Download RNSG 2463 Syllabus - TC Online

CLINICAL PACKET
RNSG 2463
CLINICAL NURSINGRegistered Nurse Training
(CDM III/Management)
Spring 2017
TABLE OF CONTENTS
Page
Course Description, Learning Outcomes, Key Concepts and General Course
Plan....................................................................................................................................... 2
Student Learning Outcomes................................................................................................... 3
Clinical Expectation/Guidelines and Evaluation
Requirements.................................................................................................................
5
Clinical Assignments and Prep
Guidelines......................................................................................................................
7
Journal Keeping
Requirements........................................................................................................................ 14
Guidelines for Intensive Care ………………………………………………………….... . 15
Special Procedures/Dialysis Lab Guide………………………………….……………... .. 18
Guidelines for Management of Care.................................................................................... 19
Assessment Guidelines……………………………………………………………………. 21
Forms…………………………………………………………………………………
27
Clinical Evaluation Booklet—Supplement (CEB-S) …………........................................
34
Clinical Evaluation Booklet…...................................................................................……....44
Syllabus/Handbook Compliance
Form….........................................................................................................................
63
Simulation Agreement........................................................................................................... 64
1
COURSE NAME: Clinical Decision Making III
COURSE NUMBER: RNSG 2463
CREDIT HRS. 4 LECTURE: 0
LAB: 0 TOTAL CLOCK HOURS: 256
Course Title:
Clinical Decision Making III/Management
Course Level:
Advanced
Course Description: A health-related work-based learning experience that enables the student to
apply specialized occupational theory, skills, and concepts. Direct supervision is provided by the
clinical professional.
End of Course Outcomes: The student will utilize critical thinking and a systematic problemsolving process as a framework for providing care for patients in structured health care settings; and
analyze the roles of the associate degree nurse in the provision of care for patients and families.
Key Concepts and General Course Plan: Emphasis in clinical is upon application of biological,
psychological, and sociological concepts, critical thinking/decision-making, management principles,
and use of the nursing process to promote health, prevent disease, and provide nursing care during
illness to small groups of adult patients (5-8) in structured health care settings. Additional clinical
skills include administration of IV push medications and care of central lines. This course enables the
student to use critical thinking/decision-making skills to integrate interpersonal competency with
principles of management. The student will act as a patient safety advocate while assuming
responsibility and accountability for the quality of nursing care provided at the graduate nursing
level.
Prerequisites:
BIOL 2301 or 2302, 2420; PSYC 2301 and 2314;
ARTS 1301 or MUSI 1306 or DRAM 1310; and AHA/BLS-HCP.
Basic Students: 1413, 1360, 1431, 1260, 1412, 1261, 1441, 2360, and 2213
Transition Students: RNSG 1327, 1251, 1160, 1441, 2360, 2213
Corequisites:
RNSG 1443
Corequisite courses must be completed by the end of the semester.
Failure to do so prohibits progression in the program.
2
Revised: October 2014
PSLO = IE Student Learning Outcomes (Program)
QSEN – Quality & Safety Education for Nurses
SOP = Texas BON Standards of Practice (2005)
QSEN-P = Patient-centered care
CO = Student Learning Outcomes (Course)
QSEN-T = Teamwork and collaboration
DEC = Texas BON Differentiated Essential Competencies (2010)
QSEN-E = Evidence-based practice
DEC-P = Provider of Patient Centered Care
QSEN-Q = Quality Improvement
DEC-S = Patient Safety Advocate
QSEN-S = Safety
DEC-T: Member of the Health Care Team
QSEN-I = Informatics
DEC-M = Member of the Profession
RNSG 2463 Clinical Decision Making/Management
Course Student Learning Outcomes
Upon completion of this course, the student will be able to:
**1.
3A
Demonstrate the nursing process and the holistic model to make
clinical decisions in managing the care of patient (5-8). PSLO 1
DEC-M-B DEC-P-A,B,C,D,F,H
QSEN-E, P
DEC-S-AB,C,F
DEC-T-A,B,C,D,E,F,G
SOP
**2. Practice the principles of pharmacology, nutrition, fluids and electrolytes
communication, health promotion, and health teaching in the care of patients
(5-8). PSLO 1 DEC-M-B DEC-P-A,D,E,F,G,H DEC-S-B,D
DEC-T-A,C,D
SOP 1C, 1D, 1FQSEN-E, P, S
3. demonstrate effectiveness with interpersonal skills and implementation of the nursing process when
managing care for patients (5-8). PSLO 1, 4, 5 DEC-M-B,C,D
DEC-P-A,B,C,E,F,G,H
DEC-S-C,D
SOP 1H, 1R, 1T, 3A
QSEN- P,S,T
**4. Demonstrate therapeutic communication skills to interact effectively with patients, family and
appropriate health professionals. PSLO 1,2, 3, 4, 6 DEC-M-A,B,D
DEC-P-A,B,C,D,E,F,G,H
DEC-T-A,D,E,G
QSEN-Q,T
DEC-S-A,B,C,D
SOP 1D, 1L, 1P
**5. List behaviors which suggest the patient’s and family’s inability to cope
with deviations of health. PSLO 3, 6 DEC-M-B
DEC-P-A,B,D,E,F,G,H
DEC-S-B,C
DEC-T-A,B,C,D,G
SOP 1F QSEN P, Q, S
3
**6.
Demonstrate skills applicable in health promotion, health monitoring, and in managing the care of
patients (5-8) with deviations of health:
A.
assessment performance
B.
delegation of basic care to unlicensed assistive personnel
C.
tracheostomy care
D.
suctioning (NT, ET)
E.
care of patients on ventilators
F.
care of patients with chest tubes
G.
care of central lines
H.
insertion, removal, and care of gastrointestinal tubes
I.
administration of TPN and care of tubes
J.
administration of IV push medications
PSLO 1, 2, 5 DEC-P-A,B,C,D,E,G,H
1A, 1G, 1H, 1K, 1Q, 1S, 1T, 1U QSEN P, E, Q
**7.
DEC-S-B
DEC-T-A,B,C,D,F,G
SOP
Assess situational and environmental factors which contribute to or detract
from safe nursing practice when managing care for (5-8) patients.
PSLO 1,2,3,6 DEC-M-A,B
DEC-P-B,D,E,H
DEC-S-A,B,C,D,E,F
A,B,C,D,F,G SOP 1B, 1G, 1K, 1M, 1N, 1O, 1T, 1U , 3A, 5 QSEN-P, Q, S
**8.
DEC-T-
Delegate nursing care according to the Texas Nurse Practice Act when managing the care
of (5-8) patients. PSLO 4, 5 DEC-M-A,B,C
DEC-P-A,C,D,H
DEC-S-A,D,E,F
DEC-T-D,F,G
SOP 1S, 1U, 3BQSEN- E,P,Q,T
**9. Use legal and ethical principles, as well as personal values when managing the care for
patients. PSLO 1,2,5 DEC-M-A,B,C,D
DEC-P-A,B,D,E
DEC-S-A,B,D,E,F
DEC-T-A,B,C
SOP 1A, 1G, 1J, 1L
QSEN-P,S
(5-8)
**10. Teach selected principles and procedures of healthcare to the patient and/or family utilizing the
nursing process. PSLO 1, 2, 6
DEC-P-D,E,G,H
DEC-S-B
DEC-T-A,B,C
SOP 1D, 1F, 1P QSEN—P,T,Q,S
**11. Utilize evidence-based practices in the delivery of care in the clinical setting. PSLO 1, 5
DEC-M-D
DEC-P-A,B,C,D,E,H
DEC-S-C
DEC-T-A,B,D,E
SOP 1C, 1H, 1Q, 1R, 2, 3A
QSEN—E,P,Q,S
12. Perform organizational skills and apply resources to meet goals and enhance quality
of nursing care when managing the care for small groups (3-4) of patients.
PSLO 1, 4
DEC-M-B
1Q, 3A4, 3A5
QSEN-P,T,Q,E,S,I
DEC-P-A,C,E,H
DEC-S-C
DEC-T-A,F,G
13. Display professional behavior which reflects a positive image of nursing.
PSLO 5
QSEN-T, Q, S
DEC-M-A,B,C,D DEC-P-A,D DEC-S-A,B,E DEC-T-B,D
4
SOP 1J, 1K, 1R
SOP
CLINICAL EXPECTATIONS
1.
Clinical attendance - Refer to the Health Science Student Handbook.
Satisfactory completion of all assignments in RNSG 2463 is necessary in order to pass
the course. Because of the importance of the clinical component, the student is expected
to be present for all scheduled clinical days. However, if absence is due to emergencies or
extenuating circumstances does occur, the following policy will apply:
A.
Students must be in the hospital lobby by 0640 and report to the clinical
instructor to be considered on time for clinical. If the student arrives in
the hospital lobby 0641-0655, the student will be counted tardy. If the
student arrives in the lobby after 0655, the student will be counted absent and will be sent home. Three
(3) tardies equal one (1) absence.
B.
Students may not have more than two (2) clinical absences during the semester. Three (3) clinical
absences during the semester will result in the student not progressing in the program. Exceeding the
allowed absences in clinical will result in the student being dropped from the course. In accordance with
Texarkana College policy, students who exceed the allowed absences for attendance in any of their
courses will be given a “W” on their transcript.
If a student has been placed on Level III Evaluation and Progression with one-on-one
observation and is absent on the designated day of evaluation, the absence may be made up
in the clinical area at the discretion of the faculty and Division Chair. If no time remains in the semester, the
student may not progress in the program.
If the clinical course (RNSG 2463) is dropped, the student cannot continue in theory (RNSG 1443). If theory
(RNSG 1443) is dropped, the student cannot continue in the clinical course (RNSG 2463). The student must pass
RNSG 1443, and 2463 concurrently in order to continue in the Associate Degree Nursing Program
2.
Clinical dress code should be adhered to at all times as specified by the Health Science Student
Handbook and/or clinical agency. Noncompliance with the Nursing Uniform Code and failure to
adequately prepare for clinical assignments may result in the student's dismissal from the Clinical Unit with a
clinical absence.
3.
AHA/BLS-HCP must be current through May of the year you expect to graduate.
4.
A TB test that is valid through graduation date is required for all 2nd year ADN students.
5.
Be prepared to supply your own vehicle for transportation between clinical sites or residences
when you are assigned to Community Experiences. Riding in the preceptors’ private vehicle is prohibited.
5
CLINICAL EVALUATION REQUIREMENTS
1.
Clinical attendance, as stated in Health Science Student Handbook
2.
Journals will be submitted as assigned and pertaining to the guidelines on page 12.
3.
Post-conference presentations:
Patient presentation guideline: Beginning the second clinical day, students will be asked to
orally present their patient during post-conference.
Evidence-based practice presentations: Students will be assigned to present an evidence-based nursing practice
during the post-conference time.
4.
Skills introduced in this course as well as previously learned skills and guidelines must be
performed satisfactorily.
5.
Simulation activities are part of the overall clinical experience and are designed as a learning
opportunity for students. The simulation policy can be reviewed in Health Science Student Handbook.
6
CLINICAL INFORMATION
Assignments: The clinical instructor will make the assignments. Should a patient be discharged, transferred, etc. the
student is responsible for working with the staff to secure another assignment of comparable difficulty. The student should
inform their clinical instructor of assignment changes in a timely manner.
Clinical Guidelines:
1.
Students must be in the hospital lobby by 0640 and report to the clinical instructor to be considered on time for
clinical. If the student arrives in the hospital lobby 0641-0655, the student will be counted tardy. If the student
arrives in the lobby after 0655, the student will be counted absent and will be sent home. Three (3) tardies equal
one (1) absence.
2.
On clinical days the student will report to his assigned unit at 0645, or as appropriate
in full uniform and ready to listen to change of shift report. Following report, the
student will take and record morning vital signs, perform nursing assessments and make opening entries in the
chart. As well the student will review the patient’s chart and check to see if medications to be given are available.
3.
Breaks are allowed after finishing patient care and charting. Breaks are to be taken off the unit and are not to
exceed 15 minutes. Break time is lost if not taken by 10:30 AM.
4.
Students are allowed a 30-minute lunch break and are encouraged to take the lunch
break. Students are to report off to the hospital staff prior to leaving the Unit for any
reason. Lunch must be taken at the clinical site in the cafeteria area. Students will not take
a terminal lunch. Lunch times are 11:00-11:30 and 11:30-12:00.
5.
Keep your team leader aware of the skills in which you have had instruction, but need
further practice. Seek out learning experiences!
6.
All students are to attend post conference unless otherwise instructed. Report off to
the team leader before leaving the unit. Manage your time effectively so that you are on time for post
conference. Post conference times are 1:45-2:45 p.m.
7.
Post conferences will be utilized to correlate theory (classroom) content with the student
clinical experiences by use of the nursing process.
8.
If unable to attend clinical, the student must telephone the assigned unit to report the
absence. Take the name of the person to whom you speak and ask that a note be given to
your instructor and the team leader. This must be done prior to 0630am.
9.
Clinical experience will emphasize a management role for (5-10) patients. Biopsychosocial and cultural aspects
will be considered when caring for these patients in the clinical setting.
The management of these groups of patients will consists of:
a.
Assessment and documentation
b.
Collaboration with other health care professional
c.
Administration of medications will be as follows:
1)
The student may administer “non-parenteral” medications
without supervision.
2)
The student may administer IM, SubQ or intradermal medications with RN supervision.
3)
Insulin administration must be supervised by an RN or the clinical
7
4)
5)
6)
7)
instructor.
Student may start an IV with the assistance of the RN or
clinical instructor only.
Designated IV push medications MUST BE SUPERVISED BY THE CLINICAL
INSTRUCTOR.
The designated IV push medications include:
Saline
Diuretics (ex. Lasix, Bumex, Diamox)
Steroids (ex. SoluMedrol, SoluCortef, Decadron)
Protonix
The student may begin giving (with instructor) these meds after
instruction of administration of IV push medications. No other IV push
medications are allowed to be administered by the student during this course.
Students may administer IVPB (piggyback) with an RN or clinical instructor only.
d.
Treatments including IV care, dressing changes, GI tube care, Foley care, and trach care after
discussion in class or with the clinical instructor.
e.
Rounding with physicians. Students are not to accept verbal orders or telephone orders.
f.
Transcribing physicians’ orders, only if the RN is available to co-sign.
g.
Admissions of new patients. Discharge or transfer of patients.
h.
Bathing, changing linens, oral care and meeting elimination needs on a prn basis only when assigned 3 or
more patients. Total care will be provided if student is assigned less than three (3) patients
8
CLINICAL PREPARATION
1.
All prep forms must be completed as assigned by the faculty. The instructor will view your work for
completeness. If unprepared and/or not knowledgeable of patient needs, action taken will be at the discretion of
the instructor. This action may include a failing grade for the day or being dismissed from the clinical area
resulting in a clinical absence.
2.
ICU Clinical Preparation (Must be completed prior to day of care):
1)
ICU Prep Form with additional pathophysiology sheets and drug sheets as listed.
2)
See: Guidelines for Intensive Care
3)
Preceptor Feedback- https://www.texarkanacollege.edu/forms/nursing-preceptor-student-feedback/
4)
Feedback on Preceptor (done by the student)
https://www.texarkanacollege.edu/forms/nursing-student-preceptor-feedback/
3.
Community Agency Assignment
1)
Complete the Community Agency form. Submit to clinical instructor by next clinical day.
2)
Preceptor Feedback- https://www.texarkanacollege.edu/forms/nursing-preceptor-student-feedback/
3)
Feedback on Preceptor (done by the student) –
https://www.texarkanacollege.edu/forms/nursing-student-preceptor-feedback/
4.
Special Procedures / Dialysis
1)
See Special procedures/dialysis page
5.
Management Days
1)
Instructions to be provided by faculty based on clinical site
6.
Pathophysiology pages
1)
A pathophysiology page is to be completed in correlation with each RNSG 1443 Unit. The disease
process and due dates for each pathophysiology page will be assigned by faculty.
7.
Nursing Diagnosis form
1)
Two (2) NANDA nursing diagnosis are to be done for each assigned patient, or as instructed by faculty,
for each clinical day. The nursing diagnosis must include subjective and objective data.
Written and/or oral assignments are to be completed on time. Students should put their name on every piece of
paper. All work should be submitted in an envelope or folder. Written assignments will be graded.
Grades are reflected in the Clinical Evaluation Booklet (CEB).
9
Nursing Diagnosis Form
Student Name:
Room #
Clinical Instructor:
Age:
Date:
Gender:
Diagnosis:
Nursing Diagnosis #1
Subjective data:
Objective data:
Nursing Diagnosis #2
Subjective data:
Objective data:
Room #
Age:
Gender:
Diagnosis:
Nursing Diagnosis #1
Subjective data:
Objective data:
Nursing Diagnosis #2
Subjective data:
Objective data:
___________________________________________
10
Nursing Diagnosis Form
Student Name:
Room #
Clinical Instructor:
Age:
Date:
Gender:
Diagnosis:
Nursing Diagnosis #1
Subjective data:
Objective data:
Nursing Diagnosis #2
Subjective data:
Objective data:
Room #
Age:
Gender:
Diagnosis:
Nursing Diagnosis #1
Subjective data:
Objective data:
Nursing Diagnosis #2
Subjective data:
Objective data:
11
Nursing Diagnosis Form
Student Name:
Room #
Clinical Instructor:
Age:
Date:
Gender:
Diagnosis:
Nursing Diagnosis #1
Subjective data:
Objective data:
Nursing Diagnosis #2
Subjective data:
Objective data:
Room #
Age:
Gender:
Diagnosis:
Nursing Diagnosis #1
Subjective data:
Objective data:
Nursing Diagnosis #2
Subjective data:
Objective data:
12
Nursing Diagnosis Form
Student Name:
Room #
Clinical Instructor:
Age:
Date:
Gender:
Diagnosis:
Nursing Diagnosis #1
Subjective data:
Objective data:
Nursing Diagnosis #2
Subjective data:
Objective data:
Room #
Age:
Gender:
Diagnosis:
Nursing Diagnosis #1
Subjective data:
Objective data:
Nursing Diagnosis #2
Subjective data:
Objective data:
13
JOURNAL KEEPING: A CRITICAL THINKING TOOL
PURPOSE: To reflect on your own thoughts, feelings, and actions occurring as a result of
clinical management experiences; a way to enhance effective decision making skills and jurisprudence
knowledge in preparation for a professional role in nursing.
Personal attitudes and self-awareness in relation to others are key issues of which the nursing student must be aware.
Journal keeping is a critical thinking tool that allows the nursing student to explore personal thoughts and events as a way
to grow professionally.
Topics for the weekly journal assignment are accessed on the MyTC website under the clinical course/faculty for each
student. Journal entry will be made directly on the site each week. Faculty will access the journal entries and provide
feedback each week. The journal topics have been designed to assist the student with critical thinking and provide an
opportunity for reflection on clinical learning. The journals also allow the student to become familiar with the Nurse
Practice Act, BON website and the Rule and Regulations pertaining to nursing practice. This will help to prepare the
student for the Jurisprudence Exam that will be taken prior to licensure.
Journal keeping is a partial requirement for a Satisfactory Clinical grade (CEBS #34). A letter grade will not be given on
the journals, but you will be credited for your entry. Omission or late submission of journal assignments will result in a
grade deduction for the next graded day in the CEB.
One (1) point will be deducted from Professional Growth & Development each time a journal assignment is not
completed on time and one (1) point will be deducted from Interpersonal Relations for the first omission or late
submission of the semester, two (2) points for the second omission or late submission, three (3) points for the third
omission or late submission, four (4) points for the fourth omission or late submission, etc.
If a student omits more than five (5) journals or submits them late for the semester, subsequent points will be deducted
from the Professional Growth category as well.
If four omissions or late submissions occur for journal entries within the semester, the student will be placed on a
Level I Warning as outlined in the CEB-S.
14
GUIDELINES FOR INTENSIVE CARE
1.
You will be assigned a nurse preceptor. You will work directly with the
nurse and will not be working alone with a patient. Always ask questions
if you are unsure of a procedure or do not understand instructions.
2.
Do not bring book bags or backpacks (no place to store them).
3.
Check in with instructor by 0640 and be present for morning report at 6:45 a.m.
4.
Review trach care and nursing measures related to mechanical ventilators prior to your
ICU rotation.
5.
Post conference attendance is required.
6.
On procedures such as trach care or wound irrigations, the student may perform the procedure with the assistance
of the RN.
7.
Document a head-to-toe assessment and hourly rounding on a separate sheet of paper and submit to the clinical
instructor.
8.
You will be administering medications in ICU. All medications are to be
checked with your preceptor prior to administration. No IV pushes will be
given by student in the ICU’s.
9.
Focus on care of the patient and any skills you might perform rather than
becoming preoccupied with equipment.
10.
Report any change in the patient’s condition to the nurse.
11.
Report in full uniform with all needed supplies.
12.
Each student is responsible for seeking opportunities to perform oral-pharyngeal, nasopharyngeal, or tracheal
suctioning while in the intensive care units.
13.
Preceptors will give feedback on student performance using the preceptor feedback link on the TC website:
https://www.texarkanacollege.edu/forms/nursing-preceptor-student-feedback/
14.
You must complete a Feedback on Preceptor using the student the link for student feedback on the TC website:
https://www.texarkanacollege.edu/forms/nursing-student-preceptor-feedback/
15
INTENSIVE CARE PREP
Review: Clinical Nursing Skills - Smith, Duell and Martin (8th edition) and Medical – Surgical Nursing
Ignatavicius and Workman (8th edition). Answer the following questions:
1. Review care of the patient with an arterial line and define the following:
Allen’s Test:
Zeroing:
Waveform:
2. List 2 common uses of the arterial line (art line):
3. List 5 possible complications of the art line:
4. Review care of the patient with a pulmonary artery catheter (Iggy) and define the following:
Right Atrial Pressure (RA)
Pulmonary Artery Pressure (PAP)
Pulmonary Artery Wedge Pressure (PAWP)
16
5. List 5 possible complications associated with pulmonary artery catheters:
6. Describe measurement of cardiac output.
7. Complete the 5 required IV medication sheets using the format on the blank drug sheet provided in the
syllabus for:
A. Amiodaron
B. Diltiazem
C. Nesiritide
D. Nitroglycerin
E. Phenytoin
8. Complete the 5 required pathophysiology maps:
A. Acute Renal Failure [ARF]
B. Closed Head Injury [CHI]
C. Liver Failure
D. Myocardial Infarction [MI]
17
Special Procedures/Dialysis Lab Guide
Special Procedures:
1.
Arrive in the special area by 6:40 a.m. You will still check-in in the lobby with the instructor at
the normal clinical time per attendance policy.
2.
The special procedures nurses will inform you of procedures to be done that
day. The emphasis for this experience is to observe cardiac caths, although
you may observe other procedures if there are no cardiac caths scheduled.
3.
Your role during the cardiac cath is observation. Observe the technique
utilized, the nurse’s role, the patient’s response. Ask questions
appropriately. Most questions may be better asked before or after the
procedure, as the physician and the staff are focusing upon the patient
during the procedure.
4.
Occasionally, there are no scheduled procedures, or all those scheduled
are completed early. Should this not produce a learning experience, report to your instructor.
Dialysis:
1.
2.
3.
4.
Prior to your experience in dialysis, review your text about renal
failure and dialysis.
Dialysis units at both hospitals usually do not begin until after 8 a.m. The
clinical instructor will give you alternative care activities to complete until
the unit is open.
Wadley - in the SICU
Christus St. Michael - 5 North
Your role during the dialysis experience is observation. Observe the dialysis
procedure, the nurse’s role, the patient’s response. Review the patient’s lab
work -- try to figure out how deviations from normal are related to renal
failure. Ask questions!
Objectives:
a.
Identify the dialysis types and their indications and contraindications.
b.
Explain the physiologic principles of hemodialysis.
c.
Discuss nursing assessment and management of the patient before,
during and after hemodialysis.
d.
Identify the adverse effects of hemodialysis and nursing measures to
prevent them.
e.
Determine if dialysis affects the body’s use of medications
administered prior to dialysis.
Attend post conference on second clinical day of each week.
18
Guideline for Management of Care
1.
Listen to report.
2.
Assist with team assignments.
3.
Review physician orders, lab work, and medications.
4.
Assess 4-10 patients and document. Prioritize which patient needs to be
seen first.
5.
Assess for medication actions and side effects.
6.
Consult with staff R.N. regarding changes in patients’ condition.
7.
Prioritize and delegate needs of patients to appropriate staff.
8.
Evaluate patient response to care.
9.
Relate standards/regulations covered by the Joint Commission
10.
Communicate with physician, dietitian, resource persons, etc.
11.
Participate in multidisciplinary team conferences.
12.
Reassess and evaluate outcomes.
13.
Admit, discharge, and/or transfer patients as ordered.
14.
Accompany physicians on patient rounds.
15.
Transcribe physician’s orders with staff R.N.’s co-signature.
16.
Give end of clinical day report to RN.
19
Simulation Philosophy
Texarkana College, including its Health Science Division, is dedicated to serving the educational needs of
diverse individuals through relevant programs and services that are high quality, affordable and accessible. The
Health Science Division includes a diverse population of well-qualified, competent, committed and caring
faculty who engage in the supporting and attaining student success. In support of Texarkana College’s Mission,
the Health Science Division curriculum includes Simulated Lab experiences designed for adult learners which
develop progressively higher levels of cognitive, affective, and psychomotor competencies needed to provide
safe entry level practice. Utilizing a guided Simulation Lab provides the faculty the opportunity to mentor
students’ development of critical thinking skills, clarity of oral and written expression, and the application of the
nursing process in a safe in a safe supportive and positive learning environment. The Simulation Lab is
designed to help achieve course learning outcomes.
Benefits of Simulation
1. Enriches and enhances course content.
2. Creates a safe practice environment for students.
3. Creates practice environments not readily available for students.
4. Develops and encourages the use of effective communication between team members and the
application of critical thinking skills.
5. Allows students to implement the nursing process to reinforce course content within the context of a
practice scenario/simulation exercises.
6. Promotes learning through a collaborative process.
7. Encourages reflective thinking by students during the debriefing process.
Reference Sources:
Texarkana College (2012). Texarkana College Mission Statement. Texarkana College 2012-2013 College Catalog. Retrieved October
31, 2012 from https://www.texarkanacollege.edu/PDFFiles/Admissions/Catalog/TexarkanaCollegeCatalog.pdf
Nurse Educator, Using Simulated Clinical Scenarios to Evaluate Student Performance, Wolf, Dion, Lamoureaux et al, Vol. 36, No. 3
128 – 134
20
ASSESSMENT GUIDELINES
21
Cardiovascular Assessment Guide
History
Physical Exam
BP
T
P
R
Wt.
Ht.
History MI
Orthostatic BP Lying ___ Sitting ___ Standing ___
Apical Pulse
rate
rhythm
Jugular vein distension
Murmurs
Bruits
Location
Bleeding disorder
Breath sounds
Amount
Current Medications
Extremities: Pulses (location, presence, strength)
Capillary refill (location, quality)
Temperature/Color
Homan’s sign
Previous Illnesses
Varicose veins
Psychosocial Assessment
Stressors:
Coping skills:
Activity level
Drug/Alcohol abuse:
Chief Complaint
Pertinent Nursing Diagnoses
Decreased cardiac output R/T altered heart rhythm
Diagnostic Tests
CBC with differential
Platelet count
PT/PTT
Cardiac Enzymes
Troponin
Electrolytes (K+, Na+, Ca+)
BUN
Lipid studies (LDL, HDL, Total Chol, Triglycerides)
Serum Glucose
EKG
Doppler Studies
Chest X-Ray
Echocardiogram
Stress Test
Cardiac Cath
Fluid volume excess/deficit R/T compromised
regulatory mechanisms
Acute pain R/T tissue damage and ischemia
Impaired gas exchange R/T alveolar changes
Altered tissue perfusion R/T exchange problems
Altered nutrition
Activity intolerance R/T imbalance in O2
supply/demand
Powerlessness R/T illness related regimen
Anxiety R/T change in health status
Ineffectual individual coping R/T uncertainty
22
Neurological Assessment Guide
History
Age
Sex
Physical Exam
Mental Status
BP
Chief Complaint:
T
P
R
Wt.
Ht.
Level of Consciousness
Pupil Size (each eye)
Medications:
Pupillary Response
Speech pattern
Coordination/fine motor skills
Use of alcohol/tobacco/drugs:
Balance/Equilibrium/Gait
Superficial Pain Response only if ↓ LOC
Deep Pain Response only if ø superficial response
History of illnesses/hospitalizations/surgeries:
Cranial Nerves intact (I-XII)
Glasgow Coma Score
Family history of illnesses:
Pertinent Nursing Diagnoses
Have you experienced?
Acute or Chronic Pain R/T motor and sensory nerve damage
Seizures
Stroke
Ineffective breathing pattern R/T neuromuscular weakness/
paralysis of facial, throat, or respiratory muscles
Risk for disuse syndrome R/T paralysis/immobilization
Recent infection
Forgetfulness
Altered cardiopulmonary or cerebral tissue perfusion R/T BP
fluctuations secondary to autonomic dysfunction
Risk for trauma R/T unsteady gait/weakness/paresthesia
Impaired verbal communication R/T aphasia/cognitive deficits
H
Risk for violence R/T irritability, frustration, or disorientation
Diagnostic Tests
Skull/spinal x-rays
CT/MRI/PET Scans
EEG
Lumbar puncture
Myelogram
Angiography
EMG
Pschological Testing
Ultrasound
Drug Screen
Urinary retention or reflex incontinence R/T neurological
impairment (spasticity or flaccidity)
Impaired physical mobility R/T limited use of upper and/or
lower limbs
23
Glasgow Coma Scale
(Adult)
Best Eye Opening Response
Best Verbal Response
Best Motor Response
Spontaneously
4
To command or voice
3
To pain
2
No response
1
Oriented x 3
5
Confused conversation
4
Inappropriate words
3
Incomprehensible words/sounds
2
No response
1
Obeys commands for movement
6
Localizes pain/Purposeful mvmt.
5
Withdraws to pain
4
Flexion to pain (decorticate)
3
Extension to pain (decerebrate)
2
No response
1
Eye + Verbal + Motor = GCS Score (valid range 3-15)
The Glasgow Coma Scale correlates well with survival and cognitive outcome. Patients with low scores (3,4)
have a high mortality and poor prognosis for cognitive recovery, whereas patients with high scores (>8) have a
good prognosis for recovery.
Based on motor responsiveness, verbal performance and eye opening to appropriate stimuli, the Glascow Coma
Scale was designed and should be used to assess the depth and duration coma and impaired consciousness. This
scale helps to gauge the impact of a wide variety of conditions such as acute brain damage due to traumatic and
/or vascular injuries or infections, metabolic disorders (i.e., hepatic or renal failure, hypoglycemia, DKA, etc).
See specific facility policies for variations on scoring for intubated or tracheostomy patients.
**Adapted from GCS on CDC website at http://www.bt.cdc.gov/masstrauma/gscale.asp
24
Renal Assessment Guide
History
Age
Physical Exam
Sex
Voiding Patterns
Changes in urinary function:
BP
T
Skin:
Color
P
R
Wt.
Pruritis
Ht.
Petechiae
Uremic frost
Frequency
Abdomen: Bladder distention
Incontinence
Masses
CVA tenderness
Past surgeries
Urinary meatus/perineal area: Discharge
Location of meatus
Fluid status: Oliguria
Polyuria
Breakdown
Anuria
I/O past 24 hours
Any weight change in past 24 hours
Diet
Activity
Current medications
Pertinent Nursing Diagnoses
Urinary elimination, altered R/T retention, urgency,
Age-related changes, etc.
Chief complaint
Incontinence R/T inflammation, sphincter weakness etc.
Infection, risk for R/T stasis, obstruction, or other risk factors
Knowledge deficit R/T prevention, medications, hygiene, care
Diagnostic Tests
of equipment, fluid intake, dialysis
Xrays (KUB, IVP, Pyelogram, VCUG)
Individual coping, ineffective R/T effects of long-term
Cystoscopy
treatment regimen, chronic illness etc.
CT scan
US
Urodynamic studies
Biopsies
UA
Urine C/S
CBC
BUN
Creatinine
Electrolytes
25
Assessment of Patients with Dysfunction of the Liver, Gallbladder, or Pancreas
History
Age
Sex
Physical Exam
Mental Status
Level of Consciousness
Chief Complaint:
BP
T
P
R
Wt.
Ht.
Skin Color/Texture
Medications:
Petechiae
Purpura
Sclera color
Hard palate color
Abdominal size
appearance
Allergies:
Ascites
Asterixis
History of illnesses/surgeries/hospitalizations:
If distended, fluid wave present?
Urine character
Stool character
Family History of Illnesses:
Edema
location
Respiratory pattern
Usual diet:
Intake
Output
Have you experienced?
Pertinent Nursing Diagnoses
Skin integrity, Impaired R/T pruritis
Nutrition, altered < body requirements R/T anorexia, N/V
Decreased Cardiac Output R/T hypovolemia
Fluid volume imbalances R/T fluid shifts
Knowledge deficit R/T self-care after discharge
Cha
Breathing Pattern, Ineffective R/T ↑ intra-abdominal pressure
Appetite changes
Thought processes, Altered R/T encephalopathy
Nausea/vomiting
Ineffective coping R/T personal vulnerability
Food intolerances
Altered family processes (alcoholism) R/T substance abuse
Itching
Blood transf
Amount of alcohol consumed
Diagnostic Tests
Serum bilirubin
Serum ammonia
Serum amylase
Serum lipase
A/G Ratio
Liver enzymes
PT/PTT
Gallbladder Series
IV Cholangiogram
Ultrasound
CT
Angiography
Paracentesis
Biops
26
FORMS
27
I.V. DRUG SHEET
Drug Name (generic)
(brand)
Action:
Indication/usage:
Contraindications:
Usual dose:
Pediatric dose
Dilution:
Incompatibilities:
Rate of I.V. administration:
Side Effects:
Nursing Implications:
28
I.V. DRUG SHEET
Drug Name (generic)
(brand)
Action:
Indication/usage:
Contraindications:
Usual dose:
Pediatric dose
Dilution:
Incompatibilities:
Rate of I.V. administration:
Side Effects:
Nursing Implications:
29
I.V. DRUG SHEET
Drug Name (generic)
(brand)
Action:
Indication/usage:
Contraindications:
Usual dose:
Pediatric dose
Dilution:
Incompatibilities:
Rate of I.V. administration:
Side Effects:
Nursing Implications:
30
I.V. DRUG SHEET
Drug Name (generic)
(brand)
Action:
Indication/usage:
Contraindications:
Usual dose:
Pediatric dose
Dilution:
Incompatibilities:
Rate of I.V. administration:
Side Effects:
Nursing Implications:
31
I.V. DRUG SHEET
Drug Name (generic)
(brand)
Action:
Indication/usage:
Contraindications:
Usual dose:
Pediatric dose
Dilution:
Incompatibilities:
Rate of I.V. administration:
Side Effects:
Nursing Implications:
32
Texarkana College
Associate Degree Nursing
COMMUNITY-BASED AGENCIES
Name of Agency
At completion of the rotation, the student will:
(Write answers on back of sheet)
A.
explain the role of the agency in the delivery of community health care.
B.
describe means of funding of the agency.
C.
state ways by which patients are referred to the agency for nursing care.
1.
Is a physician’s referral required?
2.
By what means are hospital patients referred for care following
discharge?
3.
Can the nurse see patient prior to physicians’ approval? If so,
are there limitations as to her role?
D.
describe the various functions of the nurse in this agency.
E.
differentiate between the role of the LVN or aide and the RN within the
agency.
Student: Please list below patient/patients seen and skills performed or observed.
Patient’s
Initials
Diagnosis
Skills
Observed
Performed
Comments:
Date
Student Signature
5/10
32
33
TEXARKANA COLLEGE
ASSOCIATE DEGREE NURSING
CLINICAL EVALUATION
AND
CLINICAL EVALUATION BOOKLET-SUPPLEMENT
(CEB-S)
34
TEXARKANA COLLEGE
ASSOCIATE DEGREE NURSING
CLINICAL GRADING PROCESS
Clinical evaluation in the associate degree nursing program at Texarkana College reflects the program
philosophy. Learning is:
1.
Comprised of cognitive, affective, and psychomotor components,
2.
An additive process,
3.
Demonstrated by a change in behavior,
4.
Enhanced by a multi-sensory approach, and
5.
Individualistic.
While the faculty is accountable for curricular planning and the creation of a learning environment, learning is
ultimately the responsibility of the student.
The clinical grading process is based upon the program philosophy, the Code of Ethics, and standards for
nursing practice. Evaluation of student learning is the responsibility of the faculty. Not all student behaviors
and faculty decisions about such behaviors are predictable or quantifiable; therefore, the clinical evaluation
tool (CEB, CEB-S) is a reference tool only and not an exhaustive contract. Students should be aware that they
are in a professional program and the faculty has the responsibility to:
1.
use their collective professional judgment to determine when the student’s
clinical, academic, or personal performance and professional accountability
are inconsistent with the responsibility for guarding patient safety, and
2.
determine if the student is to be given re-learning opportunity, asked to withdraw from the program, or
subject to disciplinary action, as outlined in the Texarkana College Student Handbook.
PROCESS
This time of learning, beginning when the clinical nursing course starts, provides opportunity for the student to
learn and practice cognitive, affective, and psychomotor skills needed for the implementation of safe nursing
care. Clinical evaluation is based upon eight categories identified in the Clinical Evaluation Booklet (CEB):
1.
Assessment
2.
Planning
3.
Implementation (plan of care)
4.
Implementation (selected skills)
5.
Interpersonal relations
6.
Evaluation
7.
Professional growth and ethics
8.
Safety
35
The Clinical Evaluation Booklet Supplement (CEB-S) identifies the specific clinical objectives and cues in
each of the eight categories for determination of a clinical grade.
1.
Each student will be evaluated daily on the basis of the 8 categories.
2.
A scale of 1-5 will be used:
5 - independent
4 - supervised
3 - assisted
2 - marginal
1 - dependent
3.
The maximum score each day is 40.
The minimum score each day is 8.
4.
The grading scale will be:
36-40
=A
32.4-35.9 = B
30.0-32.3 = C
26.0-29.9 = D
Below 25.9= F
5.
The final grade will be determined by adding the total daily scores and dividing
by total number of days.
6.
When the student is with a preceptor the student will be graded as “S” and “U”.
7.
If a student’s grade is marginal or failing, the student will not be assigned to
a precepted experience.
As learning is additive, the student is expected to learn from any errors in judgment or practice and to
continuously improve clinical abilities. The student is expected to perform clinical skills based on content
from previous courses in the curriculum and from the current nursing course.
The clinical instructor will give verbal feedback to the student regarding clinical performance. Written
feedback is documented in the Clinical Evaluation Booklet (CEB) for each clinical day. While the student has
access to the evaluation information for each clinical day, a conference may be initiated by the student or
instructor if clarification is necessary. Failure to show progression in any of the eight categories of evaluation
each clinical day may result in the student being placed in a level of evaluation and progression as described
below.
36
DEFINITIONS OF THE CRITERIA
Professional Standards:
Display of knowledge base, therapeutic and interpersonal skills,
values and attitudes that characterize the nursing profession, are
safe for the public, and reflect the philosophy of the program;
can be applied to behavior in three domains: cognitive,
affective, and psychomotor.
Effect:
Refers to achieving the intended purpose of the behavior.
Affect:
Refers to the manner in which the behavior is performed and the
demeanor of the student.
Quality of the Performance:
Based upon degrees of skill development which encompass the
use of time, space, equipment, and the utilization or
expenditure of energy.
Assistance Required:
The type and amount of instructor assistance or cues needed
to demonstrate the behavior.
37
CRITERIA FOR CLINICAL EVALUATION
SCALE
5
SCALE LABEL
Independent
4
Supervised
3
Assisted
2
Marginal
STANDARD
PROCEDURE
QUALITY OF
PERFORMANCE
ASSISTANCE
SAFE and ACCURATE in
EFFECT and AFFECT
Each Time
Proficient; Coordinated; Confident; Occasional
Expenditure of Excess
Energy Within an Expedient Time Period
WITHOUT SUPPORTING CUES
SAFE and ACCURATE
in EFFECT and AFFECT
Each Time
Efficient; Coordinated; Confident; Some
Expenditure of Excess Energy Within a Reasonable
Time Period
OCCASIONAL SUPPORTIVE CUES
SAFE and ACCURATE
in EFFECT and AFFECT
Each Time--Most of the time
Skillful in Parts of Behavior; Inefficient;
Uncoordinated; Expends Excess Energy Within a
Delayed Time Period
FREQUENT VERBAL and
OCCASIONAL PHYSICAL
DIRECTIVE CUES in ADDITION to
SUPPORTIVE CUES
SAFE--but not alone
Performs at risk
ACCURATE—not always
in EFFECT and AFFECT
Occasionally
Unskilled; Inefficient; Expends Considerable Excess
Energy Within a Prolonged Time Period
CONTINUOUS VERBAL and
FREQUENT PHYSICAL CUES
Unable to Demonstrate Procedure/Behavior; Lacks
Confidence, Coordination, Efficiency
N
CONTINUOUS
VERBAL and
S
PHYSICAL
CUES
A
U
1
Dependent
F
E
UNABLE TO
DEMONSTRATE BEHAVIOR
Revised 12/2010
38
LEVELS OF EVALUATION AND PROGRESSION
Level I:
Student errors in judgment or practice in the clinical setting will be addressed by the instructor. If, in the
professional judgment of the clinical instructor and upon documentation in the CEB and in accordance with
the CEB-S, these errors do not significantly compromise patient safety, jeopardize clinical environment
relationships, or deviate from standards of nursing practice, the student will be allowed to continue in the
nursing course. If the stated clinical objectives are met, the student will earn a passing grade. A minimum of
C clinical grade is required for progression to the next higher level nursing course.
Level II:
If, in the professional judgment of the clinical instructor and upon documentation in the CEB and in
accordance with the CEB-S, the student repeatedly requires assistance to meet clinical objectives, a written
learning contract may be developed. This action indicates that the student is placed on “WARNING”. If the
student demonstrates that self-correction has occurred, the student will be allowed to continue in the nursing
course. If the stated clinical objectives are met, the student will earn a passing grade. A minimum of C
clinical grade is required for progression to the next higher level nursing course.
Level III:
When, in the professional judgment of the clinical instructor and upon documentation in the CEB in
accordance with the CEB-S, the student’s clinical performance does significantly compromise patient safety,
jeopardize clinical environment relationships, or deviate from standards of nursing practice, another level for
progression and evaluation is indicated. Based upon the seriousness in nature and/or frequency of the clinical
error(s), the student is in danger of not passing the course. The student, therefore, is placed on “WARNING”.
To confirm the student’s competence, the instructor may initiate one or more of the following strategies:
1.
Implement direct, one-on-one observation of the student’s clinical performance,
2.
Implement direct, one-on-one observation of the clinical performance by
another designated member of the faculty, and/or
3.
Implement a review of the student’s performance in consultation with other
members of the teaching team, the associate degree program coordinator,
and the division chair for a professional consensus.
If the student’s performance is determined to be a minimum of C at the end of either of these three strategies
implemented by the faculty, the student will be allowed to continue in the course. If the stated clinical
objectives are met, the student will earn a passing grade. A minimum of C course grade is required for
progression to the next higher level nursing course.
If the student’s performance remains less than a C following implementation of any two of these three
previous strategies, the student will
1.
not be allowed to continue in the nursing program.
2.
earn a D or F as a grade for the course.
3.
receive no credit for the accompanying theory course if a D or F is earned in
clinical.
4.
not be allowed to progress to the next higher level nursing course.
*To progress in the program the student must pass both clinical and the accompanying
theory course during the same semester.
Revised: November, 2013
SLO= I.E. Student Learning Outcomes
CO=Course Objectives
RNSG 2463 - CLINICAL DECISION MAKING/MANAGEMENT
CLINICAL EVALUATION BOOKLET - SUPPLEMENT (CEB-S)
I- Assessment: Data gathering & analysis prior to care which includes:
** 1. gathering biopsychosocial data from patient, family and/or chart.
CO 1,2,3,9,13,19,20
** 2. assessing the patient’s strengths and limitations.
CO 3,10,13
** 3. utilizing multidisciplinary resources to address biopsychosocial concerns.
CO 16,24,27,31
**4. relating the results of diagnostic studies to the nursing diagnosis.
CO 3,5,24
** 5. stating the rationale for dietary and pharmacological therapies including specific actions and side effects.
CO 2,3
** 6. collaborating with multidisciplinary teams to determine rationale
for prescribed therapies, i.e., respiratory therapy, physical therapy, speech therapy, etc.
CO 1,3,13,17,25,27
**7. selecting nursing diagnoses based upon analysis of health data.
CO 1,3,21,24
--------------------------------------------------------------------------------------------------------II- Planning: Prior to care, develop a written plan designed to achieve expected
outcomes, based on appropriate rationale by:
** 8. utilizing critical thinking skills to establish priorities.
CO 1,2,3,5,12,21,25,27
** 9. establishing short and long term goals and expected outcomes in conjunction with patient and family.
CO 1,3,20
**10. planning for patient and family education based on values, beliefs, cultural, and health
needs. CO 1,2,20,21,26
**11. incorporating multidisciplinary therapies into the plan of care.
CO 1,11,27
**12. utilizing community resources available to patient and family for discharge planning.
CO 16,20,27
**13. distinguishing independent, interdependent, and dependent aspects of decision making.
CO 1,3,5,14,15,27
**14. differentiating roles and functions of members of the health care team when planning care.
CO 3,14,15,20,23
III- Implementation: Implements the plan of care to meet the patient’s biopsychosocial needs by:
**15. organizing nursing care efficiently using current technology in a cost effective manner.
CO 1,3,25,26
**16. implementing nursing interventions to achieve expected outcomes.
CO 2,3,5,9,10,11,12,13,15,19,20,21
**17. collaborating with patient and family in decision making regarding nursing care.
CO 3,9,16,20,27
**18. teaching selected principles and procedures of health promotion/care to patient and/or
family based on developmental stages and sociocultural variables.
CO 1,2,3,9,10,11,12,13,19,20,21
**19. utilizing therapeutic communication skills.
CO 2,3,9
**20. displaying behaviors that exemplify the belief that humans are holistic beings with
worth and dignity.
CO 3,19,20
--------------------------------------------------------------------------------------------------------IV- Implementation: Performs selected nursing interventions with competence, in addition to those skills
previously performed.
**21. Selected Assessment techniques
CO 11,18,19,29
A. Neuro/Psych Assessment
B. Orthopedic
C. Integumentary
D. Assessment of Critically ill or injured patients
**22. Other previously learned skills
CO 11,18,19,29
A. Genitourinary
B. Cardiovascular
C. Peripheral Vascular and Hematologic
D. Substance Abuse Assessment
V- Interpersonal Relations: Exhibits written, verbal, and nonverbal communication by:
**23. creating and maintaining effective interpersonal relationships, using therapeutic
communication skills based on values, beliefs, and culture of the individual.
CO 9
**24. maintaining patient confidentiality.
CO 9,19
**25. explaining the nursing plan of care and/or selected treatment modalities in a way that is understandable to the
patient and family. CO 3,9,12,20
**26. developing and presenting oral and/or written assignments that are concise, organized, and accurate using
medical terminology and correct spelling. CO 24,29
VI- Evaluation: With assistance the student is involved by:
**27. evaluating own ability to implement each step of the nursing process.
CO 6,7
**28. evaluating patient’s and family’s response to nursing care.
CO 1,2,3,4,7,9,10,16,17,27
**29. modifying the nursing care plan and communicating reasons and rationales for changes to the multidisciplinary
team. CO 4,6,7
**30. evaluating own effectiveness with intra/interpersonal skills.
CO 8
**31. evaluating the effect of therapeutic milieu as part of the treatment regime.
CO 8
**32. collaborating with facility staff to determine the effectiveness of institutional cost
containment and quality improvement. CO 25,26,27
VII- Professional Growth and Ethics: Demonstrates professional growth by:
**33. accepting responsibility for own behavior.
CO 6, 17, 19
**34. reporting own mistakes honestly and promptly even if mistakes would have been otherwise unnoticed.
CO 6,13,23,29,32
**35. accepts suggestions for improvement and modifies performance.
CO 6,8
** 36. serving as a positive role model for members of the health care team.
CO 1,17,19,20,29,32
** 37. acting as an advocate for the patient and family to promote health care planning
according to the Patient Bill Of Rights.
CO 25,27
** 38. using critical thinking skills in decision making and problem solving processes.
CO 1,2,3,9,14,19
** 39. healthy adaptation to stressful situations.
CO 6,17,29,32
** 40. assisting health care providers to solve patient care problems within the organizational
structure. CO 1, 3,23,25,27
** 41. examining personal values to related current health care issues.
CO 17
** 42. adhering to ethical and legal standards.
CO 19,29
** 43. adhering to policies of the College and external agencies.
CO 19,29
VIII- Safety: Practices techniques that promote biopsychosocial safety by:
**44. implementing nursing interventions safely.
CO 1,3,9,10,11,12,13,14,19,25
**45. implementing measures to maintain physical and psychological safety for
patients and others.
CO 1,3,5,9,10,11,12,13,14,19,24
**46. accurately reporting and documenting the patient’s symptoms, responses, and status
within an appropriate timeframe.
CO 3,5,9,27
**47. implementing nursing interventions to prevent complications.
CO 1,3,9,11,12,13,19
**48. recognizing when care is beyond student's role and refers procedure to appropriate
personnel. CO 6,14,15,17
**49. recognizing and reporting, in a timely manner, situations which violate standards of practice.
CO 1,5,19
STUDENT
INSTRUCTOR
COURSE RNSG 2463
SEMESTER/YEAR- Spring 2017
TEXARKANA COLLEGE
ASSOCIATE DEGREE NURSING
CLINICAL EVALUATION BOOKLET
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date _____
I.
I.
II.
II.
III.
III.
IV.
V.
IV.
V.
VI.
VII.
VI.
VII.
VIII.
VIII.
ASSESSMENT: Data gathering and analysis prior to care.
PLANNING: Develops a written plan designed to achieve expected outcomes based on
appropriate rationale.
IMPLEMENTATION: Implements the plan of care to meet the patient’s biopsychosocial
needs.
IMPLEMENTATION: Performs selected nursing measures with competence
INTERPERSONAL RELATIONS: Exhibits, written, verbal, and nonverbal communication.
EVALUATION: Evaluates self, patient, revises plan of care appropriately.
PROFESSIONAL GROWTH AND ETHICS: Shows professional growth and practices ethical
behavior.
SAFETY: Practices techniques that promote biopsychosocial safety.
TOTAL
Ins. Initial
ROTATIONS
Date _____
Special Procedures
_____
ICU
_____
HD
_____
Other
Community Rotation
_____ / _____________________
ASSIGNMENTS
Pathophysiology
DUE / COMPLETED
AFIB ____/ _____
CHF ___ / _____
UTI ____ / _____
TIA ____ / _____
Parkinson’s ____ / _____
Sickle Cell ____/_____
Pancreatitis ____/_____
Journal
DUE / COMPLETE
EBP Presentation
_____ / ________________
_____ 1 _____ _____ 9 _____
_____ 2 _____ ____ 10 _____
_____ 3 _____ ____ 11 _____
_____ 4 _____ ____ 12 _____
_____ 5 _____ ____ 13 _____
_____ 6 _____ ____ 14 _____
_____ 7 _____ ____ 15 _____
_____ 8 _____ ____ 16 _____
Capstone
Simulation
REAL life SIM
RENAL
GI SYSTEM
RNSG 2463 daily CLINICAL GRADING
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
Name: ______________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Instructor: __________________________________
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
RNSG 2463 daily CLINICAL GRADING
Name: ______________________________
Instructor: __________________________________
Date ____
I.
I.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
Date _____
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
TOTAL
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
____ Arrives on time, dressed professionally, prepared for clinical day (VII)
____ Obtains report on ALL assigned patients from previous shift (RN or SN) (I, II)
____ Reviews/clarifies current physician orders in chart/online (I, II, III)
____ Performs detailed assessment first thing; beginning shift with documentation done by 1000 (I, II, IV, V)
____ F/U assessments completed, documented, & reported in a timely manner on ANY abnormal findings (I, VI)
____ Nurse rounds will be done at least every 2 hours documenting safety & skin care measures (I, IV)
____ Reports to instructor in organized fashion (SBAR) to include V/S, pertinent lab, DX testing, medications,
treatments, etc. (VI, VII)
____ Prioritizes, organizes, & delegates’ tasks / patient care to LVN, UAP, or SN as appropriate.
(assessment, medications, personal care / linen change) (III)
____ Administers medications safely and on time with instructor or RN preceptor (I, IV, VIII)
____ Seeks out new learning opportunities both knowledge & skill based. Identifies patient care team (VII)
____ Make EVERY effort to round with care provider and ancillary departments (V, VI)
____ Post-clinical: on time with COMPLETED POC, participates in discussion / activity (I, II, III, VI, V, VI, VII)
____ Professional communication & behavior, to include use of correct terminology, grammar, and spelling (V, VII)
____ Relate the ethical & legal factors of nursing practice including the Texas Nurse Practice Act (VI, VII)
Comments:
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
SKILLS AND COMMENTS
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
SKILLS AND COMMENTS
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
SKILLS AND COMMENTS
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
SKILLS AND COMMENTS
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
SKILLS AND COMMENTS
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
TEXARKANA COLLEGE
HEALTH SCIENCES DIVISION
ADN
First Enrollment
Second Enrollment
STUDENT
COURSE RNSG 2463 SEM/YR Spring 2017
RNSG 2463 COURSE GRADE: LETTER
ABSENCES
TARDIES
RNSG 1443 COURSE GRADE: LETTER
ABSENCES
TARDIES
SUMMARY
STUDENT’S STRENGTHS
Student Assessment
NUMERICAL
DOSAGE CALC
NUMERICAL
FINAL EXAM
STUDENT’S AREAS TO IMPROVE
Faculty Assessment
Instructor
Date
NAME ___________________ DATE _________
Student
Date
INSTRUCTOR ______________________ DATE ______
TEXARKANA COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
Student Course Requirement and Program Compliance Agreement
I have read the current Course Syllabus and Clinical Packet and understand the course requirements and
policies. I agree to comply with the clinical and classroom policies to meet the requirements for course
completion.
I have read the Texarkana College Health Science Division Handbook and understand the policies and
procedures stated therein. I agree to comply with all of these policies and procedures
in order to meet the requirements for course completion.
I have read the Texarkana College Student Handbook and understand the policies described
therein. I agree to comply with these policies.
I understand and am capable of utilizing the procedures for Standard Precautions that are in
the Health Science Student Handbook.
I understand that as a student in Health Science, I am required to be up to date on all immunizations
(including TDaP, TB skin test, influenza, and Hepatitis B) during my enrollment in the Health Science
Program.
I understand that as a student enrolled at Texarkana College in the Associate Degree Nursing Program I
am entering a profession with a stated code of ethics, Texarkana College Student Handbook.
I agree to adhere to and maintain strict CONFIDENTIALITY in all situations relating to patient
information and care. I also recognize that disclosing content of clinical teaching scenarios constitutes a
breach in ethics. I, therefore, agree to refrain from discussing the contents of these learning experiences
with anyone other than the faculty.
During my enrollment in RNSG 1443 and 2463, I understand that photographs and/or videos of clinical
teaching/learning activities may take place. Such photos/videos will be the property of Texarkana College
and used for learning or advertising purposes only and would not be used for profit by Texarkana College
or the Health Science Division. By signing below, I consent to the above mentioned activities.
Courses: RNSG1443 and 2463
Signature: _____________________________
Date: _________________________________
Name (Printed)_______________________________
Revised 12/2016
NAME ___________________ DATE _________
INSTRUCTOR ______________________ DATE ______
Clinical Simulation Confidentiality
Agreement
I understand that as a student enrolled at Texarkana College in the Associate Degree Nursing
Program I am entering a profession with a stated code of ethics, Texarkana College Student
Handbook.
I recognize that disclosing the content of this clinical teaching scenario to others constitutes a
breach in ethics. I, therefore, agree to refrain from discussing the contents of this learning
experience with anyone other than the faculty.
Student Signature
NAME ___________________ DATE _________
Date
INSTRUCTOR ______________________ DATE ______