Download NR 33 ACTIVITY FOR FIRST CLINICAL DAY page 2

SUFFOLK COUNTY COMMUNITIY COLLEGE
AMMERMAN CAMPUS
DEPARTMENT OF NURSING
NR 33 CLINICAL FOLDER
Revised 8/07 sm
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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
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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.
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SUFFOLK COUNTY COMMUNITY COLLEGE
SCHOOL OF NURSING
Medication Administration for a Client/Group of Clients NR33/40
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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
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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.
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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)
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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.
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Check for labs tests released and pending.
Labs released:
Labs pending:
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Check for orders written in last 24-48 hours:
New orders/changes:
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Check last 24 hours of progress notes (MD, NURSING, CONSULTS)
MD plan
Nursing plan
Consults
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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)
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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
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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.
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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.
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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)
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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