Download Final Evaluation in Acute Care Setting

TRINITY VALLEY COMMUNITY COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
FINAL CLINICAL EVALUATION IN ACUTE CARE SETTING
EXPECTED BEHAVIORS
FINAL
P oints
Awarded
1.
Completes a Concept Care Map for each
assigned patient.
A. Identifies appropriate assessment data.
Head to toe assessment is complete
(I/II/III).
B. Identifies appropriate diagnostic/
laboratory data.
Identifies pertinent abnormal
lab/diagnostic values (I/II).
Interprets and incorporates patient’s
lab/diagnostic values (III).
C. Identifies appropriate nursing diagnoses &
goals.
Identifies highest priority problem (I).
Identifies the priority physiological,
psychosocial, and teaching problems (II).
Identifies priority problems (IIII).
Identifies measurable and realistic shortterm goal for each problem (I/II/III).
D. Identifies sufficient nursing interventions
with scientific rationale.
Identifies at least five pertinent nursing
interventions for identified patient
problem (I).
Indentifies a minimum of fifteen pertinent
nursing interventions addressing all
identifies patient problems (II).
Identifies sufficient and appropriate
nursing interventions to provide safe care
for assigned patients (III).
Possible
Points
STUDENT COMMENTS
SUPPORTING EXPECTED
BEHAVIOR
EXPECTED BEHAVIORS
FINAL
Points
Awarded
E. Addresses delegation of nursing tasks.
Identifies delegation of nursing
interventions to appropriate personnel as
per the Texas Nursing Practice Act
(I/II/III).
F. Documents medications with key nursing
interventions.
Completes all categories with most
important information for medications to
be administered (I).
Completes all categories with most
important information for all routine
medications and any prn medications that
will be administered (II).
Completes all categories with most
important information for all prescribed
medications (III).
G.
Utilizes therapeutic communication.
Identifies techniques of therapeutic
communications (I/II).
Utilize therapeutic communication
techniques for goal directed communication
during patient care (III).
H.
Addresses teaching needs and referrals.
Identifies one teaching need (I).
Identifies two priority teaching needs
and/or discharge teaching (II).
Identifies all teaching needs including
discharge teaching (III).
Identifies appropriate resources/referrals
and rationale (I/II/III).
Possible
Points
STUDENT COMMENTS
SUPPORTING EXPECTED
BEHAVIOR
EXPECTED BEHAVIORS
FINAL
Points
Awarded
I.
Addresses reportable data and health care
provider orders.
Identifies pertinent data requiring
collaborative interventions (III).
Identifies data to report to the primary nurse
(I/II).
Identify possible “Failure to Rescue” events
(III).
Identify current, pertinent doctor’s orders
(I/II).
Identify anticipated orders in response to
abnormal data (III).
J.
Evaluates nursing intervention and goals.
Documents the results of interventions
implemented from the generic and clinical
prep sheets (I, II, III).
Documents the outcomes of the identified
goals (met, partially met, not met) (I, II).
2. Safely administer medication/treatments
*A. Administer according to five rights.
Follows TVCC “Supervision of
Medication Administration Policy”
(I/II/III).
Properly documents medications (I/II/III).
Follows TVCC “Medication Error Policy
& Procedure” (I/II/III).
Adheres to safe, honest, ethical/legal
principles (I/II/III).
Gives medications according to the five
rights (I/II/III).
Possible
Points
STUDENT COMMENTS
SUPPORTING EXPECTED
BEHAVIOR
EXPECTED BEHAVIORS
FINAL
Points
Awarded
*B.
Demonstrates knowledge about
medications/treatments.
Verbalizes pertinent information for
administered medications (I/II).
Verbalizes pertinent information for all
prescribed medications/treatments (III).
3.
Performs nursing care competently.
*A. Follows Applicable Policies/ Procedures.
Adheres to TVCC policies, procedures,
guidelines, and regulations (I/II/III).
Adheres to Occupational Safety Health
Administration (OSHA) regulations
(I/II/III).
Adheres to Joint Commission/Medicare
guidelines and Hospital National Patient
Safety Goals (I/II/III).
Adheres to Nursing Practice Act and
Board of Nursing Rules and Regulations
(I/II/III).
*B. Maintains patient safety and meets
patient’s basic needs.
Provides for physical safety of patients
(I/II/III).
Checked off independently on oral
medication and subcutaneous injections
(II/Transition-III).
Performed 2 IVPB medications, I IVP
medication, and 1 sterile procedure (II).
Checked off independently on IVPB, IV
starts, and flushing central lines (III).
Possible
Points
STUDENT COMMENTS
SUPPORTING EXPECTED
BEHAVIOR
EXPECTED BEHAVIORS
FINAL
Points
Awarded
Performed 1 sterile procedure and
administered a minimum of 5 IVP (III).
Adheres to Standard Precautions
(I/II/III).
Provides care for one patient (I).
Provides care for a group of patients
(recommended up to three by end of
semester) (II).
Provides and directs care for a group of
patients (recommended up to five end of
semester) (III).
C. Implements plan of care.
Implements some interventions for one
patient problem (I).
Implements some interventions for each
patient problem (II).
Implements majority of interventions for
all patient problem (III).
D. Documents appropriately.
Documentations is concise, pertinent,
reflects changes in patient condition and
is completed in a timely manner (I/II/III).
Documents nursing interventions and
ensuing effectiveness (I/II/III).
E. Demonstrates professional interpersonal
skills when collaborating with
patients/family/ staff/peers.
Exhibits respectful attitude (I/II/III).
Performs within the limitations of the
student nurse (I/II/III).
Is contributing m ember of health care
team (I/II/III).
Possible
Points
STUDENT COMMENTS
SUPPORTING EXPECTED
BEHAVIOR
EXPECTED BEHAVIORS
FINAL
Points
Awarded
Respects peers/patients/family/health
care team members (I/II/III).
Utilizes appropriate communications skill
(I/II/III).
Initiates and evaluates referral for
assigned patients (III).
F.
Reports appropriate information to
health care team.
Receives report at beginning of shift and
gives report at end of shift (I/II/III).
Follows line of authority (I/II/III).
Reports critical patient information in a
timely manner (I/II/III).
Keeps instructor informed appropriately
(I/II/III).
G. Utilizes critical thinking skills supported
by scientific rationale.
Identifies scientific principles/rationale for
nursing interventions (I/II/III).
Is able to prioritize nursing care (I/II).
Utilizes basic decision-making skills when
caring for a group of patients (II).
Reevaluates priorities and adjusts nursing
care (III).
Incorporates standards of care in decision
making process (III)
Individualizes plan of care for each patient
(III).
H. Meets patient’s teaching needs with
appropriate and accurate information.
Implements basic teaching with assigned
patient (I).
Possible
Points
STUDENT COMMENTS
SUPPORTING EXPECTED
BEHAVIOR
EXPECTED BEHAVIORS
FINAL
Points
Awarded
Develops and implements a teaching care
plan (II).
Develops, implements, evaluates and revises
teaching plan considering age, developmental
level, cultural, psychosocial, socioeconomic
considerations (III).
I.
Demonstrates patient advocacy.
Intervenes with a HCP on a patient’s behalf at
least once a semester (II).
Intervenes with a HCP on a patient’s behalf at
least twice a semester (III).
Follows through toward resolution of patient
issues/problems (I/II/III).
4. Maintains professionalism.
*A. Performs in a professionally honest /ethical/
legal/culturally sensitive manner.
Maintains patient/facility confidentiality
(I/II/III).
Adheres to the TVCC Student Handbook
policies related to honesty and ethical/legal
behavior (I/II/III).
Is accountable for behavior (I/II/III).
Notifies appropriate personnel for absences
(I/II/III).
Provides nursing care in a cost-effective
manner (I/II/III).
Incorporates cultural influences in patient
care (I/II/III).
*B. Completes requirements for clinical.
Follows verbal and written directions
(I/II/III).
Meets clinical objectives (I/II/III).
Completes corrections for written
assignments on time (I/II/III).
Possible
Points
STUDENT COMMENTS
SUPPORTING EXPECTED
BEHAVIOR
EXPECTED BEHAVIORS
FINAL
Points
Awarded
STUDENT COMMENTS
SUPPORTING EXPECTED
BEHAVIOR
Possible
Points
C. Maintains appropriate clinical behavior.
Maintains professionalism in stressful situation
(I/II/III).
Demonstrates a neat and appropriate
appearance (I/II/III).
Is punctual to clinical and remains designated
time (I/II/III).
Participation clinical seminar and postconference (I/II/III).
Uses initiative in seeking learning experiences
(I/II/III).
D. Displays caring attitude.
Cares for all patients irrespective of social or
economic status, personal attributes, or the
nature of health problems (I/II/III).
TOTAL
STUDENT’S COMMENTS (MUST PUT STRENGTHS/WEAKNESSES):
INSTRUCTOR’S COMMENTS:
Instructor’s Signature_____________________________________________Facility_________________________
Student’s Signature_______________________________________________Date___________________________
N/ADN Syllabus/Core/Final Evaluation Acute Care Setting – Level II Highlighted
Reviewed 03/13