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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 2 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 3 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. 5 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. 6 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 7 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. 8 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. 9 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. 10 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% 11 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 17 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% 18 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. 19 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). 20 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 21 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 22 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 24 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? 26 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? 27 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. 28 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? 29 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? 32 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. 48 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: 50 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: 51 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. 57 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. 58 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 61 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. 62 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 63 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 64 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. 65 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