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1 NEO 114 Fall 2011 Family Nursing Clinical North Seattle Community College Course Syllabus Course Prefix and Number: NEO 114 Course Title: Family Nursing Clinical Course Credits: 5 Course Start Date: September 26, 2011 Course Location: Northwest Hospital Medical Center Course Times: 6:30am- 6:30pm INSTRUCTOR INFORMATION: Margaret Johnston, RN-BC, BSN, M.Ed. Email: [email protected] [email protected] Phone: 206-265-9907 Kristi Cunnington, RN-BC, BSN, CDE Email: [email protected] Phone: 425-466-8119 Jessica Gonzales RN, BSN, MSN Email: [email protected] Phone: 425.761.7224 Email or text messaging is the best and quickest way to reach us. We will make every effort to get back to you within 24 hours. If there is an emergency, or if you will be absent from clinical, for any reason, a phone call is required. TEACHING PHILOSOPHY: As the instructors for this course, we believe it is our job to foster a safe learning environment, to provide experiences that will facilitate achievement of the course outcomes, to clearly communicate expectations, and to provide constructive evaluation. It is our expectation that each student will assume responsibility for their own learning by completing all of the reading assignments and activities provided as well as actively participating in clinical. It is the student’s responsibility to seek instructor or preceptor guidance and support in performing nursing care. COURSE DESCRIPTION Provides opportunities to build on previously learned skills and apply knowledge gained in NEO 104 through expanding the performance of nursing care in the role of caregiver, collaborator of care, decision-maker, communicator, teacher and professional, into care of the family. COURSE Skills goals: 1. Plan and implement care for clients with normal and complex conditions in labor and delivery and postpartum while meeting clinical evaluation criteria 2. Observe therapeutic interventions in labor and delivery and postpartum 3. Complete physical and psychosocial assessment of families 4. Apply therapeutic communication skills 2 5. Implement the nursing process in the care of clients with complex conditions 6. Demonstrate effective, independent, problem solving skills in the care of clients with complex and well conditions 7. Demonstrate ability to collaborate with other members of the healthcare team. 8. Plan and implement safe and effective nursing care in antepartum, labor and delivery, SCN, and postpartum units 9. Perform assessment of antepartum, labor and delivery, neonatal, and postpartum patients 10. Identify and describe communication strategies for interviewing labor and delivery and postpartum 11. Perform nursing skills in a safe and effective manner that demonstrates a caring ethic in labor and delivery, antepartum, postpartum, nursery care and pediatric care settings 12. Assess current knowledge level, learning readiness, and developmental level of client in regard to her health status 13. Utilize appropriate channels of communication with client, family, faculty, preceptor and staff 14. Collaborate with healthcare team to develop plan of care to achieve desired outcomes 15. Adhere to standards of professional practice in nursing 16. Identify and separate self issues from those of clients NSCC General Learning outcomes and/or Related Instructional Outcomes (for Technical courses) met by this course: Outcome 2. Intellectual and Practical Skills. Critical thinking and problem solving. Communication and self-expression. Quantitative reasoning. Information literacy. Technological proficiency. Collaboration: group and team work. Outcome 4. Integrative and Applied Leaning. Synthesis and application of knowledge, skills, and responsibilities to new settings and problems. Course Outcomes/Learning Objectives: 1. Holistically care for the medical-surgical and psychiatric adult within an ethical, legal and diverse framework under the designated health care provider within the scope of practice of the practical nurse. 2. Demonstrate competency in educating and communicating with the medical-surgical and psychiatric adult patient, patient families and the health care team. 3. Demonstrate competency in data gathering, problem identification, planning, implementing nursing care and contributing to evaluation within a variety of settings utilizing appropriate technology for the medical-surgical and psychiatric adult. 4. Use critical thinking to identify normal and abnormal patterns in the medical-surgical and psychiatric patient, children and childbearing families based on understanding anatomy, physiology, pathophysiology in order to contribute to the safe management of all patient care. 5. Effectively delegate and collaborate with the medical-surgical and psychiatric patient, patient’s family and healthcare team 3 COURSE POLICIES: Conform to NSCC policies regarding appearance and professional behavior at all times. Come to clinical prepared. You are not to perform any procedure (giving meds, dressing changes, catheters etc) without notifying your instructor or preceptor first. Failure to do so will result in immediate dismissal for the day, followed by disciplinary action. The role of the clinical instructor is one of instruction and evaluation. It is the student’s responsibility to seek instructor guidance and support in performing nursing care. For a positive clinical experience it is recommended to bring a nursing drug reference and care plan reference. Come to clinical prepared. This means being able to develop a plan of care for your assigned patient and to answer questions about your client's diagnosis, medications, and therapy with your instructor each day. It also means having the appropriate equipment and the ability to research or provide the appropriate data. Course expectations are the following: Arrive on time Come prepared Ask for help Use each other as resources Actively participate in discussion Communicate information clearly to staff, instructor, team, patients and families Use your critical thinking skills to the best of your ability when making decisions about patient care Check in with instructor/preceptor prior to meal breaks ATTENDANCE/TARDINESS POLICY All students must attend all laboratory and clinical/lab sessions, arrive on time, attend the class during all assigned class hours, and be prepared to actively participate. Any scheduled laboratory, or clinical/laboratory time missed will be considered an absence. Students are expected to attend all orientation classes. Theory course instructors may implement their own course attendance policy which can be found in the course syllabus. Students will need to comply with their instructors attendance policy if applicable. Guidelines: 1. Absences will jeopardize meeting daily objectives, and therefore, success. 2. A student is allowed one medical or family emergency absence from clinical/lab each quarter not to exceed 33% of that clinical/laboratory experience (for example, if OB is 3 days, a student can not miss more than 1 day for emergency purposes, and pass the course ). Any additional absences OR a tardy greater than 45 minutes OR absences that are not a medical emergency (unexcused) will result in a 0 for the day which in clinical/lab may result in failing the course. 3. Two tardies of greater than 5 minutes in clinical/laboratory will constitute an absence, and a zero for the day which may result in failing the clinical/laboratory course. 4. There is no scheduled “make up” laboratory or clinical days. 5. In the case of an absence, the student must: a. Call their instructor a minimum of 1 hour before the start of clinical/lab, and report the absence and state the reason why. Sending a message with a fellow student will not be accepted. b. Provide a note in writing to the Director of Nursing explaining the reason for the absence. c. Any injuries, or change in health status requires a healthcare provider‟s release to attend clinical, and lab courses. 4 A “No Call, No Show” is a serious offense, and is not permitted at the clinical facility sites by students. Not calling or showing may be grounds for dismissal, and will be referred to the Director of Nursing, Dean of Health & Human Services, and/or the Vice President of Student Services. ALSO see APPENDIX Section 9.11 Policies Regarding Attendance form. EXPECTATION OF THE STUDENTS Because you have only two shifts in OB, you will not be giving any medications. Your experience will focus on observation as well as practice of clinical skills. You will be assigned to work with a staff nurse and will be expected to participate in caring for mothers and infants, doing assessments, and practicing any skills that are within your scope of practice as student LPNs. You are expected to arrange your nursing activities so you are on time for conferences. Students are expected to come to pre and post conference ready to discuss and actively participate. Information shared in pre and post conference regarding patients or fellow classmates is considered confidential. “What is shared in the classroom stays in the classroom”. NURSING CLINICAL POLICIES Guidelines for Student Conduct: Students are expected to comply with student conduct policy and procedures. Information on student responsibilities and rights is available at the following websites: http://www.seattlecolleges.com/studentrules.aspx or Intranet site: http://www.seattlecolleges.com/studentrules.aspx Patient Confidentiality Strict confidentiality should be maintained at all times. Refer to LPN Student Handbook. Cell Phone Etiquette: To avoid disruption of the learning environment, students are expected to turn off or silence cell phones. Phones are not to be on the student’s person. Do not answer phone calls while on the unit. Please use scheduled breaks to return calls. Classroom Diversity Statement: Respect for diversity is a core value of NSCC. Our college community fosters an optimal learning climate and an environment of mutual respect. We, the college community, recognize individual differences. Therefore, we are responsible for the content and tone of our statements and are empathetic speakers and listeners. Respectful and Inclusive Environment: The instructor and student share the responsibility to foster a learning environment that is welcoming, supportive, and respectful of cultural and individual differences. Open and respectful communication that allows for the expression of varied opinions and multicultural perspectives encourages us to learn freely from each other. Fragrance Policy: Students are requested to refrain from wearing heavily scented products during class sessions, since some individuals may experience chemical sensitivities to fragrances that interfere with their learning. Do not wear any scents, perfumes, strong smelling deodorants or lotions. 5 Transportation: Clinical instruction and experience are provided throughout the program in long-term care facilities, acute care hospitals, and clinics. It is the student’s responsibility to arrange transportation to and from these facilities. Student Ratios: Clinical placements are made to ensure that all students receive the appropriate variety of experiences. Long term care facilities and acute care facilities generally have a ratio of 6-8 students per instructor and clinics utilize the nurses as preceptors in a 1:1 ratio. Dress Code: Students are to adhere to the standards, policies, and regulations of the clinical sites during their clinical education program. These standards include wearing appropriate attire, including nametags, and patches ironed on the left upper arm at the shoulder, and conforming to the standards and practices of the site. Nametags and patches must remain visible at all times and must not be covered by a sweater while on the floor. A sweater or T-shirt may be worn under the scrubs. Students should wear casual business attire (no jeans) with facility ID badge during the pediatric clinical if scrubs are not requested by your preceptor. Facility Orientation: If the clinical site requires a special orientation of students, students MUST attend or they will be unable to attend clinical. Each facility has unique policies, procedures, and documentation practices. Students must attend the orientation in order to be prepared to attend clinical and provide safe care for patients within these facilities. Students who do not attend the orientation will meet with the Nursing Faculty and the Program Director, and referred to the VP of Student Services. Leaving the Unit: Students are to remain at the site during the clinical assignment. Leaving the floor without notifying the staff and instructor/preceptor where patients are assigned is considered abandonment of patients. If a student is found to have abandoned his/her patients, the student may be referred to the VP of Student Services, which may lead to dismissal from the program. If the student needs to leave the floor for any reason he/she must let the nurse in charge and the instructor/preceptor know. Standard Precautions: Students are expected to follow the Standard Precautions with ALL patients regardless of whether they have a communicable disease or not. Procedures and Treatments: Students should NOT perform any procedure/treatment independently (i.e. giving meds, dressing changes, catheters, etc) without first obtaining permission from the instructor/preceptor. Failure to do so may result in immediate dismissal for the day followed by disciplinary action. Clinical Errors: Clinical errors must be reported immediately to the charge nurse and the clinical instructor. An NSCC Practical Nursing Program Student incident report must be filled out, even if the instructor catches the error before the student administers the medicine or treatment. In the event that the student does perform the wrong procedure a facility incident report must also be made out. The student incident report will be placed in the student’s file until graduation. Serious errors will be reviewed by the faculty and administration and may be referred to the VP of Student Services. (See Student Clinical Incident Report in Section VII.) 6 Injuries and Accidents: Any injuries sustained during the clinical day should be reported to the nursing instructor immediately. Student Support Services: Students are encouraged to seek campus support services when necessary to support their learning and academic progress. Refer to student handbook, brochures/flyers, or college website for information about: Disability Services, Advising Center, Tutoring Services, Student Leadership Programs, Library, Financial Aid Office, LOFT Writing Center Plus, Admission/Registration/Records/Credentials (ARRC), Counseling, Women’s Center, Multicultural Services Office, and/or Wellness Center http://www.northseattle.edu/services/tutor/ INFORMATION FOR CLINICAL SITES OB Clinical at Northwest Hospital: Please meet instructors Margaret Johnston or Kristi Cunnington in the family waiting room next to the nursing station of the Childbirth Center at 0630. Please arrive with your student ID badge from Northwest Hospital. Your badge must be obtained from Security at Northwest Hospital prior to beginning your clinical rotation. NEO 114 Fall 2011 Childbirth Center Clinical Assignments 1) Weekly Goals and Reflection Paper Weekly Goals are to be completed and turned in at the beginning of each day of the clinical rotation. Turn in your goal sheet at the beginning of the clinical day with your identified goals and plan for meeting those goals. After you have completed the clinical day, take them home to complete the evaluation portion. The completed goal worksheets should be typed and turned in with your OB Care Plans. Your instructor may request that you submit them as an attachment to an email or on ANGEL. Reflection papers should also be submitted with your OB Care Plans. 2) OB Care Plans There are three different types of OB Nursing Care Plans. You are expected to complete one of the following Nursing Care Plans (NCPs), which includes both a maternal and neonatal assessment: Labor and Delivery/Neonatal, Postpartum/Neonatal, or Antepartum (however, if you use the antepartum NCP, you will also need to incorporate the neonatal assessment section).One complete NCP is to be completed during the three shifts you will be in OB clinical at Northwest Hospital. The NCPs should be turned in to your instructor’s mailbox by 5pm within three days of your second clinical experience. However, your instructor may request that you submit it as an attachment to an email or on ANGEL. 7 NEO 114 Fall 2011 Pediatric Clinical Assignments Pediatric Clinical Sites: Students will attend a total of three days: two at a Group Health clinic and one at a child care center. The clinical sites are: 1. Pinehurst Child Care Center 7330 35th Ave NE Seattle, WA 98115 206-365-2197 Plan to arrive at 8am and stay until 3:30pm Bring a lunch with you 2. Burien- Group Health Clinic 140 SW 146th St. Burien, WA 98166 3. Factoria- Group Health Clinic 13451 SE 36th St. Bellevue, WA 98006 4. Lynnwood (no Mondays) - Group Health Clinic 20200 54th Ave W. Lynnwood, WA 98036 5. Northgate – Group Health Clinic 9800 4th Ave. NE Seattle, WA 98115 6. North shore – Group Health Clinic 11913 NE 195th St. Bothell, WA 98011 7. Redmond (no Mondays) – Group Health Clinic 15809 Bear Creek Pkwy Suite 100 Redmond, WA 98052 8. Renton- Group Health Clinic 275 Bronson Way NE Renton, WA 98056 8 Clinical Goals are to be completed and turned in the night before each clinical day by midnight, electronically. Turn in your goal sheet with your identified goals and plan for meeting those goals. After you have completed the clinical day complete the evaluation portion. The completed goal worksheets should be typed and turned in by midnight one week after your clinical date. For example, if you have clinical on Monday, your assignment will be turned in the following Sunday by midnight (along with your reflection and assignment). If you have clinical on Tuesday, then your assignment is due the following week on Monday by midnight, etc. PLEASE LET ME KNOW IF THIS DOESN’T MAKE SENSE TO YOU SO I CAN CLARIFY. As you interact with and observe the children attending the clinics and Pinehurst, you will be able to apply what you learn in class to what you observe. Keys to your assignment are your knowledge about child growth and development and stages of play. Your assignment (along with goals and reflection) will be submitted to me electronically, one (1) week after your last clinical day, in APA format, consisting of no more than 5 pages double spaced, using at least one outside source other than your textbook; citations on the last page in APA format. Well Child Observation (at Pinehurst Clinic), please address all of the following: 1. Observe at least 3 different child/adult interactions (parents dropping of their child, various staff members). Briefly describe the individuals involved (age attire, affect, comfort with the situation), and their interactions within the pair. 2. Assess the interactions observed in relation to theories of growth and development (for example, Erikson, Piaget, Bowen, or Freud). Also assess how the child’s needs are being met according to Maslow’s Hierarchy. 3. Comment on behaviors observed in terms of your own personal thoughts. 4. assess the environment in relation to child health and safety: a. Are their restrooms with provisions for diaper change and disposal? Can children reach the sinks? b. Is food available for lunch and/or snacks? What kind of food? Is it suitable for the for the age children you have observed? Why or why not? c. What safety measures are there? Is their a first aid station? d. What facilities are there for handicapped individuals? What is needed? Feel free to add extra comments or observations. 9 Sick Child Observation (at Group Health Clinics) Please use the following points as a guide and address as many or as little as is possible. When obtaining the Health History (bullet “I” below), address as many systems/questions as possible for a complete history. 1. What are most of the children coming in for? 2. Who is accompanying the child? Both parents? Caregiver? Other siblings present? 3. How is the parental involvement? Are the parents anxious? How did this make you feel as a student? How is/does the family cope/react to the child being ill? 4. Are there any socioeconomic, cultural, or religious factors that influence the child’s health? 5. Did you notice various roles the nurse played? Family advocate? Health promoter? Health teacher? Counselor? 6. Perform at least one Health History on a child to include: a. Biographical data: name (watch HIPPA), address, telephone, parents name, date and place of birth, gender, race, religion, nationality or culture background. b. Chief complaint: why is the child here? c. Current health or illness status: refers to the sequence of events that led to the chief complaint and related information including – symptom analysis of chief complaint (onset, timing, duration, character, severity, precipitating factors, associated symptoms, and alleviating factors) d. Other current or recurrent illness or problems e. Current medications, vitamins, over the counter drugs, herbal remedies, and folk remedies f. Any other health concerns g. Allergies h. Past health: refers to problems and health promotion activities, including birth history (pregnancy, labor and delivery, perinatal history), previous injury, illness, or surgeries, allergies, immunization status, growth and development milestones, habits. i. Review of systems- ask about child’s overall health status, Health History - integumentary system: ask about lesions, bruising, skin care habits, problems with hair and nails - head: ask about trauma and headaches - eyes: ask about visual acuity, last eye exam, drainage, infections - ears: ask about hearing acuity, last hearing exam, drainage and infections - nose: ask about bleeding, congestion, discharge, and sinus infections - mouth: lesions, soreness, tooth eruption, patterns of dental care, last dental exam - throat: sore throats, hoarseness - neck: stiffness, tenderness - chest (respiratory system): ask about pain, cough, wheezing, shortness of breath, asthma, infections - cardiovascular system: history of murmurs, exercise tolerance, dizziness, congenital defects 10 j. k. l. m. n. gastrointestinal system: ask about appetite, bowel habits, food intolerance, nausea, vomiting, pain genitourinary system: ask about urgency, frequency, discharge, urinary tract infections, musculoskeletal system: ask about pain, swelling, fractures, mobility problems, scoliosis Neurological system: seizures? Unusual movements? Endocrine or metabolic system: ask about growth patterns Psychiatric history: substance abuse? Eating disorders? Family history: should include any family genetic traits or disease with familial tendencies, communicable disease Nutritional history: quantity and kind of food or formula ingested daily, problems with feeding, use of vitamins and supplements, cultural or religious preferences Sleep history: bed time habits, nap time Psychosocial history: home and family function assessment (communication patterns, family roles, pets, financial), school behavior (grades, peers), activity assessment (activities, TV/computer time), discipline assessment ( type of discipline) Obtain vital signs of patient: compare to normal vital sign ranges for age group you are working with 11 ____________NORTH SEATTLE COMMUNITY COLLEGE_____________ NEO 114 DAILY CLINICAL PERSONAL/PROFESSIONAL GOALS Personal/Professional Goals How to Meet These Goals Evaluation (filled out prior to clinical; goals should have specific clinical skill focus) (filled out prior to clinical) (filled out after you’ve completed your clinical) Goal 1 Goal 2 Goal 3 12 ____________NORTH SEATTLE COMMUNITY COLLEGE_____________ DAILY REFLECTION: Complete after each clinical day and turn in with OB Nursing Care Plan. Description of Clinical Experience Reflection on Clinical Experience (What happened in clinical today? Provide details) (How did you feel about what happened today in clinical? What did you learn, what did you already know? What are your next steps?) 13 North Seattle Community College NEO 114 Labor and Delivery Nursing Care Plan Student: ____________________________________________________________ Date: _________________ Date of Patient Admission: ___________________ PATIENT INFORMATION Pt initials/identification: Delivery date: Time: Age: Type of delivery: Gravida: Para: EBL: Ab: LC: Complications of labor/del: EDD: Total length of labor: Allergies: Pain management in labor: Maternal V.S. Infant’s age at time of exam: Infant Sex: Apgars: Birth Weight: lbs./ gms Feeding Method: LABS AND DIAGNOSTIC TESTING (Include dates; indicate if abnormal value; discuss potential implications if abnormal) Rh and type: Rubella: HBsAG: GBS: HIV: Antibody Screen: Other: (STDs, Hep C, UA, etc) Prenatal Labs: Hgb: Hct: GDM Screening: Other: Ultrasounds: Post Partum Labs: Hct: Hgb: CBC: MEDICATIONS (Include all medications during current hospitalization) Name of Drug Dosage/Route/Frequency Indication Generic &Trade Other: Effectiveness/ Side effects 14 North Seattle Community College Neo 114 Signs of labor prior to admission: (bloody show, SROM, U/Cs, mucous plug) Discuss any prenatal diagnosis/es and implications (for both Cesarean and vaginal deliveries): Pain management: (non-pharmacologic comfort measures, narcotics, epidural/spinal) Stages and phases of labor: (describe each in detail) Fetal monitoring: (describe contractions, FHR baseline, variability, accelerations, deceleration, use NICHD terminology; discuss interventions and rationale) Care of neonate and rationale in delivery room and during recovery: (drying, tactile stimulation, any resuscitation measures, vital signs, Apgars, medications, bonding, feeding) Maternal care during recovery: (BUBBLE, vital signs, comfort measures) Parent/infant attachment after delivery and during recovery: Summary/other: 15 North Seattle Community College NEO 114 NURSING DIAGNOSIS/ PROBLEM LIST IN PRIORITY ORDER: PRIORITY#____ (Identify by number and provide brief rationale for your decision) Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms) Assessments: Interventions: Outcomes: Evaluations: PRIORITY#____ (Identify by number and provide brief rationale for your decision) Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms) Assessments: Interventions: Outcomes: Evaluations: PRIORITY#____ (Identify by number and provide brief rationale for your decision) Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms) Assessments: Interventions: Outcomes: Evaluations: COMMENTS/HISTORY/REVIEW (Include a review of any significant medical history, prenatal diagnoses, delivery complications, family adjustment, involvement of partner/father, support system, developmental phase of postpartum family) DISCHARGE NEEDS/PLAN: (Are there identified problems or barriers to discharge? What are the needs at home after discharge? Resources? Discuss involvement of social work, home visits or referrals, developmental phase of family) NAME: North Seattle Community College North Seattle Community College 16 NEO 114 Post Partum Nursing Care Plan: Student: ____________________________________________________________ Date: _________________ Date of Patient Admission:____________ PATIENT INFORMATION Pt initials/identification: Delivery date: Time: Age: Type of delivery: Gravida: Para: EBL: Ab: LC: Complications of labor/del: EDD: Total length of labor: Allergies: Pain Management in labor: Maternal V.S. Infant’s age at time of exam: Infant Sex: Apgars: Birth Weight: lbs./ gms Feeding Method: LABS AND DIAGNOSTIC TESTING (Include dates; indicate if abnormal value; discuss potential implications if abnormal) Rh and type: Rubella: HBsAG: GBS: HIV: Antibody Screen: Other: : (STDs, Hep C, UA, etc) Prenatal Labs: Hgb: Hct: GDM Screening: Other: Ultrasounds: Post Partum Labs: Hct: Hgb: CBC: MEDICATIONS (Include all medications during current hospitalization) Name of Drug Dosage/Route/Frequency Indication Generic &Trade North Seattle Community College Other: Effectiveness/ Side Effects 17 NEO 114 SYSTEMS/MATERNAL ASSESSMENT Cardiovascular: (include VS, heart rhythm, postruals prn, edema, pulses, Homan’s sign, activity tolerance, hx c/v problems, HTN) Respiratory: (RR, breath sounds, O2 sats, cough, Hx asthma, smoking in household?) Neurologic: (Pain Status, Sleep/Rest Patterns; also consider communication barriers, sensory deficits) Breastfeeding: (include nipples, breasts, colostrum/milk, knowledge & preparation, past experience or concerns, your observations, lactation interventions) GI : (include wt. or BMI, wt gain through pregnancy. bowel sounds, diet progression and appetite, hx eating disorders, dietary restrictions?, last BM, hemorrhoids, usual bowel habits) GU: (include fundus, lochia amount and character, I&O prn, ability to void after anesthesia/birth, dysuria, discharge, pp diuresis) Integument: (include hygiene, perineum, incision, IVs, rashes) Endocrine: (consider thyroid, diabetes, hx infertility) Psychosocial/Cultural: (include bonding, parent-infant attachment, role adaptations, family interaction, emotional state & perceptions, cultural/religious practices/traditions, language barriers, alternative or complimentary health practices, home environment, support, resources): Infant Care: (participation in newborn care, assess learning needs, bonding, challenges) Other: North Seattle Community College 18 NEO114 NEONATAL ASSESSMENT Skin: (color, acrocyanosis, turgor, mucous membranes, jaundice, mottling, rashes, lanugo, vernix, Mongolian spots, birth marks, echymosis, lesions) Head/Neck: (symmetry, caput, cephalohematoma, lesions, echymosis, types/ description of fontanels) Eyes/Ears/Nose/Mouth/Face: (symmetry, position, abnormalities, epicanthal folds, sclera, drainage, edema, ear pinna, nasal patency, palate, mucous membranes, tongue) Chest/Lungs: (RR, bilateral breath sounds, grunting/retracting, nasal flaring, rales, rhonchi, nipple buds, clavicle, symmetry) Cardiac: (heart rate and rhythm, murmurs, color changes, peripheral pulses, cap refill) Abdomen: (shape, tone, umbilical cord, bowel tones, palpation) Genitals: (uretheral opening, penis, scrotal rugue, testes, labia majora, pseudo menses) Extremities: (ROM, equal size, length, gluteal folds, symmetry, digits, webbing, color, cap refill, palmar & plantar creases, reflexes) Back: (spine curvature, sacral dimple, anal patency) Neurologic: (all reflexes, deficits, hips) Behavioral State: (feeding cues, crying, visual) Feeding/ Elimination: (breast, bottle, frequency, suck, latch, Lactation Consult; void, anal patency, stool, frequency) Attachment/Bonding: (maternal, family, bonding, skin-to-skin) Labs/tests: List all labs during hospitalization or labs you anticipate prior to discharge (bilirubin, glucose, CBC, hematocrit, Rh, hearing screen: include dates, normal or abnormal value, if abnormal discuss implications) 19 NEONATAL MEDICATIONS (Include all medications during current hospitalization) Name of Drug Dosage/Route/Frequency Indication Effectiveness/ Generic &Trade Side Effects NURSING DIAGNOSIS/ PROBLEM LIST IN PRIORITY ORDER (INCLUDES MOTHER/INFANT DYAD): PRIORITY#____ (Identify by number and provide brief rationale for your decision) Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms) Assessments: Interventions: Outcomes: Evaluations: PRIORITY#____ (Identify by number and provide brief rationale for your decision) Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms) Assessments: Interventions: Outcomes: Evaluations: PRIORITY#____ (Identify by number and provide brief rationale for your decision) Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms) Assessments: Interventions: Outcomes: Evaluations: COMMENTS/HISTORY/REVIEW (Include a review of any significant medical history, prenatal diagnoses, delivery complications, family adjustment, involvement of partner/father, support system, developmental phase of family) DISCHARGE NEEDS/PLAN: (Are there identified problems or barriers to discharge? What are the needs at home after discharge? Resources? Discuss involvement of social work, home visits or referrals) 20 North Seattle Community College NEO 114 Antepartum Nursing Care Plan: Student: ____________________________________________________________ Date: _________________ Date of Patient Admission:_______________ PATIENT INFORMATION Pt initials/identification: Age: Gravida: Para: Ab: LC: Allergies: EDD: Current Gestational Age: Birth Plan: Anticipated Feeding Method: V.S. LABS AND DIAGNOSTIC TESTING (Include dates; indicate if abnormal values, implications) Rh and type: Hct: Rubella: Hgb: HBsAG: GDM Screening: GBS: HIV: Ultrasounds: Antibody Screen: Other: MEDICATIONS (Include all medications during current hospitalization) Name of Drug Dosage/Route/Frequency Indication Generic &Trade Effectiveness/ Side effects 21 North Seattle Community College NEO 114 SYSTEMS/MATERNAL ASSESSMENT Cardiovascular:(include VS, heart rhythm, postruals prn, edema, pulses, Homan’s sign, activity tolerance hx c/v problems, HTN) Respiratory: (RR, breath sounds,O2 sats, ?cough, Hx asthma, smoking in household?) Neurologic: Pain Status, Sleep/Rest Patterns (also consider communication barriers, sensory deficits) GI: (include wt. or BMI, wt gain through pregnancy, bowel sounds, appetite, hx eating disorders, dietary restrictions?, last BM, hemorrhoids, usual bowel habits) GU: (include bleeding, bladder, dysuria, discharge) Integument: (include hygiene, perineum, IVs, rashes) Endocrine: (consider thyroid, diabetes, hx.infertility) Psychosocial/Cultural: (role adaptations, family interaction, emotional state & perceptions, cultural/religious practices/traditions, language barriers, alternative or complimentary health practices, home environment, support, resources): Other: 22 North Seattle Community College NEO 114 1. Describe past medical/obstetrical history and prenatal diagnoses that may have contributed to present risk factors for antepartum hospitalization. 2. What interventions have taken place? Also provide rationale for each intervention. 3. What information did you gain by reviewing the fetal monitor? (Use NICHD terminology for baseline, variability, acceleration, decelerations). If early gestation, ultrasound monitor may not be used for FHTs, describe the uterine contraction pattern. 4. Review implications of lab work, ultrasound reports, and/or any other diagnostic modalities for this client. 5. What teaching needs does this client have and how would you present this information to her? 6. Summarize the care you gave to this client during her hospitalization. 23 North Seattle Community College NEO 114 NURSING DIAGNOSIS/ PROBLEM LIST IN PRIORITY ORDER: PRIORITY#____ (Identify by number and provide brief rationale for your decision) Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms) Assessments: Interventions: Outcomes: Evaluations: PRIORITY#____ (Identify by number and provide brief rationale for your decision) Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms) Assessments: Interventions: Outcomes: Evaluations: PRIORITY#____ (Identify by number and provide brief rationale for your decision) Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms) Assessments: Interventions: Outcomes: Evaluations: COMMENTS/HISTORY/REVIEW (Include a review of any significant medical history, prenatal diagnoses, family adjustment, involvement of partner/father, support system, developmental phase of family) DISCHARGE NEEDS/PLAN: (Are there identified problems or barriers to discharge? What are the needs at home after discharge? Resources? Discuss involvement of social work, home visits or referrals) CLINICAL EVALUATION OF STUDENTS 24 1. Clinical Evaluation Grading is based on the attached form with the point scale of 1-4 for each category each clinical day. a. Each student receives a formal, written clinical performance evaluation from the instructor. The written clinical evaluation measures the student’s performance of the course objectives, outlines strengths and weakness, and makes appropriate recommendations for improvement if necessary. Students in danger of failing will receive a Learning Agreement, which remains in the student file until graduation from the program. (See Section VII for the Learning Agreement) b. The student must sign the evaluation to show that he/she has read the evaluation. If the student does not agree with the instructor’s evaluation he/she may make comments on the document. A copy will be given to the student. (See Clinical Evaluation Objectives/Clinical Evaluation in Appendix) c. Clinical performance will be evaluated on a daily basis. If the student is deemed unsafe, a Learning Agreement will be issued and the student will plan for improvement with the instructor. If the safety issue continues, the student will meet with the faculty and administration to discuss the student’s ability to progress in the program. Performance evaluations will be written by the instructor, reviewed by the student, and MUST be signed as evidence of having been read. The student will receive a copy. Students may write a response to instructor’s anecdotal notes. 25 EDUCATIONAL OBJECTIVES Educational Objective: To develop a basic level of understanding and communication for different obstetrical patients Definitions: Mastery = student is able to complete a skill with minimal cueing from the instructor. Competency = student is able to complete skill with some cueing (no more than 1-2 reminders) from the instructor Student needs > 2 reminders from the instructor Student is unable to perform skill or unable to perform skills at mastery level with mastery requirement (skills designated with *) The student demonstrates 1. Application of the nursing process in skills demonstrations: a. Verbalizes necessary assessment prior to skill b. Verbalizes the goal and /or rationale for the skill c. Accurately identifies the client and introduces self d. Implements the plan of care by performing the skill with proficiency e. Evaluating the outcome of care plan f. Modifying the plan of care to reflect the diverse needs of the client g. Reports outcomes and findings to the appropriate person h. Documents care given according to standards 2. Ability to organize client care and self by: a. Completing all care within allotted time b. Establishing appropriate priorities for care c. Conserving supplies 3. Ability to adapt to change by: a. Adapting to new clinical scenarios b. Adapting care for individual client needs c. Responding in a positive way to constructive criticism 4. Professional and therapeutic communication skills by: a. Using correct medical terminology in all verbal and written communication b. Demonstrating legible handwriting, correct spelling and grammar in all written work c. Protecting client confidentiality at all times d. Demonstrating the ability to interact professionally with peers and instructors e. Demonstrating the ability to interact with diverse populations 26 5. * Demonstrate application of microbiological principles by: a. Following infection control procedures b. Hand washing c. Using surgical and medical asepsis correctly d. Following standard and transmission based precautions e. Following disinfection and cleaning techniques f. Safely collecting specimens for testing 6. Demonstrates knowledge of NANDA Nursing Diagnoses 7. Demonstrates knowledge of and ability to obtain a thorough physical assessment in the clinical setting 8. Demonstrates knowledge and understanding of a variety of medications, the medication classification, what symptoms or disorders each medication is commonly used to treat, the intended medication effect, common and serious side effects and contraindications. 9. Demonstrates knowledge of the Nursing Process in planning the care of clients from diverse cultures while in the labor and delivery and postpartum clinical setting. 10. Demonstrates knowledge of the Nursing Process in formulating appropriate discharge goals/discharge plans for labor and delivery and postpartum clients in the clinical setting. 27 NEO114: FAMILY NURSING CLINICAL OB CLINICAL EVALUATION SUMMARY STUDENT ____________________ INSTRUCTOR __________________ LOCATION _ NWHMC __________ DATES: FROM _______ TO _______ ABSENCES ____________ TARDIES _________ Clinical Day: 1 2 AVERAGE: CLIENT CARE: SAFETY INFECTION CONTROL & UNIVERSAL PRECAUTIONS PREPARATION SKILLS APPLICATION PRIORITIZATION& ORGANIZATION NURSING PROCESS: HEALTH ASSESSMENT PROBLEM IDENTIFICATION & NURSING DIAGNOSIS PLANNING &IMPLEMENTATION RELATING INFORMATION EVALUATION & FOLLOW-UP DOCUMENTATION: DOCUMENTATION OF PATIENT DATA & CARE ASSIGNMENTS & CLINICAL DAILY SHEETS COMMUNICATION: COMMUNICATION SKILLS FEEDBACK PROFESSIONAL BEHAVIOR: PROFESSIONAL BEHAVIOR & RESPONSIBILITY TOTAL POINTS: _____ 53-60= MEETS EXPECTATIONS CONSISTENTLY WITHOUT PROMPTS/REMINDERS 45-52= MEETS EXPECTATIONS CONSISTENTLY WITH PROMPTS/REMINDERS 37-44= MEETS EXPECTATIONS INCONSISTENTLY WITH PROMPTS/REMINDERS <37 = DOES NOT MEET EXPECTATIONS <77% (FAIL) 28 ______________NORTH SEATTLE COMMUNITY COLLEGE___________________ NEO 114: CLINICAL EVALUATION OBJECTIVES EVALUATION OBJECTIVES I. CLIENT CARE: SAFETY INFECTION CONTROL & UNIVERSAL PRECAUTIONS PREPARATION DESCRIPTION Demonstrate safe patient care within the childbirth center and pediatric setting Maintain a safe environment for self and patients. (Examples: side rails up, bed low & locked, transfers, fall prevention, patient identification, rights of medication administration, disposal of sharps) Demonstrate understanding of infection control and universal precautions in delivery of patient care within the childbirth center and pediatric setting Adheres to infection control precautions. Applies appropriate PPE for care and procedures. Demonstrates competency in use of aseptic & sterile technique for care and procedures. Disposal of waste in accordance to facility policy and procedure. Demonstrate initial understanding of data gathering within the childbirth center and pediatric setting Research patient diagnoses, medications, treatments, labs. Review medical record for patient history, labs, medications and physician orders. Review skills manual and/or facility policy and procedure prior to treatments and procedures. Review physician order and gather supplies for treatments and procedures. SKILLS APPLICATION Demonstrate competency in skills within the childbirth center and pediatric setting Demonstrate competency in skills learned in NUR 117 & NUR 118. Performs skills and procedures with attention to patient safety. PRIORITIZATION & ORGANIZATION OF CARE Demonstrate prioritization & organization of care for assigned patients within the childbirth center and pediatric setting Plan care for the shift; Adjust plan of care as needed; Prioritize tasks and care for assigned patients; Seek assistance as needed. Complete care and documentation for assigned patients in timely manner. Collaborate with members of the health care team to meet patient needs. Demonstrate initial understanding of health assessment including newborn, pediatric, labor & delivery, postpartum and parenting patient population Complete head to toe physical assessment of assigned patients. HEALTH ASSESSMENT 29 Collect patient history data from medical record and/or patient. Perform psychosocial assessment. Review lab work and diagnostic test results. Compare assessment findings to patient baseline. PROBLEM IDENTIFICATION & NURSING DIAGNOSIS Demonstrate initial understanding of problem identification for the newborn, pediatric, labor & delivery, postpartum and parenting patient population Identify significant patient problems and provide nursing care that reflects an understanding of those problems. Identify at least two significant nursing diagnoses for assigned patients. Write NANDA nursing diagnoses in correct format. PLANNING & IMPLEMENTATION Demonstrates initial understanding of planning and implementation of care for the newborn, pediatric, labor & delivery, postpartum and parenting patient population Reviews plan of care and implements interventions and basic nursing care to assist assigned patients in meeting outcomes. RELATING INFORMATION Demonstrate use of quantitative reasoning processes to understand, analyze, interpret and solve problems for the newborn, pediatric, labor & delivery, postpartum and parenting patient population Access, evaluate and apply information from a variety of sources and a variety of contexts. Identify significant and relevant assessment findings and relate these to the plan of care and implementation of interventions. EVALUATION & FOLLOW-UP Demonstrate initial understanding of evaluation of patient health status and response to interventions for the newborn, pediatric, labor & delivery, postpartum and parenting patient population Identify and follow up with abnormal physical assessment findings. Identify and follow up with abnormal vital signs, lab and/or diagnostic test results. Evaluate and follow up with patient response to treatments and interventions. II. DOCUMENTATION DOCUMENTATION OF PATIENT DATA & CARE Demonstrate initial understanding of documentation within the childbirth center and pediatric setting Document holistic care of the newborn, pediatric, labor & delivery, postpartum and parenting patient population within the scope of the practical nurse. Document relevant patient assessment data, nursing care, medications and treatments objectively and accurately in patient charts (paper and/or electronic). Document data in timely manner and according to 30 CLINICAL DAILY SHEETS & ASSIGNMENTS III. COMMUNICATION COMMUNICATION SKILLS FEEDBACK IV. PROFESSIONAL BEHAVIOR & RESPONSIBILITY facility policy and procedure. Demonstrate daily clinical sheets accurately Assignments and clinical daily sheets are completed according to instructions and turned in to instructor on due date. Assignments and clinical daily sheets are detailed and thorough showing evidence of understanding the patient condition, medications, treatments, labs and nursing care) Demonstrate effective communication with patients and the health care team Reports changes in patient health status, abnormal vital signs, lab values and assessment findings to nurse preceptor and clinical instructor in a timely manner. Use effective interpersonal communication skills with patients, families and members of the health care team. Provide education to patients, families and members of the health care team with focus on health promotion. Identify patients’ health beliefs, knowledge level, and learning styles and incorporate these into the provision of education. Deal constructively with information, ideas, and emotions associated with such issues of diversity and conflict as culture, ethnicity, race, gender, religion, age, sexual orientation and abilities. Seek, accept and utilize feedback to improve professional behavior and skills. Respond positively to staff and/or instructor feedback and exhibit recommended behaviors. Response to feedback is positive & part of recommended behaviors exhibited (-1 point) Response to feedback is negative & part of recommended behaviors exhibited (negative compliance) (-2 points) Response to feedback is positive or negative but recommended behaviors not exhibited (zero points) Response to feedback is hostile or aggressive behavior is exhibited (zero points) Demonstrate and exhibit professional behavior in the learning environment Adhere to established policies of the NSCC nursing program and of the clinical facility. (EX: Dress code; Confidentiality (HIPPA); Attendance & punctuality; Professional behavior; Student responsibilities & limitations). Accept responsibility for own actions and behaviors. Holistically care for self, others, and community within an ethical, legal and diverse framework within the scope of practice of the LPN. 31 ____NORTH SEATTLE COMMUNITY COLLEGE_________________________ NOE 114 EVALUATION TOOL SCORING Directions: Each of the clinical objectives is scored on each clinical day using the following point scale* 4- Student meets expectations (objectives) consistently by performing previously learned tasks and providing client care with no prompting or reminders and performing newly learned tasks and client care with 1 reminder or prompting given throughout the shift. 3- Student meets expectations (objective) consistently by performing previously learned tasks and providing client care with no prompting or reminders and performing newly learned tasks and client care with 2 occasional reminders or prompting given throughout the shift. 2- Student meets expectations (objectives) inconsistently by performing previously and newly learned tasks and client care with 3 reminders or prompting given throughout the shift. 1- Student does not meet expectations (Objective). Student is unable to perform previously or newly learned tasks and provide client care unless provided with more than 3 reminders and/or step-by-step instruction from instructor. N/A- No opportunity to observe *Note: Partial points (ie. 0.5 or 0.25) may be given. Any score of <2 requires a separate anecdotal note to be written and placed with the student’s evaluation. The instructor should meet with the student to discuss the anecdotal note & inform the student of inconsistency in meeting the clinical objectives. The clinical expectations and objectives should be reinforced and the student assisted in forming a plan to meet those objectives. If during any clinical day or week the student receives a total of <37 points, the student may be dismissed immediately from the clinical rotation. This indicates that the student is not safe in the clinical setting. 32 CLINICAL EVALUATION OF SITE AND INSTRUCTOR 1. The following forms will be given to the clinical groups in the classroom at the end of the quarter. a. CLINICAL SITE EVALUATION Students are expected to evaluate the clinical sites after their rotation. Classroom instructors will administer these evaluations. See form in Appendix. b. CLINICAL INSTRUCTOR/PRECEPTOR EVALUATION Students are expected to evaluate the clinical instructors/preceptors after their rotation. Classroom instructors will administer these evaluations. NORTH SEATTLE COMMUNITY COLLEGE 33 NEO 114 CLINICAL EVALUATION This is the OB evaluation for NEO 114 (50%) CLINICAL GRADE: ______________________ ________________________________ INSTRUCTOR SIGNATURE ________________ DATE (Signature indicates that you have reviewed this document with the student and provided an opportunity for the student to read the document and ask questions) ________________________________ STUDENT SIGNATURE ________________ DATE (Signature indicates that you have read this document and been offered the opportunity to ask questions) COMMENTS 34 NORTH SEATTLE COMMUNITY COLLEGE NEO 114 Pediatric CLINICAL EVALUATION This is the final evaluation for NEO 114. CLINICAL GRADE OB (50%): ______________________ CLINICAL GRADE Pediatric (50%):___________________ Final Grade:______________ ________________________________ INSTRUCTOR SIGNATURE ________________ DATE (Signature indicates that you have reviewed this document with the student and provided an opportunity for the student to read the document and ask questions) ________________________________ STUDENT SIGNATURE ________________ DATE (Signature indicates that you have read this document and been offered the opportunity to ask questions) COMMENTS: