Download advanced medical-surgical nursing clinical outcomes

WNMU
ADVANCED MEDICALSURGICAL NURSING
Priorities in Critical Care Nursing
Part 1 pgs 1-67
11
Advanced Medical Surgical Nursing 2010
Table of Contents
Content
Instructor
Demographics/Course
Description
Course Outcomes
Clinical Outcomes
Required Text’s
Communication Statement
Grading Scale/Testing
Policy/Absence Policy
Assignments
Nursing Care Plan
Guidelines
Log Guidelines
Preceptorship Guidelines
Activities Beyond the
Scope of Practice
Clinical Evaluation
Unit I
Unit II
Unit III – Cardiovascular
Alterations
Unit IV – Pulmonary
Alterations
Unit V – Neurologic
Alterations
Unit VI&VII – Renal & GI
Alterations
Unit VII/VIII Endocrine &
Hematologic Alterations
Unit VIII/IX
MSOD/Trauma/Shock
Skills Lab Objectives &
Check-lists
Clinical Journal Guidelines
and Grading Rubric
Instructor
Page Numbers
Vigil/Escobedo
3
4
4-6
7
8
9
10
11-36
37-54
45-58
59-60
61-67
Part 2
Escobedo
Escobedo
Escobedo
68-69
69-72
73-78
Vigil
79-81
Escobedo
82-85
Vigil
86-89
Escobedo
90-94
Vigil
95-97
Vigil/Escobedo
98-115
Vigil/Escobedo
116-117
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Advanced Medical Surgical Nursing 2010
WNMU
Med-Surg. II Nursing (Nur 270/272)
Spring 2011
Professor: Charnelle Escobedo, BSN, RN
Office: School of Nursing, Office 126
Phone: 538-6960 or 538-6964 Fax: 538-6961
E-Mail: [email protected]
Cell: 956-8156
Office Hours: Wednesday 0830 - 1430 or by appointment
Professor: James Vigil, BSN, RN
Office: School of Nursing, Office 130
Phone: 538-6960 or 538-6963 Fax: 538-6961
E-Mail: [email protected]
Cell: 313-3841
Office Hours: Monday 1:30-4:30, Tuesday 1:30-4:30, or by appointment
Course Description: Advanced Medical Surgical Nursing & lab. The emphasis for this
course will be the development of skills necessary to manage the
care of a group of patients. A preceptorship experience in this
semester will help students with the transition to the work
setting following graduation.
The focus of Advanced Medical-Surgical Nursing is nursing care
for the patient who is hospitalized with complex needs.
There
is also emphasis on management of patient care and advanced
nursing skills.
Theory content will include application of the nursing process
to
the
critically
ill
patient,
time
management,
and
collaboration with other members of the healthcare team.
Selected topics in critical care and emergency room nursing will
be addressed.
Students will be expected to meet with a faculty member every
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Advanced Medical Surgical Nursing 2010
two weeks to discuss learning experiences and to review their
clinical experience.
Since this is a separate course, the
student will need to pass this course independently of
Psychiatric Nursing.
ADVANCED MEDICAL-SURGICAL NURSING
Course Outcomes
1.
Implement knowledge of nursing process, cultural competence
and hierarchy of needs to plan care for multiple patients
with common health care needs in a structured setting.
2.
Participate in the prescribed medical regime by preparing
and
assisting
patients
undergoing
diagnostic
and/or
therapeutic medical procedures.
3.
Organize knowledge of an acuity system and/or a triage
system to determine the level of care needed by selected
patients.
4.
Organize a work assignment for a group of patients and
complete assigned care in the time allotted.
5.
Implement
knowledge
of
effective
communication
to
coordinate patient care with other members of the health
team.
6.
Implement knowledge of therapeutic communication to patient
care situations.
7.
Apply knowledge of pharmacology, science, and nursing
process to the administration of medications for a group of
patients.
8.
Develop beginning skills in caring
emergencies and critical care problems.
4
for
patients
with
Advanced Medical Surgical Nursing 2010
ADVANCED MEDICAL-SURGICAL NURSING CLINICAL OUTCOMES
I.
Role of Provider of Care - The student will:
A.
II.
Apply knowledge of nursing process to assessment,
planning, implementing and evaluating nursing care.
1.
Utilize knowledge of patient needs to plan care
for several patients.
2.
Apply knowledge of socio-cultural, psychosocial,
physiological and developmental health requisites
to the process of planning, implementing and
evaluating patient care.
3.
Organize priorities for providing care based on
patient assessment and theoretical knowledge.
B.
Utilize established criteria for evaluation of nursing
care.
C.
Analyze and document changes in the illness-wellness
continuum which interferes with the patient’s ability
to meet optimal health requisites.
D.
Apply knowledge of pharmacology to identify side
effects, toxic effects, and intended action of patient
medications.
Role as a manager of patient care:
A.
The student will:
Execute nursing care for a small group of patients
with common, well-defined health problems in a
structured setting.
1.
Apply knowledge of the hierarchy of need and
triage
to
prioritize
patient
care
needs
identified through patient assessment.
2.
Apply knowledge of patient safety to assess for
hazards in the patient environment, and plan care
to prevent injury.
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Advanced Medical Surgical Nursing 2010
B.
Plan, implement and evaluate patient care utilizing
available resources including policy and procedure
manuals, references, and texts.
C.
Organize a work assignment and complete assigned care
in the time allotted.
D.
Explain patient status and the plan of care to faculty
and staff both verbally and in writing.
E.
Evaluate the plan of care using established criteria
and modify the plan of care using collected data,
standards of practice and patient input.
III. Role as a member of the profession – the student will:
A.
Assess his/her role as a member of the profession
including identifying learning needs and goals.
B.
Elicit feedback from
self improvement.
and
faculty
for
C.
Utilize texts and library resources to
implement a plan for ongoing learning.
develop
and
D.
Utilize clinical time to enhance learning.
E.
Utilize the log format to apply theoretical concepts
peers,
staff,
to the clinical setting.
F.
G.
Evaluate his/her own learning in terms of the role of
a member of the profession.
1.
Utilize the self-evaluation process to identify
needed learning experiences.
2.
Assume responsibility for nursing care given.
Delineate strategies for coping with ethical, legal,
and educational challenges encountered in nursing care
environments.
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Advanced Medical Surgical Nursing 2010
Required TEXT’s:
Urden, Stacy & Lough (2008).
Nursing, 5th ed.
Priorities in Critical Care
Philadelphia:W.B. Saunders.
Ignatavicius, Donna & Workman, Linda M. (2006).
Medical
Surgical Nursing: Critical Thinking for Collaborative Care,
(5th Ed).
Jones,
St.Louis:Elsevier:Saunders.
Shirley,
A.
(2008).
ECG
Success:
Exercises
in
Interpretation. Philadelphia: FA Davis.
Silvestri, Linda Anne, MSN, RN, Saunders Comprehensive Review
For the NCLEX-RN Examination, 3rd. ed.,
Elsevier:Saunders:St.Louis
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ECG
Advanced Medical Surgical Nursing 2010
COMMUNICATION POLICY STATEMENT REGARDING OFFICIAL EMAIL
WNMU’s policy requires that all official communication be sent via
Mustang Express. As a result, all emails related to your enrollment
at WNMU and class communication, including changes in assignments and
grades, will be sent to your wnmu.edu email address. It is very
important that you access your Mustang Express e-mail periodically to
check for correspondence from the University. If you receive most of
your email at a different address you can forward your messages from
Mustang Express to your other address.
WNMU Policy on Email Passwords
WNMU requires that passwords for access to all of the protected
software, programs, and applications will be robust, including
complexity in the number of characters required, the combination of
characters required, and the frequency in which passwords are required
to be changed. Minimum complexity shall include:
Passwords shall contain at least six (6) characters
Passwords shall contain at least one capital (upper case)
letter, and at least one symbol (numbers and characters
such as @ # $ % & *
Passwords shall be changed at least every 90 days (8/6/08)
Class Procedures for Inclement Weather
Refer to the WNMU policy for notification procedures. In the event
that classes are closed during scheduled exams or clinical days,
alternative arrangements will be made.
Academic Integrity Policy and Procedures
Each student shall observe standards of honesty and integrity in
academic work completed at WNMU. Students may be penalized for
violations of the Academic Integrity Policy. Generally violations of
the academic integrity include cheating and plagiarism. Please refer
to pages 60 and 61 of the 2008-2009 Catalog and page 31 of the Student
Guidelines for the ADN Program.
Students who are having difficulty with the subject matter
should make an appointment with one of the professors as soon as
possible to defer further problems.
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Advanced Medical Surgical Nursing 2010
** Students with special learning needs should visit the special
needs office in Room 210 of the Juan Chacon building and inform
their professor of their needs early in the semester.
During testing remember that other students are testing and all
students should be quiet during the exam. When you have
finished your test, please leave the room and the testing lobby.
All books, cell phones, backpacks, bags or electronic devices
are not allowed with the student during the exam. Please leave
these items outside or you will need to leave them near the
door.
GRADING SCALE
A
92 - 100
B
84 – 91.9
C
76 – 83.9
D
70 – 75.
F
69 & Below
Course Grading: You must have an average of 76.0 or better on
exams and written work to pass the theory and clinical portion
of the course. Exam Policy: You may challenge any exam question
by submitting the question in writing along with the answer you
believe is correct, and references supporting the choice.
Students are expected to do their own work on challenges.
The
faculty will review the information and respond within ten days.
Absence Policy – Refer to student guidelines. Missing scheduled
tests is considered an absence. Student must call the instructor
and must present a medical release if an exam is missed. If the
student does not comply with this requirement the exam cannot be
made up and the grade received will be a zero. Absence in
clinical for more than 3 clinical days will result in a failing
grade and the student will have to return and repeat the MS 2
course.
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Advanced Medical Surgical Nursing 2010
COURSE REQUIREMENTS
THEORY
Tests:
Total worth is 50%, the amount per test is dependent
on the number of tests administered each course.
Comprehensive Final _______________________15%
Kaplan Tests_______________________________05%
70%
Clinical and Assignments:
Logs (3)
10%
Care Plan (1)
10%
Clinical
Pass/Fail
Clinical Journal
10%
Total of 30% of Score
Recommended:
Comprehensive
questions.
NCLEX-RN
Review
Saunders
Assigned
Chapters
and
All 3 Logs must reflect individualized patient care.
Please
review the instructions related to the logs in this syllabus and
do your logs according to the list of instructions.
Your
instructor will expect you to make an appointment to review your
logs at the beginning of the third week of semester. You must
have completed a minimum of 1 log by this time.
Test questions for this course will be taken from Urden,
et.al,Priorities in Critical Care Nursing, Saunders,
and
Comprehensive Review for the NCLEX-RN Examination, Ignatavicius,
and Medical-Surgical Nursing.
You are expected to be familiar
with the content in all three texts.
If you have difficulty
understanding
material
in
Urden,
reread
Ignatavicius’s
information on the topic to review the basics.
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Advanced Medical Surgical Nursing 2010
Care Plan Grading Sheet (Final)
One care plan is required in the Medical-Surgical II clinical
rotation. It is graded according to the following criteria and
format: Grading Sheet must accompany care plan, as well as being
placed in a three prong paper folder before it will be graded. Each
nursing diagnosis and the collaborative problem(s) must be in
landscape format. All of content needs to be typed or care plan will
be handed back to the student. It will be considered late from that
point on. No redo’s allowed if student receives a failing grade after
care plan is graded by instructor.
I.
Organization, grammar, spelling: If the student turns in a paper
with greater than 10 grammatical or spelling errors per page, and/or
does not follow the organizational direction in the care plan, the
result will be a letter grade reduction. (Please edit your work, and
obtain help from the writing center if this is a problem for you)
II. Data Base: _______________________________________________22%
Patient/Family History________________________________________5%
Cultural Assessment __________________________________________4%
Review of Systems_____________________________________________3%
Functional Health Patterns____________________________________3%
Physical Exam_________________________________________________7%
III.
Complete problem list developed from the entire data base:-2.%
V.
Nursing Diagnosis (Actual)4____________________________48%
VII.
Knowledge Deficit (1) __________________________________8%
VII.
Risk For Diagnosis (1)__________________________________5%
VIII.
Collaborative Problem (1)_______________________________5%
IX.
References (8 Total) in APA Format with 2 Nursing Journals less
than five years old, must be applicable to patient. (10%)
Student Score _______________________________________________100%
Student Score _______________________________________________100%
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Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis #1 Care Plan
Reference where you get each of your components please
Nursing Diagnosis 2%
Instructor Comments
Prioritized
Written Correctly with
Supporting
Subjective/Objective Data
Desired Outcome
2%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 2%
Prioritized Individualized
Time Limited/Measurable
Complete
Rationales – Referenced 2%
Match Intervention
Present for each intervention
Implementation(s) 2%
Specific to nursing action
If not explained
Evaluation (s) Results of
Implementation Documented
Specifically for Each one 1%
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
12%
Score - Total Possible
12
Student Score
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis #2 Care Plan
Reference where you get each of your components please
Nursing Diagnosis 2%
Instructor Comments
Prioritized
Written Correctly with
Supporting
Subjective/Objective Data
Desired Outcome
2%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 2%
Prioritized Individualized
Time Limited/Measurable
Complete
Rationales – Referenced 2%
Match Intervention
Present for each intervention
Implementation(s) 2%
Specific to nursing action
If not explained
Evaluation (s) Results of
Implementation Documented
Specifically for Each one 1%
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
12%
Score - Total Possible
13
Student Score
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis #3 Care Plan
Reference where you get each of your components please
Nursing Diagnosis 2%
Instructor Comments
Prioritized
Written Correctly with
Supporting
Subjective/Objective Data
Desired Outcome
2%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 2%
Prioritized Individualized
Time Limited/Measurable
Complete
Rationales – Referenced 2%
Match Intervention
Present for each intervention
Implementation(s) 2%
Specific to nursing action
If not explained
Evaluation (s) Results of
Implementation Documented
Specifically for Each one 1%
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
12%
Score - Total Possible
14
Student Score
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis #4Care Plan
Reference where you get each of your components please
Nursing Diagnosis 2%
Instructor Comments
Prioritized
Written Correctly with
Supporting
Subjective/Objective Data
Desired Outcome
2%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 2%
Prioritized Individualized
Time Limited/Measurable
Complete (6 needed)
Rationales – Referenced 2%
Match Intervention(6 needed)
Present for each intervention
Implementation(s) 2%
Specific to nursing action
If not explained(6 needed)
Evaluation (s) Results of
Implementation Documented
Specifically for Each one 1%(6
needed)
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
12%
Score - Total Possible
15
Student Score
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis #5 Care Plan
Reference where you get each of your components please
Knowledge Deficit
Nursing Diagnosis 2%
Instructor Comments
Prioritized
Written Correctly with
Supporting
Subjective/Objective Data
Desired Outcome
2%
Applicable to Pt. (6 needed)
Time – Limited/Measurable
Nursing Interventions 2%
Prioritized Individualized
Time Limited/Measurable
Complete(6 needed)
Rationales – Referenced 2%
Match Intervention(6 needed)
Present for each intervention
Implementation(s) 2%
Specific to nursing action
If not explained(6 needed)
Evaluation (s) Results of
Implementation Documented
Specifically for Each one 1%(6
needed)
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
12%
Score - Total Possible
16
Student Score
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis Care Plan
Risk For -#6
Nursing Diagnosis 2%
Instructor Comments
Prioritized
Written Correctly with
Supporting
Subjective/Objective Data
Desired Outcome
2%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 2%
Prioritized Individualized
Time Limited/Measurable
Complete(6 needed)
Rationales – Referenced 2%
Match Intervention(6 needed)
Present for each intervention
Implementation(s) 2%
Specific to nursing action
If not explained(6 needed)
Evaluation (s) Results of
Implementation Documented
Specifically for Each one 1%(6
needed)
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
12%
Score - Total Possible
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Student Score
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis
#7 Care Plan
Reference all your components
Collaborative Diagnosis
Instructor
Comments
Collaborative Problem2%
Written Correctly
Desired Outcome
2%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 2%
Prioritized (6 needed)
Individualized
Time Limited/Measurable
Complete
Rationales – Referenced 2%
Match Intervention(6 needed)
Present for each intervention
Implementation(s) 2%
Specific to nursing action
If not explained(6 needed)
Evaluation
(s)
Implementation
Specifically
for
needed)
Results
of
Documented
Each
one
1%(6
Evaluation of Desired Outcome (1%) –
Was goal met if not, explanation
present
Score - Total Possible
12%
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Student Score
Advanced Medical Surgical Nursing 2010
Landscape Nursing Diagnosis/Collaborative Problem Template
Nursing Diagnosis #
R/T
AMB
Reference:
Goal:
Goal Evaluation
Reference:
Intervention with
Rationale Italicized
listed under
statement with
reference
Implementation
1.
2.
3.
4.
5.
6.
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Evaluation
Advanced Medical Surgical Nursing 2010
Care Plan Database
Student Name-_____________________________________________
Date(s) of Care - ________________________________________
Patient Admission Date - _________________________________
Unit Patient on - ________________________________________
Chief Complaint - ________________________________________
Present Medical Diagnosis (Use you own words after researching the condition in your textbook
and the textbook signs and symptoms. Then, individualize the condition with what the patient’s
signs/symptoms are):
PAST MEDICAL HISTORY
Present and Past Chronic Conditions: (Use your Textbook and define the conditions, list the
common signs and symptoms, then individualize this section with what signs and symptoms the
patient displays).
Past Accidents:
Allergies: (Food, Drug, and Environmental and Patient Reaction to Allergens)
Past Surgery: (List all past surgeries, dates and reasons for the procedures
Immunizations – Type and Date Received – (Tetanus, Flu, Pneumonia etc.,).
Personal/Social Habits – (smoking/tobacco Use: current & historical/amount, exercise habits,
alcohol Use – type/amount/date of last drink if applicable, diet, recreational Drugs).
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Advanced Medical Surgical Nursing 2010
Current Medical Data
ABG’s: (If available) - Identify the type of acid/base imbalance, and explain why your patient is
displaying this problem based on their condition.
ABG
Abnormal with Normal
Range
Date
What Disease Process is
Causing this
Abnormality
Comments
PhPCO2 PO2 HCO3-
Laboratory Values: (Cite the abnormal/explain the abnormal(s) as they relate to your patient.).
Use a table format to present this material.
Lab Type
Abnormal with Normal
Range
What Disease Process is
Causing this Lab Value
Abnormality
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Comments
Advanced Medical Surgical Nursing 2010
X-rays: (State why these x-rays were ordered for this patient and explain the results if
abnormal
Reason for Obtaining
Summary of Results
Comments
Type Of X-Ray
X-Ray
IV Therapy – (Site assessment, location of all IV sites, IV solution rate and if on an infusion
pump, saline lock, or central lines. Date started if possible). If you restart an IV state so here with
same criteria along with the reason why.
Intravenous
Therapy
Location
Date Started
Type-Peripheral/Saline
Lock
Nursing Care –Dressing
Change/Flush
Site #1
Gauge
Solution/Rate if
applicable
Time(s) Performed
Discontinued:
Comments
Comments
Comments
Location
Date Started
Type-Peripheral/Saline
Lock
Nursing Care –Dressing
Change/Flush
Site #2
Gauge
Solution/Rate if
applicable
Time(s) Performed
Comments
Comments
Discontinued:
Comments
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Advanced Medical Surgical Nursing 2010
Current Home Medication List & Summary/Hospital Prescribed Meds
Medication
Trade
Name/Generic
Name
Reason for
this client
being
prescribed
this
medication
Drug
Classification
23
If the
patient was
admitted,
was it
reordered?
If Not Was
there a
substitution
or reason
for omission
Advanced Medical Surgical Nursing 2010
Medications Given By the Student
Medication
Trade
Name/Generic
Name
Reason for
this client
being
prescribed
this
medication
Drug
Classification
Time Given
Assessment
Performed
Before
Administration
Time Given
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Post
Assessment
Data
Time
Performed
Advanced Medical Surgical Nursing 2010
Nursing Care
Performed by
the Student
Time and
Results
Purpose
Patient
Response/Nursing
Documentation
Evaluation
Vitals Q4h
See
physical
assessment
Assess
patient
physiological
status
Tolerated
without problem
VS WNL for
patient
throughout
care period
0800
Patient
Incontinent
of bowel and
bladder due
to CVA
Skin intact
Critically
Ill Patient
who is
incontinent
needs
accurate I&O
Tolerated Well
(example)
Incontinence
Care
1200
1600
Example
Foley
Insertion
Example
1900
1/22/2010
25
Odor Free
Inserted first
attempt with
sterile
technique
Clear
yellow
urine
return
obtained.
Advanced Medical Surgical Nursing 2010
Guideline - Cultural Assessment Summary (Care Plan Only)
From your questions summarize and describe your patient dealing
with each issue listed below. Use Headings for each item listed
below.
1)
Identify the group(s) with whom your patient identifies.
2)
Family and kinship systems: Is the family nuclear, extended
or blended? Do family members live nearby? What are the
communication patterns among family members? What is the
role and status of the individual members? What is the role
and status of individual members by age and gender?
3)
Language and Traditions: Are there any differences in
dialects or language spoken between healthcare
professionals and the cultural group? What are the common
language patterns in regards to verbal and non-verbal
communication? How is the use of personal space related to
communication?
4)
Religion: What are the religious beliefs and practices of
the group? How do they relate to
health practices? What
are the rituals and taboos surrounding major life events
such as
birth and death? (Explore the use of prayer,
meditation and other activities that help
individuals
reach fulfillment.
5)
What are the cultural belief and responses to pain in your
patient’s culture?
6)
Describe the acceptance of blood and blood products, organ
transplantation in your patient’s culture?
7)
Health beliefs and practices: What are the group’s
attitudes and beliefs regarding health and illness? Does
the cultural group seek care from indigenous health (or
folk) practitioners? Who makes decisions about health
care? Are there biologic variations that are important to
the health of this group?
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Advanced Medical Surgical Nursing 2010
8)
Does the gender of the health care provider make a
difference in the acceptance of
comfort with health care
delivery to this patient?
9)
What preventive health care does the patient and/or family
participate in?
10)
Describe behaviors related to the use of alcohol, tobacco,
and recreational drugs in
your patient’s culture?
11)
Is family income adequate for buying goods and services?
12)
Please summarize the cultural factors that you will take
into consideration for your patient and describe the
cultural interventions that will be included in this care
plan based on your cultural assessment?
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Advanced Medical Surgical Nursing 2010
Review of Systems (Required along with Functional Health
Patterns)(This is ALL subjective data.)ASK and if the answers is
no problem state negative for or client denies.
General Health Status: In their own words how they view their
own health on a scale of 1-10 with one being very ill/not good.
Ask why they score their health this way.
Skin, Hair, Nails: Skin problems, i.e. dryness, itching,
scales, warts, tumor, soar. Changes or anomalies in nails,
splitting, cracking or breaking.
Head and Neck: Lumps, bumps, scars, headaches, head trauma,
unconsciousness, dizzy spells, stiffness, hoarseness, swallowing
difficulties.
Nose and Sinuses: Nosebleeds, allergies, postnasal drip,
stuffiness, smelling ability, pain over sinuses.Mouth and
Throat: History of sore throat, strep throat, last dental exam,
dentures or bridges, bleeding gums, changes in taste.
Eyes: Last vision exam, eye trauma, glasses, blurred or double
vision, visual disturbances, night blindness.
Ears: Last hearing exam, ear aches, hearing loss, aides, ear
wax removal, vertigo.
Respiratory System: Asthma, chronic cough, SOB after exertion,
sputum production, history of pneumonia or bronchitis and
treatment.
Cardiovascular System: Chest pain, palpations. Heart murmur,
irregular pulses, hypertension, coldness or numbness in
extremities, edema, leg pain when walking, hair loss on legs
Gastrointestinal System: Indigestion, ulcers, constipation or
diarrhea, jaundice, hemorrhoids, digestive aides or laxative
use, alcohol use, food intolerances.
Urinary System: Pattern of urination, nocturia, and changes in
stream. History of bladder, kidney infections. History of
incontinence.
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Advanced Medical Surgical Nursing 2010
Reproductive System: Menstrual Hx, date started, irregularity.
Hx of births, satisfaction with sexual experiences, STD’s,
contraceptive experience, impotence.
Nervous System: Vertigo, loss of consciousness, forgetfulness,
coordination or muscle weakness, numbness, tremors, spasms, and
ability to concentrate.
Musculoskeletal System: Painful joints, swelling, weakness,
limitations in movement, cracking, popping of joints. History
of injury, chronic back pain.
Immune System and Blood: Transfusions, easy bruising, anemia or
low red blood cells, fatigue, frequency of infections.
Endocrine System: Thyroid problems such as cold or heat
intolerance, unexplained changes in weight, increased thirst,
urination, increased appetite, changes in hair distribution,
skin pigmentation, hormone therapy.
12)
Please summarize the factors (abnormal/potential problems)
that you will take into consideration for your patient and
describe the interventions that will be included in this
care plan based on your review of systems assessment?
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Advanced Medical Surgical Nursing 2010
Functional Health Patterns Assessment
1.
Health – perception and health management:
Describe client’s perceived pattern of health and wellbeing and how health is managed.
Is client aware of
medical diagnosis?
Does client give thorough history of
illnesses and surgeries?
Is client compliant with
medication regime?
Does client understand progression of
illness?
2.
Nutritional – metabolic pattern:
Describe
the
client’s
pattern
of
food
and
fluid
consumption.
Data on food intake may be collected using
the
24-hour
recall,
the
basic
food
groups
and/or
recommended daily dietary allowances.
Assess the client’s
weight relative to age and height.
Identify cultural
patterns which affect nutritional patterns. If a client is
on enteral feedings describe this also.
3.
Elimination pattern
Describe patterns of excretory function. Include bowel and
bladder patterns and the client’s perception of regularity.
Assess and document if the client uses laxatives. Describe
recent changes in eliminations.
4.
Activity – exercise pattern:
Describe pattern of exercise, activity, leisure and
recreation. Is there a planned pattern of
exercise
(3-4 times per week)? Describe how the client feels after
exercising. Is
there
shortness of breath or chest
pain upon exertion?
30
Advanced Medical Surgical Nursing 2010
5.
Cognitive-perceptual pattern:
Describe sensory – perceptual and cognitive patterns. Are
there sensory (vision, hearing,
taste, smell, touch)
deficits? Is the client oriented and responsive to you in
an appropriate
or inappropriate way? Assess recent
and remote memory. Assess education and
intelligence
level. Assess any lack of feeling in any part of the body.
Assess sensitivity to pain and how pain is handled when
experienced.
6.
Sleep-rest pattern:
Describe patterns of sleep, rest and relaxation over a 24hour period. Describe what time
client goes to bed,
falls asleep and awakens in A.M. Also describe how many
times
client awakes during the night and for what
reason. Does client awaken refreshed? How does the
client relax? Describe the client’s energy level, dream
patterns, and discuss
whether or not sleeping aids are
necessary.
7.
Self-perception and self-concept patterns:
Describe self-concept pattern and perceptions of self (e.g.
body comfort, body image,
feeling state).
Assess if
client feels good about self. Ask client to describe self
to you – including
physical
appearance,
personality,
strengths and weaknesses and any changes
the
client
would
like to make. Does the client have future goals
s/he would like to achieve?
8.
Role-relationship pattern: Discuss with the client the
various roles s/he assumes
(e.g.father,
son,
husband,
provider (occupation), community activist,etc.) and the
responsibilities of each role.
Is the client satisfied
with each role and would the client
like
to
make
changes in any role(s)?
31
Advanced Medical Surgical Nursing 2010
9.
Sexuality-reproductive pattern: Describe client’s patterns
of satisfaction and
dissatisfaction with sexuality
patterns. Describe reproductive patterns. How does your
client feel about being male or female? Is your client
sexually active? How does your
client protect self
against STD? Is the client knowledgeable about sex, birth
control, pregnancy, menstrual cycles and/or menopause? Are
there issues regarding sexuality or
reproduction (e.g.
same sex relationships, children).Are breasts, testes
examined regularly? Date of last pap smear. Does the
client have children?
10.
Coping – stress tolerance pattern:
Describe how the client generally copes with life. Are the
coping mechanisms effective
or self-defeating?
Can your
client handle daily stresses and life crisis?
Assess for
alcohol,substance use and if food is used to cope with
stress.
11.
Value – belief pattern:
Describe patterns of values and beliefs and/or goals that
guide choices of decisions.
Identify
those
values
and
beliefs that guide your client in life. Include religious
and spiritual beliefs.
Identify what the client values
most in
life and changes the client would like to make
to improve the quality of life.
12)
Please summarize the factors (abnormal/potential problems)
that you will take into consideration for your patient and
describe the interventions that will be included in this
care plan based on your review of systems assessment?
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Advanced Medical Surgical Nursing 2010
Physical Assessment-Content for Logs and Care Plan
Document in Narrative Format
General Survey: This assessment is your initial observation of the
patient you are caring for. You should note: affect, alertness,
hygiene, ability to speak, move, contractures, race, hair color; skin
color, any skin defects that you can observed, body size, appearance
close to written age, drooling, etc. Any observations that you can
readily see and hear are used here as you care for them during
clinical.
Problems:
VITALS:
You should have all vitals from the clinical day you take
care of this patient and noted variations.
Method of temperature
measurement should be documented. Pulse should be apical and radial.
Note HT. & WT. on your patients to see if diets are adequate or
excessive. Use a standard chart to determine proper weight for size.
Problems:
PAIN ASSESSMENT: Document according to pain assessment in Urden.
Utilize PQRSTU model, Behavioral and Physiologic Indicators, or
Critical Care Pain Observation Tool. Assess pain on all patients’
document pain intensity on a scale the patient can understand or
respond to.
Problems:
Integumentary:
Note any scars, moles, skin tags, bruises, turgor,
moistness of mucous membranes, and color of conjunctiva, breakdowns,
scratches, and redness, condition of toe and fingernails, hair
quality, quantity, skin dryness, patchy pigmentation, lumps.
If
something is not noted or on this patient, then do: (this means
negative for) decubiti, dryness, moles, redness, Edema etc.
In this
way we, as your instructors, will know that you have observed for
these. Condition of Intravenous sites, incisions, Foley catheters,
nasogastric tubes, gastrostomy tubes, ETT, tracheostomy sites and
dressings should be assessed and documented under this category.
Problems:
33
Advanced Medical Surgical Nursing 2010
Respiratory: Rate, rhythm, work of breathing, color of lips and nails,
any assistive breathing devices, oxygen and method of delivery, chest
shape , use of accessory muscles of resp.,
including nasal flaring,
mouth or abdominal or pursed lip breathing, cough and the frequency
and whether non-productive or productive, sputum or nasal drainage and
the color and amount. Lung sounds –auscultation of all lobes, vocal
sounds, position of comfort, skin color if hypoxia is an issue.
Problems:
Cardiac: S1, S2 =normal lub-dub of heart sounds.
Abnormal heart
sounds (S3 or S4) will have extra sounds before the Lub, between the
Lub and the dub, or after the dub. Note the rhythm and whether it is
irregular. Auscultate for murmurs, if not present document this.
Check whether the apical and radial pulses match in beats. If on
telemetry or the cardiac monitor print a strip for your log/care plan.
Document the rhythm, intervals and presence of ectopy. Assess
tolerance of ectopy by the patient.
Check capillary refill.
(Blanching)
Note the color of nails and lips again.
Grade the
pulses. 0-3+ check the radials, femoral, post tibia’s, and pedals. 0
mean’s that the pulse is absent. 1+ means that the pulse is felt but
easily obliterated with pressure. 2+ is a normal pulse that is easily
felt but with light pressure may not be obliterated. 3+ is a bounding
pulse and is not obliterated.
Note areas of edema, cyanosis, and
temperature changes between like extremities, and patchy brown
pigmentation on lower limbs which could indicate venous insufficiency.
Document the presence or absence of JVD/HJVD.
Reminder: If you do not find a finding, say:
negative for edema,
temperature change, etc. This lets us know that you assessed this.
Problems:
GI: Observe first.
Is the abdomen flat, round, distended, note
hernia(s), old scars, pulsation’s. Then auscultate in the five
positions starting at the lower quadrant where the ileum meets the
ascending colon. Then move up to the right upper quadrant where the
ascending meets the transverse colon. Then right above the umbilicus
for the transverse colon then move to the left upper quadrant in which
the transverse meets the descending colon and then listen in the left
34
Advanced Medical Surgical Nursing 2010
lower quadrant.
Normal bowel sounds can be heard within 15 sec.
Hyperactive are constant, diminished bowel sounds heard after one
minute of listening.
Absent bowel sounds are not heard after 5
minutes. Percuss the abdomen to hear tympani over most of it except
where the liver is located. That sound should be dull. Dull sounds
in the abdomen could mean stool, tumor, and full bladder. Note area
of G-tube placement and in what quadrant. . Note when the last B. M.
was. Part of the GI is the conditions of the mouth mucous membranes,
odor, teeth and tongue condition.
Problems:
GU:
Note times of voiding, or degree of dampness of depends when
changed. Note color if able and odor of urine. Again note moistness
of mucous membranes and skin turgor.
Note circumcises males and
drainage from vagina of females when doing peri care. Note assistive
devices to urinate if appropriate.
Palpate above the pubis for
distension.
Should not feel the bladder.
Circumcised, testes down
X2. Foley catheter – amount q8hr if applicable. Document urine output
and the amounts over a period of time if applicable.
Problems:
MUSCULOSKELETAL SYSTEM:
Note where there are contractures of each
joint.
For example:
the arm includes the shoulder, elbow, wrist,
hand, and fingers. If the patient can extend the limb to 180 degrees,
this is normal.
If the patient has a permanent contracture of any
joint, then they can only flex or hyperextend to a certain degree from
180 degrees and permanent position is at 10 degrees.
Each joint
should be evaluated for degree of movement and use the proper
terminology:
hyperextension of the right hand at the wrist
permanently at 10 degrees with extension and hyperextension to 5
degrees.
Note deformities, hammer toes, muscle tone.
Of the spine,
note kyphosis, lordosis, scoliosis.
(Look these up)
Note
amputations.
When an extremity has full ROM say so.
Also state in
this section whether the patient can do what ADL’s on own or what
needs assistance because of musculoskeletal restrictions if that is
the cause.
You may use a stick man drawing. Describe ambulatory
abilities, assistive devices if needed, gait, impairment if present
with underlying cause. Document Fall Program and why it is needed.
35
Advanced Medical Surgical Nursing 2010
Problems:
NEURO: Check pupils for size, are they equal?
Then shine a light,
while covering the other pupil not being tested with your hand. Bring
the light from the side of the head of the uncovered pupil and shine
the light onto the pupil being tested. Note if the pupil, noting the
size of that pupil, (do they match in size from the start and do they
constrict to the same size?) And degree. Does the patient follow you
with their eyes, can they see things across the room, and do they move
their limbs at will or only after stimulation. Do their limbs spasm
or truly move at will. Can they follow commands? Do they feel when
you wiggle their toe, prick with a pin, move a toe, and rub with a
finger or cotton ball on the periphery of the body.
These are very
important tests for diabetics, peripheral vascular disease patients,
CVA’s.
Know to what degree they have feeling.
Check the Babinski
reflex if applicable.
Check hand grasps, leg rises alone or against
pressure. Cranial nerves III, IV, VI, move the eyes in all 6 cardinal
areas.
As you care for your patient watch to see if the patient’s
eyes move in tandem to all of these areas or if your patient is able
to follow directions, test this. Can your patient smile, frown, move
the tongue from side to side? These are all cranial nerves. Do DTR’s
& clonus if applicable. List cranial nerves 1 – 12, noting deficits if
present. If the patient is confused and in restraints include
restraint documentation, type of restraint, frequency of assessment,
and patient tolerance of restraints. State why the patient is in
restraints. If restraints are present an appropriate nursing diagnosis
must be present in your log or care plan.
Problems:
36
Advanced Medical Surgical Nursing 2010
Clinical Rotation Guidelines
The clinical hours for Medical/Surgical Nursing 2 will total 135
hours.
The first week of classes, we will spend two clinical
days reviewing skills in the nursing lab (this totals eight
hours. Care plan data gathering and patient assessment will be
allowed totaling 8 hours. The following seven weeks you will be
expected to complete 120 hours working with your assigned
preceptor. Which is 10 twelve hour shifts.
Have your preceptor sign in/out on your clinical days. This
sheet must be turned in for you to receive credit for your
clinical. This will also verify your presence in the clinical
setting.
Students will be expected to complete logs on 3 patients during
the seven week clinical portion of the course.
All logs must
have 4 nursing diagnosis and 4 interventions. You can use risk
for and collaborative diagnoses as well.
NOTE: Each student is required to turn in one log every two
weeks. If this is not possible you must meet with your
instructor and make arrangements for remedial work. If you do
not meet with your instructor the log will be considered late.
It
is
imperative
that
your
nursing
interventions
be
individualized for each of your patients.
Although you will
utilize some nursing diagnoses more than once, the interventions
you should use should reflect patient individuality.
ALL LOGS MUST BE typed!!
37
Advanced Medical Surgical Nursing 2010
Grading Sheet for Logs
CRITERIA FOR EVALUATING LOGS – Use care plan guidelines for the
content listed below for what needs to be in each category.
I.
Spelling, grammar, neatness____________________________06%
II.
Data base______________________________________________12%
(Content follow sheet with heading care plan log guidelines)
III.
Physical assessment____________________________________10%
V.
Nursing diagnoses #1
VI.
Nursing Diagnosis #2 __________________________________17%
VI.
Nursing Diagnosis #3 __________________________________17%
VII.
Nursing Diagnosis #4 __________________________________17%
IX.
References cited in APA format throughout _____________04%
_______________________17%
TOTAL
100%
Student Score - ______________________________________________
Instructor Comments
_________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
38
Advanced Medical Surgical Nursing 2010
Grading Rubric for Database
Reference where you get each of your components please.
Log
Instructor Comments
Spelling
2%
Grammar
2%
Neatness
2%
Database
Demographics
12%
1%
Med Sheet – Summary
Sheet (Criteria met)
4%
IV Therapy
2%
Labs – normals listed
Abnormals explained
2%
X-ray – normals listed
Abnormals explained
1%
Blood Gases
1%
Treatments
1%
39
Student Score
Advanced Medical Surgical Nursing 2010
Physical Assessment
10%
General Survey (1)
Integumentary (1)
Respiratory
(1.5)
Cardiac
(1.5)
GI
(1)
GU
(1)
Neuro
(1)
Musculoskeletal(1)
Cultural (1)
40
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis #1
Reference where you get each of your components please
Log
Nursing Diagnosis 3%
Instructor Comments
Prioritized
Written
Supporting
Data
Correctly
with
Subjective/Objective
Desired Outcome
2%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 4%
Prioritized
Individualized
Time Limited/Measurable
Complete
Implementation(s) 4%
Specific to nursing action
If not explained
Evaluation
(s)
Results
of
Implementation
Documented
Specifically for Each one 1%
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
Score - Total Possible
17%
41
Student Score
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis #2
Reference where you get each of your components please
Log
Nursing Diagnosis 3%
Instructor Comments
Prioritized
Written
Supporting
Data
Correctly
with
Subjective/Objective
Desired Outcome
4%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 4%
Prioritized
Individualized
Time Limited/Measurable
Complete
Implementation(s) 4%
Specific to nursing action
If not explained
Evaluation
(s)
Results
of
Implementation
Documented
Specifically for Each one 1%
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
Score - Total Possible
17%
42
Student Score
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis #3
Reference where you get each of your components please
Log
Nursing Diagnosis 3%
Instructor Comments
Prioritized
Written
Supporting
Data
Correctly
with
Subjective/Objective
Desired Outcome
4%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 4%
Prioritized
Individualized
Time Limited/Measurable
Complete
Implementation(s) 4%
Specific to nursing action
If not explained
Evaluation
(s)
Results
of
Implementation
Documented
Specifically for Each one 1%
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
Score - Total Possible
17%
43
Student Score
Advanced Medical Surgical Nursing 2010
Grading Rubric for Each Nursing Diagnosis #4
Reference where you get each of your components please
Log
Nursing Diagnosis 3%
Instructor Comments
Prioritized
Written
Supporting
Data
Correctly
with
Subjective/Objective
Desired Outcome
4%
Applicable to Pt.
Time – Limited/Measurable
Nursing Interventions 4%
Prioritized
Individualized
Time Limited/Measurable
Complete
Implementation(s) 4%
Specific to nursing action
If not explained
Evaluation
(s)
Results
of
Implementation
Documented
Specifically for Each one 1%
Evaluation of Desired Outcome
(1%) – Was goal met if not,
explanation present
Score - Total Possible
17%
44
Student Score
Advanced Medical Surgical Nursing 2010
LOG DATABASE GUIDELINES
Student Name-_____________________________________________
Date(s) of Care - ________________________________________
Unit Patient On - ________________________________________
Patient Initials:_________
Age:______
Sex:______________
Marital Status:___________
Primary Language:_____________
Ethnic Background:________________________________________
Educational Level:________________________________________
Occupation:_______________________________________________
If Retired, former occupation:____________________________
Religion:_________________________________________________
Culture:__________________________________________________
Support Persons or Family
Members:__________________________________________________
Reason for seeking health care
patient’s own words if possible:
45
or
hospitalization:
(In
the
Advanced Medical Surgical Nursing 2010
MEDICAL HISTORY
Present Medical Diagnosis – List and define each medical
diagnosis. Identify and list signs and symptoms your patient is
experiencing.
Present and Past Chronic Conditions: (Use your Textbook and
define the conditions, list the common signs and symptoms, then
individualize this section with what signs and symptoms the
patient displays).
Past Accidents:
Allergies:
(Food, Drug, and Environmental and patient reaction)
Past Surgery:
(List all past surgeries, dates and reasons for
the procedures).
Past Illnesses:
Immunization Status: Tetanus, Flu Shot, Pneumonia Shot – Date
Received.
Treatments:
(list and explain all of the treatments that this
patient receives and are they effective, as evidenced by proof.
46
Advanced Medical Surgical Nursing 2010
Medications: (List the medications that this patient receives,
the dosages, major side effects, times received and administered
by you and if these medications are effective or not effective
for this patient). Use a Table format to present this material.
Medication
Name
Generic &
Dose,
frequency
and times
given
Side effects
you
will
watch
for.
Major only
Trade
1.
2.
3.
4.
5.
6.
7.
8.
47
Assessments
Actual
to
be patient
completed
assessment
pre/post
findings, and
effectiveness
Advanced Medical Surgical Nursing 2010
IV Therapy – (Site assessment, location of all IV sites, IV
solution rate and if on an infusion pump, saline lock, or
central lines. Date started if possible). If you restart an IV
state so here with same criteria along with the reason why.
ABG’s: (If available)(Identify abnormals and rationale for the
abnormals).
Laboratory Values: (Cite the normal/abnormal values, but explain
the abnormal as they relate to your patient). Use a table format
to present this material.
Lab Name
Patient
Abnormal
Explanation of abnormality
related to patient medical
condition
Values
1. CBC
RBC’s 3.2
Example
Hgb9,
Low values related to blood
loss from GI Bleed.
Hct of 28
2.
3.
4.
5.
6.
7.
8.
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Advanced Medical Surgical Nursing 2010
X-rays:
(State why these x-rays were ordered for this patient
and explain the results if abnormal or normal).
FAMILY CONTAGIOUS ILLNESS HISTORY
Include:
Father,
Mother,
Sisters,
Brothers,
Grandparents,
Uncles, Aunts, and Children.
(Include age of death or present
age, and cause of death).
Document: Hypertension, Diabetes, Heart Disease, Stroke, Cancer
and
of
what,
Thyroid
Problems.
Arthritis
and
Genetic
Abnormalities.
PERSONAL/SOCIAL HABITS OF THE PATIENT
Smoking/Tobacco use:
Alcohol use:
Recreational Drugs:
Family:
(Who does the patient live with).
Exercise:
Typical Day:
49
Advanced Medical Surgical Nursing 2010
Physical Assessment-Content for Logs
VITALS:
You should have all vitals from the clinical day you take
care of this patient and noted variations.
Method of temperature
measurement should be documented. Pulse should be apical and radial.
Note the difference in radial and apical beats, rhythm Note HT. & WT.
on your patients to see if diets are adequate or excessive.
Use a
standard chart to determine proper weight for size.
Problems:
PAIN ASSESSMENT: Document according to pain assessment in Urden.
Utilize PQRSTU model, Behavioral and Physiologic Indicators, or
Critical Care Pain Observation Tool. Assess pain on all patients’
document pain intensity on a scale the patient can understand or
responds to.
Problem:
GENERAL ASSESSMENT:
You should go in to speak with your patients
after you have reviewed the computerized medical record. This
assessment is your initial observation of the patient you will plan
care for the next day. You should note: affect, alertness, ability
to speak, move, contractures, position of limbs for contractures,
race, hair color; skin color, any skin defects that you can observed,
body size, appearance close to written age, drooling, etc.
Any
observations that you can readily see and hear are used here as you
care for them during clinical.
Problems:
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Advanced Medical Surgical Nursing 2010
Integumentary:
Note any scars, moles, skin tags, bruises, turgor,
moistness of mucous membranes, and color of conjunctiva, breakdowns,
scratches, and redness, condition of toe and fingernails, hair
quality, quantity, skin dryness, patchy pigmentation, lumps.
If
something is not noted or on this patient, then do: (this means
negative for) decubiti, dryness, moles, redness, Edema etc.
In this
way we, as your instructors, will know that you have observed for
these. Condition of Intravenous sites, incisions, Foley catheters,
nasogastric tubes, gastrostomy tubes, ETT, tracheostomy sites and
dressings should be assessed and documented under this category.
Problems
RESP: Breathing rate, rhythm, regularity, lung sounds – auscultated
anterior/posterior surfaces including right middle lobes, vocal
sounds, oxygen and how it is delivered, position of comfort, skin
color if hypoxia is an issue.
Problems:
Cardiac: Heart sounds, extra heart sounds or murmurs, presence of JVD,
peripheral pulse rate/strength, edema-pitting/non-pitting.
Problems:
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Advanced Medical Surgical Nursing 2010
GI: Inspect, auscultate and determine degree of bowel sounds present,
palpate for tenderness, note presence of NG tube, colostomy, last bm,
condition of teeth and oral mucosa. How is their appetite and if they
can answer, do they taste their food.
Do they swallow, eat all or
less than they should. Percentage of meals taken under your care.
Problems:
GU:
Method of voiding, urine appearance, amount, color,
foley, condition of perineal area. Output under your care.
use of
Problems:
MUSCULOSKELETAL SYSTEM:
Gait, posture, contractures, assistive
devices, ability to transfer if appropriate, limitations, muscle
strength, range of motion.
Problems:
NEURO: LOC, mentation, cranial nerves 1 -12, grips, pushes, glascow
coma scale, DTR’s, Do they respond to touch, pinch, etc?
If the patient is confused and in restraints include restraint
documentation, type of restraint, frequency of assessment, and patient
tolerance of restraints. State why the patient is in restraints. If
restraints are present an appropriate nursing diagnosis must be
present in your log or care plan.
Problems:
52
Advanced Medical Surgical Nursing 2010
SPECIAL SENSES:
Check whether the patient follows you with their
eyes, reads, watches T.V., looks toward someone speaking, in other
words, can they see. Look for an opaque lens with a penlight. Look
for eye drainage, look for drooping lower eyelids, (extropian or
inverted eyelids, entropian) look for arcus senilicus (look this up),
can they hear you, turn to the sound of noises, responds to commands.
PSYCHOSOCIAL:
decision making
Patient
mood,
ability
to
interact,
judgment,
and
DEVELOPMENTAL STAGE: What Erickson’s stage should they be in and what
stage do they now fall into. Prove your answer.
CULTURE:
Do they follow any cultural practices and what culture do
they belong in?
Prioritized Problems List: From your database and physical
assessment, list all of the problems that you identify in
prioritized order.
53
Advanced Medical Surgical Nursing 2010
List the top 5 problems identified in nursing diagnosis and/or
collaborative problem format.
1.
2.
3.
4.
5.
After prioritizing them complete the log utilizing the template
that follows to complete your nursing diagnosis steps.
54
Advanced Medical Surgical Nursing 2010
Landscape Nursing Diagnosis/Collaborative Problem Template
Nursing Diagnosis #
R/T
AMB
Reference
Goal:
Goal Evaluation
Reference
Intervention with
Implementation
1.
2.
3.
4.
55
Evaluation
of
patient response to
intervention
and
implementation
Advanced Medical Surgical Nursing 2010
PRECEPTORSHIP
The purpose of this course is to give the student the
opportunity to work closely with another nurse over a period of
time.
The student will be given the opportunity to plan and
manage the care of a group of patients. The student will assist
in the planning of care following assessment of patients and
identification of problems.
The theoretical content of this
course
will
include
the
importance
of
time
management,
establishing priorities, and efficiency.
The course will also
review the content of previous courses and present principles of
management.
Upon successful completion of the preceptorship,
the student will be able to competently:
1.
Organize priorities for his/her assigned patients.
2.
Administer medications and monitor intravenous infusions
safely using the six rights of medication administration.
3.
Assess, plan, and implement care.
4.
Organize
team.
5.
Document care given in a clear, concise manner using the
documentation system of the facility in which the student
is conducting their clinical practice.
6.
Participate in the process of documenting new orders and
carrying out prescribed therapy.
patient
care
with
56
other
members
of
the
health
Advanced Medical Surgical Nursing 2010
7.
Execute teaching plans in collaboration with other members
of the health team.
8.
Organize patient care based on acuity.
9.
Delegate responsibilities to other members of the nursing
team with preceptor input.
10.
Evaluate management of time and resources.
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Advanced Medical Surgical Nursing 2010
Policies and Procedures for the Preceptorship Experience
1.
Preceptors must demonstrate clinical expertise in their
Clinical area.
Most will have a minimum of two years of
experience beyond graduation.
2.
Students will not be assigned to clinical units where a
close relative, spouse or significant other is employed.
3.
Preceptors need to maintain contact on a weekly basis with
the instructor of their assigned student if problems occur.
Early intervention for problems needs to occur if needed.
4.
Students may not select preceptors.
select students.
5.
The assignment of preceptors is a decision made by the
faculty as a whole.
6.
Efforts will be made to accommodate student needs related
to shifts and facilities but faculty cannot guarantee that
all student requests can be accommodated.
7.
Preceptors are to be physically present on the unit when
the student is assigned to the unit.
8.
Students are not to be assigned to supervise medication
aides.
9.
Preceptors may not
If alternate preceptors are utilized, they will be oriented
to roles, responsibilities, and objectives.
10. The preceptor will be assigned to primary supervision of no
more than two students for the duration of the experience.
11. The preceptor and/or alternate will be physically present
in the agency during scheduled learning experiences.
12. The faculty member will be accessible to
and/or the student during the designated
learning experience
the preceptor
time for the
13. Preceptors will assist in evaluating student performance.
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Advanced Medical Surgical Nursing 2010
14. Each preceptor will be given written objectives for the
experience.
15.
Each preceptor will be oriented to the role and
responsibilities of the preceptor, faculty, and students
for the learning experience.
59
Advanced Medical Surgical Nursing 2010
ACTIVITIES BEYOND THE STUDENT SCOPE OF PRACTICE DURING ANY
CLINICAL EXPERIENCE
The following are activities which nursing students may not
engage in during clinical. Conduct of this nature may result in
dismissal from the program.
1.
Preparation or IV administration of critical care drugs:
Anti-arrythymics, pressor agents, thrombolytics, and
chemotherapy agents. Oxytocics, Magnesium Sulfate, and
Terbutaline may be given under the direct supervision of
faculty or preceptor in labor and delivery only.
2.
Witnessing consent forms, living wills and/or other legal
documents.
3.
Sign out, hanging or crosschecking of blood products.
Students may monitor administration of blood products under
direct supervision of a registered nurse.
4.
Unsupervised narcotic sign-out (any licensed faculty or
staff is considered as supervisor).Students may not carry
narcotic keys.
5.
Operation of hemodynamic monitoring equipment (observation
only).
6.
Removal of central lines and/or arterial lines, may be done
under direct supervision of WNMU instructor/preceptor with
prior experience in the procedure.
7.
Removal of wound drains (may be done only under direct
supervision of instructor/preceptor).
8.
Operation or removal of temporary pacemakers.
9.
Removal
of
subcutaneous
stitches
supervision of instructor/preceptor.
10.
Assuming responsibility for patient’s valuables.
11.
Examinations related to progression of labor
and/or rectal, as well as internal monitoring).
60
only
under
direct
(vaginal
Advanced Medical Surgical Nursing 2010
12.
Primary circulating or scrub nurse.
13.
Nursery (no IV or medication administration without direct
supervision).
14.
Unsupervised charge of a unit.
15.
No medication administration in agencies other than the
hospital or nursing homes, and only under the direct
supervision of faculty or preceptor.
16.
Taking verbal or telephone orders from a physician without
supervision of instructor or preceptor/RN.
17.
Independent application of restraints
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Advanced Medical Surgical Nursing 2010
RATING SCALE FOR CLINICAL EVALUATION
Advanced Medical-Surgical Nursing
To receive a passing clinical grade, the nursing student must
receive a passing rating on all requirements.
The criteria for rating are:
Pass: Clinical performance is safe and demonstrates skills and
synthesis of learning consistent with the objectives for the
level of the course.
Fail:
Clinical performance is unsafe or demonstrates an
inability to perform skills consistent with the objectives for
the level of the course.
The student who causes physical or emotional harm to any patient
is subject to dismissal according to the dismissal policy in the
WNMU Nursing Student Guidelines.
Students will be evaluated twice during the course. The midterm
evaluation grade will appear in column 1 and the final
evaluation grade will appear in column 2.
CLINICAL GRADE____Pass/Fail___________Evaluation 1
CLINICAL GRADE____Pass/Fail__________Evaluation 2
*Student Signature:__________________________________Date_______
*Student Signature:__________________________________Date_______
Preceptor Signature:_________________________________Date_______
Faculty
Signature:___________________________________________Date_______
Faculty
Signature:___________________________________________Date_______
*The student's signature verifies that the evaluation was seen.
It does not signify agreement with the evaluation.
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Advanced Medical Surgical Nursing 2010
RATING SCALE FOR CLINICAL EVALUATION
Role as Provider of Care
1
Assessment
Collect Data by analyzing communication
from patient, family, medical records,
other health care providers, including
Psychological, Socio-cultural,
developmental, illness-wellness
continuum.
Physical Assessment of all assigned
patients in a timely manner in
accordance with Advanced Medical
Surgical 2 Guidelines
Analyze and formulate a nursing
diagnosis based on assessment data
Apply hierarchical approach to establish
a priority of needs for patient care
Assess changes in the illness-wellness
continuum that interfere with the
patient’s ability to meet his/her needs
Utilize standardized measurements to
assess status of patient’s health
Analyze and document family interaction
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2
Comments
Advanced Medical Surgical Nursing 2010
RATING SCALE FOR CLINICAL EVALUATION
Role as Provider of Care
1
Planning – Applies the nursing process
to
Develop individualized nursing care
plans based on nursing diagnoses and
patient needs, integrating
pathophysiology and culture.
Develop culturally sensitive
interventions appropriate for assigned
patients
Identify long and short-term goals for
the patient based on assessment and
scientific principles.
Confer with staff and instructor
regarding care plan and changes in care
plans
Contribute to the computerized plan of
care for each client as appropriate
Organize an environment conducive to
maintenance or restoration of patient’s
abilities to meet his or her own needs.
Preserve client confidentiality
Identify safety hazards in the
environment and institute corrective
action
Identify factors that threaten life
support systems and institute corrective
action
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2
Comments
Advanced Medical Surgical Nursing 2010
RATING SCALE FOR CLINICAL EVALUATION
Role as Provider of Care
1
2
Comments
Apply the nursing process to the
implementation of:
Performance of nursing skills learned in
Fundamentals, Med-Surg I, OB/Peds and
(Psychiatric nursing if this rotation is
completed).
Nursing care activities in accordance
with patient needs and nursing
protocols.
Nursing care and utilization of
equipment and supplies in an economical
manner and timely manner.
Patient involvement in their care
planning process and implementation.
Accurate, timely communication and
documentation of assessment, planning,
interventions and evaluations for
assigned patients.
Accurate administration and
documentation of medications.
Effective communication patterns with
patient’s, families, nursing staff,
physicians and instructors.
Communication that is clear with
preceptor and faculty regarding clinical
schedule on a regular basis.
Culturally sensitive care for patients
and families.
Planned end of shift report that is
accurate and concise.
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Advanced Medical Surgical Nursing 2010
RATING SCALE FOR CLINICAL EVALUATION
Role as Provider of Care
1
Evaluation
Collaborates with the patient and/or
family in evaluating nursing care.
Revises plan of care with preceptor
input based on evaluation of care.
Assesses the effectiveness of cultural
interventions utilized in the nursing
care plan.
Adapts evaluation criteria to
alternative patient care situations
under preceptor direction.
Explains alternative approaches to
patient care as appropriate.
Recognizes significant change in
patient’s condition and communicates
these changes to the preceptor.
Evaluates the patient’s response to
nursing care.
Evaluates one’s own communication with
patient and other health care team
members and implements positive changes
based on this evaluation
66
2
Comments
Advanced Medical Surgical Nursing 2010
RATING SCALE FOR CLINICAL EVALUATION
Role as Member of Profession
1
2
Comments
Applies knowledge of ethical/legal
issues to the care of the patient with a
health crisis.
Demonstrates punctuality in the clinical
setting.
Maintains a professional appearance
Develops and implements a plan for selfdevelopment.
Uses clinical time wisely to improve
knowledge, and complete required
assignments.
Assumes responsibility for own nursing
practice.
Practice within ethical/legal framework.
Protect patient/family rights including
confidential information
Seek feedback for clinical performance
from preceptor.
Follow standard of care for the facility
in which clinical is being performed in.
Demonstrate respect for human dignity of
patients, families, staff, faculty, and
colleagues
Consult with supervisory RN and/or
instructor prior to implementing orders
Report any errors to the supervisory
nurse and the faculty member on call
promptly
67