or in a journal folder that should be submitted periodically, at least three entries during the course of the semester as directed by the clinical instructor. Each entry submitted must be dated and answer the guiding questions appropriately. Late submissions or inadequate assignments will result in a clinical warning or failure. If a student receives a warning or a failure in clinical performance, The Written Report of Clinical Incident is submitted as their journal assignment. (Refer to guidelines for completion in the addendum) Faculty may select from the following sample guiding questions or develop their own questions that are relevant to the clinical experience: Sample Guiding Questions: What were my strengths/weaknesses in the preparation for and in the performance of this clinical experience? How did these strengths/weaknesses affect my ability to perform client care? I plan to improve my performance by ….. How did I identify physical, emotional, and learning needs of my client? How did I determine priority problems? What nursing skills did I perform? How would I rate my performance? And what would I do in the future to improve my performance? How did I demonstrate respect for my clients as a person (cultural and spiritual values, dignity, and privacy)? What did I do to manage care for the client? SEE NR 33 SELF ASSESSMENT OF APPLICATION OF NURSING PROCESS IN THE CLINICAL SETTING 37 SUFFOLK COMMUNITY COLLEGE NURSING DEPARTMENT Hospital Support Services Survey 1. Identify RNs working in your facility performing patient related jobs other than in patient care units. Include a brief description of their responsibilities. a. b. c. 2. What preparation is required for this job? 3. What past experiences qualify them for this position? 4. How can a post discharge coordinator facilitate your pt's hospital stay? 5. Can you provide the case manager with information that will influence pt outcomes? 6. Does your facility have Care Coordinators or Utilization Review (Case Manager) staff? How many? What shifts do they work? 7. Describe the responsibilities of one of the above. 8. Identify community agencies they contact for patient related services. 38 9. What barriers can you identify that will impact your patient's ability to be discharged? 10. How are hospitalization costs paid for if the patient has no insurance? What steps are required to apply for Medicare/Medicaid? 11. Describe the process involved in securing medications or supplies needed for patient care at home. Include all staff involved. 12. What interventions can you identify that require other department involvement? List department and services provided. 13. Identify 2 home care agencies servicing the facility you are doing clinical in now. a. b. 14. Identify 2 home care agencies within the township you are living in now. a. b. 39 Name:_______________________________________ NR 33 ASSIGNMENTS Date Due Date Submitted Nursing Care Plan Perioperative care plan 1 week after Or ACE assignment experience Reflective journal 1 2 3 (4) (5) (6) Nursing Notes 1 2 3 (4) (5) (6) Interview Date Hospital Support Services Survey *** ALL ASSIGNMENTS ARE TO BE SUBMITTED IN A SINGLE MANILA ENVELOPE WITH THIS PAGE AFFIXED TO THE OUTSIDE OF IT. ***** 40 STUDENT RESPONSIBILITY FOR SAFE CLINICAL PRACTICE GUIDELINES IN DETERMINING STUDENT CLINICAL GRADE The clinical component of each nursing course provides nursing students with the opportunity to apply nursing principles in a practice setting. This is an essential skill for every competent practitioner of nursing. The four overriding criteria for a satisfactory passing grade in the clinical area are: 1. 2. 3. 4. Using the steps of the nursing process for scientific problem solving. Maintaining medical and surgical asepsis. Maintaining physical safety. Maintaining psychological safety. The critical behavior for evaluating student performance is the student’s ability to make clinical decisions for safe patient care. Such decision making reflects the ability of nursing students to apply nursing principles in a variety of situations. Meeting these criteria constitutes competent performance and a satisfactory passing grade. When a student jeopardizes patient care by violating one of these principles, it shall constitute a failure for that clinical day.* A student fails a course when repeated failures occur. The specific standard for failure in each course is: 1. 2. 3. 4. 5. 6 7. NR20 – Three (3) failed clinical days NR33 – Two (2) failed clinical days NR 24 Two (2) failed clinical days NR36 – Two (2) failed clinical days NR40 – Two (2) failed clinical days NR46 – Two (2) failed clinical days NR48 – Two (2) failed clinical days *Please note that a failed clinical evaluation will constitute a failed clinical day. Student’s responsibilities in this situation include: 1. 2. 3. 4. Taking responsibility for one’s own actions. Identify own error. Ask for assistance. Develop and utilize strategies to assist in clinical decision making. Please refer to document entitled “Guidelines for student written report for student incident resulting in student warning or failed clinical day.” Faculty responsibilities in this situation include: 1. 2. 3. Counseling the student. Providing a written notification regarding the failure. Provide recommendations for corrective action. 41 Guidelines for Student Written Report of Clinical Incident Resulting in clinical warning or Failed Clinical Day Explanation This is an additional assignment that is given when the faculty identifies student decisions and/or actions that fail to meet the course objectives or standards of nursing practice during a given clinical class. The assignment is made in the spirit of student-centered learning and continued professional development. It provides a framework that assists the student to analyze clinical events, to consult the nursing literature, and to plan future nursing goals for themselves that are in keeping with professional standards. Instructions to Faculty The student’s written report should be submitted on the clinical day following the critical incident. The faculty must discuss the critical incident with the student before making this assignment. The completion of the written assignment provides tangible evidence of the student’s perspective regarding the incident. Further discussion with the student or further action may/may not be necessary depending upon the insight demonstrated in the written report as well as the student’s subsequent clinical practice. Instructions to Students 1. 2. 3. 4. Provide a written report of the critical incident to the clinical instructor. The report is due on the next clinical day following the critical incident. The report should consist of your answers to three basic questions. A. What happened? Describe the details of the incident. What were your nursing actions? What was the patient’s response? What were the actual and the potential consequences for the patient? Include any and all details you deem pertinent. B. What should have happened? Based upon your meeting with your clinical instructor after the incident, and based upon the research you have done since the incident, what should have happened in this clinical circumstance? C. What Nursing Practices will you implement in the future to prevent the recurrence of similar incidents? The report should include a bibliography of at least one pertinent nursing reference. 42 SUFFOLK COUNTY COMMUNITY COLLEGE SCHOOL OF NURSING CLINICAL EVALUATION Name: ___________________________________ Course: NR33 Adult Health Nursing I Clinical Agency: ___________________________ #Of Clinical Experiences: ______ #Of Written Assignments Required: ______ #Of Written Assignments Submitted: ______ Date: From: _____________ To: _____________ #Of Absences: ______ EVALUATION CRITERIA - NR33 ADULT HEALTH NURSING I All areas are critical. In Part I, a minimum rating of 2 or better in each category must be achieved on the final evaluation to receive a passing grade. In Part II, a rating of satisfactory must be achieved on the final evaluation to receive a passing grade. 1 2 3 NA/ NO I. PERFORMANCE OBJECTIVES FOR CLINICAL EVALUATION A. ASSESSMENT: 1. Assesses physiological and psychosocial factors that influence the needs of individual patients. 2. Identifies immediate environmental factors that influence the needs of individual patients. 3. Explains the relationship between the patient's altered health status and related therapeutic regimen. 4. Applies interviewing principles to collect data. 5. Verifies data. B. PLANNING: 1. 2. 3. 4. Establishes Nursing Diagnoses using NANDA terminology. Organizes patient care based on prioritizing frameworks. Plans nursing interventions based on actual and potential patient problems. Identifies specific cultural, religious, psychosocial and environmental aspects when formulating plan. 5. Formulates holistic patient care plans for common health problems. 6. Reviews nursing care plan with instructor. 7. Discusses appropriate community resources available for managing common predictable health problems C. IMPLEMENTATION: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Applies appropriate communication techniques. Exhibits caring attitude toward patient and family. Interacts appropriately with the patient and/or family. Discusses the nurse's role in managing patient care. Establishes therapeutic nurse/patient relationships. Applies scientific principles and critical thinking skills to provide competent care. Prioritizes nursing implementation strategies for individual patients. Seeks guidance appropriately when carrying out procedures. Demonstrates proficiency with basic skills. Provides care according to a predetermined plan to promote positive patient outcomes. Administers medications accurately and in accordance with agency protocol. Immediately reports adverse changes in patient status to instructor and/or nursing staff. 43 1 I. PERFORMANCE OBJECTIVES FOR CLINICAL EVALUATION D. EVALUATION: 2 3 NA/ NO 1. Evaluates effectiveness of planned nursing interventions. 2. Identifies factors that interfere with the effectiveness of nursing interventions. 3. Documents patient status and response to care. Satisfactory II. CRITERIA FOR EVALUATING PROFESSIONAL DEVELOPMENT A. SAFETY: 1. 2. 3. 4. 5. Verifies identity of patient. Interprets information and directions correctly. Maintains patient safety incorporating developmental level. Reports own errors Uses aseptic technique correctly. B. SKILLS IN COMMUNICATION: 1. 2. 3. 4. 5. Speaks clearly and effectively in performing nursing role. Expresses ideas clearly in writing. Interacts professionally with nursing staff. Asks relevant and appropriate questions. Act as patient advocate at a basic level. C. PROFESSIONAL STANDARDS: 1. Maintains ethical standards of practice. 2. States legal responsibilities in nursing practice. 3. Accepts responsibility for and maintains accountability for own nursing practice. D. CRITICAL THINKING: 1. 2. 3. 4. Organizes information effectively. Selects and utilizes interventions appropriately. Analyzes data using the steps of the nursing process. Identifies problems in a timely manner. E. INTERPERSONAL RELATIONSHIPS: 1. Participates effectively as a member of a group. 2. Collaborates effectively with health team members. 3. Utilizes constructive criticism and changes behavior accordingly. F. RESPONSIBILITY FOR LEARNING: 1. Evaluates own nursing competencies and changes behavior accordingly. 2. Actively seeks new learning experiences. 3. Utilizes resources to enhance learning. G. PERSONAL RESPONSIBILITY: 1. 2. 3. 4. Reports to clinical facility on time. Submits written assignments on time. Clinical absences do not exceed policy limit. Presents a professional appearance. 44 Unsatisfactory Instructor's Comments: Instructor's Signature _____________________________________________ Date ___________________ Student's Comments: Student's Signature _______________________________________________ Date ___________________ ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† KEY TO PERFORMANCE APPRAISAL 3 = Performance meets clinical objectives and exceeds requirements 2 = Performance meets clinical objectives 1 = Performance does not meet clinical objectives N/A = Not applicable N/O = Not observed 45 SUFFOLK COUNTY COMMUNITY COLLEGE SCHOOL OF NURSING NR 33 ADULT HEALTH NURSING I LABORATORY SKILL COMPETENCY STUDENT NAME __________________________________ EVALUATOR NAME __________________________________ DATE _________________ START TIME ______ END TIME ______ RESULT OF EVALUATION (Circle one) PASS FAIL CRITICAL ELEMENTS INTRAVENOUS PIGGYBACK MEDICATIONS ADMINISTRATION P F 1. Maintains client and nurse safety throughout procedure. ___ ___ 2. Maintains asepsis throughout procedure. ___ ___ 3. Checks Medication Administration Record (MAR) against MD order ___ ___ 4. Selects medication; verifies according to “rights” of medication administration ___ ___ 5. Checks allergy profile. ___ ___ 6. Identifies client using a minimum of (2) identifiers ___ ___ 7. Checks site for signs/symptoms of phlebitis/infiltration. ___ ___ 8. Assesses patency of primary IV. ___ ___ 9. Ensures medication compatibilities prior to administration. ___ ___ 10. Clears air from tubing and correctly attaches to primary line ___ ___ 11. Calculates and states appropriate flow rate of medication. ___ ___ 12. Records amount and type of solution on intake and output sheet. ___ ___ 13. Records medication on medication administration sheet. ___ ___ 14. Re-regulates primary IV to preset rate ___ ___ . 15. Completes all critical elements within a 12 minute timeframe ___ ___ If the competency is failed because of any violation of a critical element for the safe and effective performance of the skill, describe the violation in the space below using objective and specific terms. 46 THE STUDENT AND THE EVALUATOR MUST SIGN THEIR NAMES IMMEDIATELY FOLLOWING THE DESCRIPTION OF THE FAILURE. Within one week, the student must complete a 2nd performance of the competency demonstrating inclusion of all critical elements. A passing grade on the 2nd performance will permit the student to continue in the course. A failing 2nd performance will result in failure of the course __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________ STUDENT SIGNATURE _______________________________ EVALUATOR SIGNATURE _______________________________ 47 SUFFOLK COUNTY COMMUNITY COLLEGE SCHOOL OF NURSING NR 33 ADULT HEALTH NURSING I LABORATORY SKILL COMPETENCY STUDENT NAME __________________________________ EVALUATOR NAME __________________________________ DATE _________________ START TIME ______ END TIME ______ RESULT OF EVALUATION (Circle one) PASS FAIL CRITICAL ELEMENTS CLIENT TEACHING P F 1. Develops client scenario for teaching topic. ___ ___ 2. Identifies learning needs. ___ ___ 3. Lists objectives/expected outcomes. ___ ___ 4. Identifies methodology and tools. ___ ___ 5. Develops content outline. ___ ___ 6. Implements plan via demonstration. ___ ___ 7. Evaluates client's understanding of information presented. ___ ___ 8. Documents client's understanding of learning needs and/or objectives. ___ ___ 9. Completes all critical elements within a 12 minute timeframe ___ ___ 48 If the competency is failed because of any violation of a critical element for the safe and effective performance of the skill, describe the violation in the space below using objective and specific terms. THE STUDENT AND THE EVALUATOR MUST SIGN THEIR NAMES IMMEDIATELY FOLLOWING THE DESCRIPTION OF THE FAILURE. Within one week, the student must complete a 2nd performance of the competency demonstrating inclusion of all critical elements. A passing grade on the 2nd performance will permit the student to continue in the course. A failing 2nd performance will result in failure of the course __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________ STUDENT SIGNATURE _______________________________ EVALUATOR SIGNATURE _______________________________ 49 SUFFOLK COUNTY COMMUNITY COLLEGE SCHOOL OF NURSING NR 33 ADULT HEALTH NURSING I LABORATORY SKILL COMPETENCY STUDENT NAME __________________________________ EVALUATOR NAME __________________________________ DATE _________________ START TIME ______ END TIME ______ RESULT OF EVALUATION (Circle one) PASS FAIL CRITICAL ELEMENTS TRACHEAL SUCTIONING P F 1. Maintains client and nurse safety throughout procedure. ___ ___ 2. Maintains asepsis throughout procedure. ___ ___ 3. Identifies client using a minimum of (2) identifiers ___ ___ 4. Assesses need for suctioning. ___ ___ 5. Positions client for suctioning. ___ 6. Sets designated pressure on suction machine. ____ ___ 7. Verifies suction is working. ____ ___ 8. Oxygenates before, between and after as client status requires. ___ ___ 9. Inserts catheter without applying suction. ___ ___ 10. Rotates catheter continuously, applying intermittent suctioning. ___ ___ 11. Suctions for no more than 10 seconds at a time. ___ ___ 12. Gives verbal documentation of procedure. ___ ___ 13. Completes all critical elements within 12 minute timeframe ___ __ 50 ___ If the competency is failed because of any violation of a critical element for the safe and effective performance of the skill, describe the violation in the space below using objective and specific terms. THE STUDENT AND THE EVALUATOR MUST SIGN THEIR NAMES IMMEDIATELY FOLLOWING THE DESCRIPTION OF THE FAILURE. Within one week, the student must complete a 2nd performance of the competency demonstrating inclusion of all critical elements. A passing grade on the 2nd performance will permit the student to continue in the course. A failing 2nd performance will result in failure of the course __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________ STUDENT SIGNATURE _______________________________ EVALUATOR SIGNATURE _______________________________ 51 SUFFOLK COUNTY COMMUNITY COLLEGE SCHOOL OF NURSING NR 33 ADULT HEALTH NURSING I LABORATORY SKILL COMPETENCY STUDENT NAME __________________________________ EVALUATOR NAME __________________________________ DATE _________________ START TIME ______ END TIME ______ RESULT OF EVALUATION (Circle one) PASS FAIL CRITICAL ELEMENTS MEDICATION ADMINISTRATION THROUGH NG OR G-TUBE P F 1. Maintains client and nurse safety throughout procedure. ___ ___ 2. Maintains asepsis throughout procedure. ___ ___ 3. Checks Medication Administration Record (MAR) against MD order ___ ___ 4. Selects medication; verifies according to “rights” of medication administration ___ ___ 5. Checks allergy profile ___ ___ 6. Crushes and dissolves tablets in 30 ml of water. ___ ___ 7. Identifies client using a minimum of (2) identifiers ___ ___ 8. Positions client in high Fowler's position. ___ ___ 9. Checks tube for placement and residual ___ ___ 10. Administers medications by gravity flushing with 15 – 30 ml water before, between, and after each medication. ___ ___ 11. Documents in MAR and I&O sheet ___ ___ 12. Completes all critical elements within 12 minute timeframe ___ __ 52 If the competency is failed because of any violation of a critical element for the safe and effective performance of the skill, describe the violation in the space below using objective and specific terms. THE STUDENT AND THE EVALUATOR MUST SIGN THEIR NAMES IMMEDIATELY FOLLOWING THE DESCRIPTION OF THE FAILURE. Within one week, the student must complete a 2nd performance of the competency demonstrating inclusion of all critical elements. A passing grade on the 2nd performance will permit the student to continue in the course. A failing 2nd performance will result in failure of the course __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ STUDENT SIGNATURE _______________________________ EVALUATOR SIGNATURE _______________________________ 53 SUFFOLK COUNTY COMMUNITY COLLEGE SCHOOL OF NURSING NR 33 ADULT HEALTH NURSING I LABORATORY SKILL COMPETENCY STUDENT NAME __________________________________ EVALUATOR NAME __________________________________ DATE _________________ START TIME ______ END TIME ______ RESULT OF EVALUATION (Circle one) PASS FAIL CRITICAL ELEMENTS ADVANCED WOUND CARE P F 1. Maintains client and nurse safety throughout procedure. ___ ___ 2. Maintains asepsis throughout procedure. ___ ___ 3. Checks order for dressing change and treatment. ___ ___ 4. Checks allergy profile ___ ___ 5. Identifies client using a minimum of (2) identifiers. ___ ___ 6. Inspects wound for drainage, exudate, granulation, etc. ___ ___ 7. Irrigates with prescribed solution and prescribed amount. ___ ___ 8. Directs irrigating solution into wound so it flows from cleanest to dirtiest area ___ ___ 9. Collects returning solution into appropriate container. ___ ___ 10. Packs wound using prescribed materials and solution. __ ___ 11. Applies sterile dressing. ___ ___ 12. Documents wound assessment, irrigation results and type of packing done. ___ ___ 13. Completes all critical elements within 12 minute timeframe ___ ___ 54 If the competency is failed because of any violation of a critical element for the safe and effective performance of the skill, describe the violation in the space below using objective and specific terms. THE STUDENT AND THE EVALUATOR MUST SIGN THEIR NAMES IMMEDIATELY FOLLOWING THE DESCRIPTION OF THE FAILURE. Within one week, the student must complete a 2nd performance of the competency demonstrating inclusion of all critical elements. A passing grade on the 2nd performance will permit the student to continue in the course. A failing 2nd performance will result in failure of the course __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________ STUDENT SIGNATURE _______________________________ EVALUATOR SIGNATURE _______________________________ 55