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RANGER COLLEGE Syllabus COURSE NUMBER AND TITLE: RNSG 2562 – Clinical Nursing – Registered Nurse Training CREDIT HOURS: _5_ HRS/WK LEC: _0_ HRS/WKLAB:_15_ LEC/LAB/HRS/WK COMBINATION: _15_ Name of Instructor:______________ Office Location:________________Office Hours:__________ Office Phone:__________________ College E-Mail_________________ I. CATALOG DESCRIPTION A health-related work-based experience that enables the student to apply specialized occupational theory, skills, and concepts. Direct supervision is provided by the clinical professional. Utilizes assessment skills, critical thinking, and independent nursing intervention to care for individuals experiencing acute/chronic episodes of illness and/or multi-system failure. Focus is on caring, health promotion, health restoration and professional values within a legal/ethical framework. Emphasis is on collaborative clinical decision-making, nursing leadership, skills, and client management in the delivery of nursing care. Content includes applicable competencies in basic workplace skills. II. REQUIRED BACKGROUND/PREREQUISITES Program Prerequisites: PSYC 2301 Introduction to Psychology ENGL 1301 Composition I BIOL 2302 Anatomy and Physiology I BIOL 2420 Microbiology and Clinical Pathology COSC 1401 Computer Applications Semester I Courses: RNSG 1423 Introduction to Professional Nursing RNSG 1460 Clinical-Nursing (RN training) RNSG 1119 Nursing Skills I BIOL 2402 Anatomy and Physiology II PSYC 2314 Lifespan Growth and Development Semester II Courses: RNSG 2504 Care of Client with Common Health Needs RNSG 1129 Nursing Skills II RNSG 1461 Clinical-Nursing (RN training) RNSG 1311 Nursing Pathophysiology Semester III Courses: RNSG RNSG XXXX 2514 2560 xxxx Care of Client with Complex Health Needs Clinical-Nursing (RN training) Humanities/Fine Arts Elective* III. TEXTBOOK (S); READINGS; MATERIALS (See information under required texts in RNSG 2535) Uniform - see Clinical Attire in Undergraduate Nursing Handbook. Bandage scissors, watch, stethoscope, and penlight. IV. METHODS OF INSTRUCTION Lecture, discussion, audio-visual materials, clinical experiences V. COURSE OBJECTIVES As provider of care, the student will have the opportunity to: 1. Respond to signs/symptoms and adaptive behaviors to clients in the acute care settings 2. With minimal supervision safely administer care to a minimum of clients in the acute care settings, including: pediatric, maternal, psychiatric, and adult medical/surgical. 3. Formulate a specific care plan according to relevant nursing diagnosis with outcomes for the clients in the acute care settings. As coordinator of care, the student will have the opportunity to: 1. 2. 3. 4. Explore the structure, function and interdisciplinary relationships within the clinical facility. Identify cultural and spiritual needs of the clients and families in the acute care settings. Identify appropriate resources to assist the clients in the acute care settings. Demonstrate the ability to effectively communicate, as a member of the interdisciplinary team, verbally and in writing. 5. Identify specific problems involving professional issues and discuss ways to alleviate, cope or seek help with legal and ethical concerns. 6. Review ethical/legal process related to the care of clients with complex healthcare needs. 7. Examine issues and trends in delivery of care for clients/families with complex healthcare needs and available community resources As a member of the profession, the student will have the opportunity to: 1. Demonstrate professional behavior in nursing practice. 2. Recognize behaviors that support advocacy for clients with complex health care needs. 3. Explore peer review and quality improvement processes in acute care facilities. VI. COURSE CALENDAR Content Outline Readings/Class Preparation Objectives Week 1 On-Campus Clinical Week 2 Clnical Orientation Week 3 Clinical experience in acute care setting Week 4 Clinical experience in All course objectives All course objectives Learning Activities acute care setting Week 5 Clinical experience in acute care setting Week 6 Clinical experience in acute care setting Week 7 Clinical experience in acute care setting Week 8 Clinical experience in acute care setting Week 9 Clinical experience in acute care setting Week 10 Clinical experience in acute care setting Week 11 Clinical experience in acute care setting Week 12 Clinical experience in acute care setting Week 13 Clinical experience in acute care setting All course objectives All course objectives All course objectives All course objectives All course objectives All course objectives All course objectives All course objectives All course objectives Week 14 Clinical experience in acute care setting All course objectives Week 15 Clinical experience in acute care setting All course objectives Week 16 VII. COURSE/CLASSROOM POLICIES 1. Attendance/Lateness It is imperative that students attend lecture, clinical, and laboratory experiences as scheduled. A week’s worth of cumulative absences in any one course will result in faculty evaluation of the student’s ability to meet course objectives and may result in failure of the course. Three tardies (over 5 minutes late for lecture, campus laboratory, or clinical) will equal 1 hour of absence. 2. Class Participation Students are expected to take an active role in the learning experience. 3. Missed Exams/Assignments/Make-Up Policy A student not present to take an assigned nursing examination may receive a grade of zero for that examination. A student may be allowed to make-up an examination under the following circumstance: a. Absence is due to serious illness/hospitalization of the student or an *immediate family member. Documentation by a health care provider will be required at the time the student requests a make-up exam for the day they were ill. b. Absence is due to a death in the *immediate family. Documentation will be required. c. An absence the faculty and/or Department Head deems as unavoidable. *Immediate – family member living in the same household or outside household totally dependent on the student for care such as a spouse, parent, child, sibling, grandparent or grandchild. To be eligible for a make-up exam in the above circumstances, the student must notify their instructor prior to the absence, and must make arrangements within 48 hours after the absence for the retake. Faculty have the right to offer an alternative form of the exam and/or to deduct up to 10 points from the exam grade. Clinical/Skills Lab Absences During Exam Week: A student who is absent from clinical or skills lab up to 48 hours preceding an assigned nursing examination must present documentation from a health care provider at the time of the exam in order to be eligible to take the test. Students without this documentation will not be allowed to take the exam and thus will receive a grade of “0”. The student must see a health care provider on the day of the absence with the excuse dated accordingly. Documentation (excuses) dated after the date of the clinical absence will not be accepted. Faculty has the right to offer an alternate form of the exam and/or to deduct up to 10 points from the exam grade. Online Testing: Exams in online courses are always considered an independent student activity – NOT a group activity (unless otherwise indicated by your course instructor.) Students are expected to take exams alone and not in a study group. This means that you cannot refer to your textbook or any other materials while you are taking the exam. It is inappropriate to share answers with other students. It is inappropriate to talk to other students while you are taking the test. Students who do not follow the honor code will be subject to disciplinary action. 4. Lab and clinical safety/health Learning Lab Center The primary objective of the Ranger College Learning Lab Center is to promote excellence in clinical learning through low to medium fidelity lab experiences learning/teaching for students and faculty by providing an environment to evaluate basic and advanced skills/behaviors. CLINICAL LAB POLICIES • Students are never to discuss events or scenarios occurring during lab clinical simulation experiences except during debriefing sessions. “What happens in clinical simulation during lab stays in clinical simulation during lab…” There is zero tolerance for academic dishonesty. • Students are to dress for lab as if attending clinical. Scrubs, name badges and uniform policies are enforced. • Faculty are responsible for supervising all students brought to the lab for training. • Universal Precautions are to be followed at all times as are all safety guidelines used in the clinical setting. Sharps and syringes are to be disposed of in appropriate containers. Anyone sustaining an injury must report it immediately to their instructor. • Equipment may not be removed from the lab for practice nor are the labs to be used for practicing clinical skills unless supervised by faculty or staff. • Students may be recorded during scenarios. Viewing of videos recorded during training are only permitted with faculty members. The videos are the property of the nursing program and students may not possess lab videos r recordings. • Coats, backpacks and other personal belongings are not to be in the lab during clinical simulation and should be secured as directed by the instructor. • All electronic devices are forbidden during clinical experiences during lab. (Cell phones, pagers, any type of recording device, etc.). • After a simulation take your personal belongings with you (i.e. papers, pens, stethoscopes, pen lights etc.). • Food and drink are not permitted in the labs. • If you have a latex allergy, inform your instructor before beginning simulation. • Makeup days may not be available for students absent the day of simulation. Standard Precautions The Center for Disease Control and Prevention (CDC) Recommended Standard Precautions are outlined below. It is the student’s responsibility to maintain compliance with these recommendations in all clinical settings. Standard Precautions Because the potential diseases in a patient’s blood and body fluids cannot be known, blood and body fluid and substance precautions recommended by the CDC should be adhered to for all patients and for all specimens submitted to the laboratory. These precautions, called “standard precautions,” should be followed regardless of any lack of evidence of the patient’s infection status. Routinely use barrier protection to prevent skin and mucous membrane contamination with: a. secretions and excretions, except sweat, regardless of whether or not they contain visible blood b. body fluids of all patients and specimens c. non-intact skin d. mucous membranes Hand Hygiene a. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn and/or immediately prior to any client interaction or nursing intervention. Perform hand hygiene immediately after gloves are removed, between patient contacts and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross contamination of different body sites. b. Use a plain (non-antimicrobial) soap for routine hand washing. c. Use an antimicrobial agent or waterless antiseptic agent for specific circumstances (e.g., control of outbreaks or hyperendemic infections) as defined by the infection control program. Gloves Wear gloves (clean non-sterile gloves are adequate) when touching blood, body fluids, secretions, excretions and contaminated items. Put on clean gloves just before touching mucous membranes and non-intact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another patient. Perform hand hygiene immediately to avoid transfer of microorganisms to other patients or environments. Mask, Eye Protection, Face Shield Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Gown Wear a gown (a clean nonsterile gown is adequate) to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions or cause soiling of clothing. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other patients or environments. Patient Care Equipment Handle used patient care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocesses and single use items are properly discarded. Environmental Control Ensure that the hospital has adequate procedures for the routine care, cleaning and disinfection of environmental surfaces, beds, bed rails, bedside equipment and other frequently touched surfaces and that these procedures are being followed. Linen Handle, transport, and process used linen soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing and avoids transfer of microorganisms to other patients and environments. Occupational Health and Blood-borne Pathogens a. Take care to prevent injuries when using needles, scalpels and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments and when disposing of used needles. Never recap used needles or otherwise manipulate them with both hands or any other technique that involves directing the point of a needle toward any part of the body; rather, use either a one-handed scoop technique or a mechanical device designed for holding the needle sheath. Do not remove used needles from disposable syringes by hand and do not bend, break or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades and other sharp items in appropriate puncture-resistant containers located as close as practical to the area in which the items were used. Place reusable syringes and needles in a puncture resistant container for transport to the reprocessing area. b. Use mouthpieces, resuscitation bags or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable. Patient Placement Place a patient who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control in a private room. If a private room is not available, consult with infection control professionals regarding patient placement or other alternatives. Student Occurrence Any student involved in a clinical occurrence (e.g. needle stick, patient or student fall/injury, medication error, etc.) must adhere to the following protocol for reporting the occurrence: 1. Notify the nurse responsible for the patient immediately. 2. Notify the clinical instructor, preceptor and/or faculty member as quickly as possible after the occurrence happens. The clinical instructor, preceptor & faculty will provide information on appropriate actions to be taken. 3. Notify the charge nurse. 4. Be prepared with details necessary for filling out a report and to sign the report as a witness or the person responsible for the occurrence. 5. Meet any Ranger College or facility policy regarding occurrences. 5. Academic Dishonesty Nursing students are expected to maintain an environment of academic integrity. Actions involving scholastic dishonesty violate the professional code of ethics and are disruptive to the academic environment. Students found guilty of scholastic dishonesty are subject to disciplinary action including dismissal from the Associate Degree Nursing Program and Ranger College in accordance with outlined criteria. Examples of scholastic dishonesty include, but are not limited to: CHEATING: Copying from another student’s test. Possessing or using, during a test, materials which are not authorized. Using, buying, stealing, transporting, or soliciting a test, draft of a test, test facsimile, answer key, care plans, or other written works. PLAGIARISM: Using someone else’s work in your academic assignments without appropriate acknowledgment. COLLUSION: Collaborating with another person in preparing academic assignments without authorization. Procedures for discipline due to academic dishonesty have been adopted and published Ranger College Student Handbook. 6. Student Behavior Policy Students are expected to observe the following guidelines for classroom behavior: 1. Neither children nor pets may be brought to classes or clinical agencies under any circumstance. Children must not be left unattended in any area of the building. 2. All buildings housing the Associate Degree Nursing Program are nonsmoking facilities. 3. No food or drinks are allowed in classrooms. 4. Students are expected to be seated by the designated starting time for classes. 5. A student deemed disruptive by a faculty member may be asked to leave the classroom. 6. Cell phones must be turned off during class or lab. Pager/beepers, if used, must be set on silence during class or lab. Messages received during lecture may be returned during class breaks. 7. Respectful, formal communication skills are used in online forums. 7. Available Support Services Library facilities are available at the main Ranger campus, the Heartland Mall center, and the Brownwood Public Library. Reference materials are also available via online as well. 8. ADA Statement: Ranger College provides a variety of services for students with learning and/or physical disabilities. The student is responsible for making the initial contact with the Ranger College Counselor. It is advisable to make this contact before or immediately after the semester begins. VIII. ASSESSMENT The grading system used in this course, RNSG 2652 is: P (pass), F (fail), NC*, W *Note: RNSG 2535 and RNSG 2562 must be successfully completed simultaneously to receive credit in either course and graduate. See Undergraduate Nursing Student Handbook for UNSATISFACTORY & UNSAFE Clinical Performance. Satisfactory Completion of written assignments. GUIDELINES FOR ASSIGNMENTS: 1. Patient flow sheets on 2-3 patients with 2 NCPs for PRIORITY Nursing Diagnosis on each. 2. 1 Case Study: ICU IX. NON-DISCRIMINATION STATEMENT – Admission, employment, and program policies of Ranger College are non-discriminatory in regard to race, creed, color, sex, age, disability, and national origin. X. RECEIPT OF SYLLABUS FORM ALL STUDENTS MUST COMPLETE THE FOLLOWING RECEIPT OF SYLLABUS FORM AND RETURN IT TO THE INSTRUCTOR RECEIPT OF SYLLABUS FORM (Required of all students and filed by the instructor) Legibly print the following information: Name:__________________________ Date:___________________________ “I have received and understand the information in the syllabus for RNSG 2562 and I agree to abide by the stated policies.” Signature of Student: _____________________________ APPENDICES NURSING CARE PLAN FORMAT Patient’s Initials_____________ Dates of Care__________________________ Student’s Name____________________________________ NURSING DIAGNOSIS (validate with subjective and objective data) (reference) PLANNING: Outcome Criteria THE CLIENT WILL...... NANDA Problem - NURSING INTERVENTIONS (with scientific rationale and reference) EVALUATION 1. (SR) 2. RT (SR) 3. (SR) As Evidence by 4 (SR) S. 5. (SR) O. (Author, page) (OUTCOMES) AASN NURSING CARE FLOW SHEET Student’s Name Pt’s Initials Instructor Ht Dates of Care Wt HISTORY(Psycho-Socio-Economic): Room Age M/F Current Date Allergies CHIEF COMPLAINT: LAB STUDIES (results & ranges): ADMITTING DIAGNOSIS: MEDICAL HISTORY: MEDICATIONS: SURGICAL PROCEDURES: DIET: ACTIVITY: TREATMENTS NURSING DIAGNOSES (2): DIAGNOSTIC TESTS Include ALL diagnostic tests for this condition. Highlight the ones that are abnormal. PATHOPHYSIOLOGY Etiology Risk Factors SIGNS & SYMPTOMS Include ALL s/s for this condition. Highlight the ones that pertain to your patient. Pathophysiology Reference: _________________________________________________________________________________________________________________ NAME _____________________________________________ REFERENCES: ____________________________________________________ GUIDE FOR EVALUATING LAB DATA LAB DATA EXAM EXAM PATIENT VALUES NORMAL VALUES d INTERPRETATION & NURSING CONSIDERATION GUIDELINES FOR NURSING CASE STUDY (ICU) REQUIREMENTS: 1. Complete assigned case study by due date. 2. If a student receives an “Unsatisfactory” on a case study, they have one opportunity to resubmit in 1 week or 7 days a revised case study. 3. The instructor will provide written feedback on the case study - within 10 days after they are received. 4. If a personal emergency or illness occurs, the student may negotiate with the instructor for a later due date. If not completed, the late case study work will be marked “Unsatisfactory”. GUIDELINES: (see attached for Nursing Case Study Evaluation Tool) The student is to base the case study on an assigned patient/topic - but the case study needs to be in-depth and cover a unit of study area. Problems or complications are to be addressed even if not a problem for your patient. DATA COLLECTION: Use of the narrative format for writing data. NURSING DIAGNOSIS: 1. Please use standardized diagnosis where possible. If no appropriate diagnosis found, may create your own. 2. At least four nursing diagnoses are to be done. One must be psychosocial. The NCP is to be completed on each. OUTCOMES: Outcomes need to be patient centered, behavioral stated and measurable. Be aware that these are patient outcomes, not nursing outcomes. INTERVENTIONS AND RATIONALE: 1. Interventions that are individualized will be different than those found verbatim in a textbook. 2. All Nursing interventions specific to medical-surgical nursing need to be supported by a scientific rationale. The rationale must come from a reference source or lecture. Please state page numbers and book of reference. NO PAPER WILL BE SATISFACTORY WITHOUT THIS DOCUMENTATION. 3. List all references actually used for the case study in a reference list. GUIDELINES FOR NURSING CASE STUDY – (Cont.) 4. The student is strongly encouraged to use reference sources such as journal articles in addition to textbooks. 5. Teaching plans should be included as interventions wherever appropriate. EVALUATION: (Med-Surg evaluation criteria) All Case Studies should include the following: 1. APA format cover sheet (title page) APA format for paper. (Pathophysiology) 2. Proper NCP format from the present syllabus. 3. Be placed in a secure folder or binder. 4. Address Current Diagnosis textbook pathophysiology etiology risks common signs/symptoms major potential complications usual treatment/management 5. Surgical Procedures textbook explanation etiology risks common signs/symptoms major potential complications usual treatment/management 6. Appendices may be used for treatments, diagnostics, and medications. Use the format from present syllabus for the appendices. 1.AMETHODS discharge plan is to be used & may also be an appendix. WRITTEN ASSIGNMENTS ARE DUE ONE WEEK AFTER CLINICAL EXPERIENCE MUST ACHIEVE SATISFACTORY. *STARS INDICATE CRITICAL DATA MED-SURG EVALUATION CRITERIA STUDENT Biographical Data Past Medical History Present Medical History *Pathophysiology *Physical Assessment Medications (Form in syllabi) Treatments (Form) Lab Data (Form) Diagnostic Exams (Form) FORMAT (at least 4) *DX - Stated Correct *ID - Subj/Obj Data * OUTCOME CRITERIA ACTIONS - *Performed *SR c Ref *Evaluation must be included *INDIVIDUALIZES CP *INCL. PSYCOSOC DX *DISCHARGE PLAN METHODS (Form) *PATIENT TEACHING *NEATNESS/LEGIBLE (APA, Spelling, Grammar) *SUPPORTING NURSING ARTICLE REFERENCE ICU CASE STUDY CASE STUDY Redo by: DIAGNOSTIC PROCEDURES/EXAMS: (anything other than lab work that is done to diagnose the client’s problem, evaluate the effectiveness of treatment or to evaluate new findings or problems) EXAM (name it and explain what it is) __________________________________________________________________________________________ __________________________________________________________________________________________ USE/PURPOSE FOR THIS CLIENT: __________________________________________________________________________________________ NURSING IMPLICATIONS: (assessments to make, precautions, teaching) Results: EXAM (name it and explain what it is) __________________________________________________________________________________________ __________________________________________________________________________________________ USE/PURPOSE FOR THIS CLIENT: __________________________________________________________________________________________ NURSING IMPLICATIONS: (assessments to make, precautions, teaching) Results: EXAM (name it and explain what it is) __________________________________________________________________________________________ __________________________________________________________________________________________ USE/PURPOSE FOR THIS CLIENT: __________________________________________________________________________________________ NURSING IMPLICATIONS: (assessments to make, precautions, teaching) Results: Name _______________________________ TREATMENTS: (anything ordered for client other than medications or evaluative exams) TREATMENT: (name it and explain what it is) __________________________________________________________________________________________ __________________________________________________________________________________________ USE/PURPOSE FOR THIS CLIENT: __________________________________________________________________________________________ NURSING IMPLICATIONS: (assessments to make, precautions, teaching) TREATMENTS: (anything ordered for client other than medications or evaluative exams) TREATMENT: (name it and explain what it is) __________________________________________________________________________________________ __________________________________________________________________________________________ USE/PURPOSE FOR THIS CLIENT: ___________________________________________________________________________________ NURSING IMPLICATIONS: (assessments to make, precautions, teaching) TREATMENTS: (anything ordered for client other than medications or evaluative exams) TREATMENT: (name it and explain what it is) __________________________________________________________________________________________ __________________________________________________________________________________________ USE/PURPOSE FOR THIS CLIENT: __________________________________________________________________________________________ NURSING IMPLICATIONS: (assessments to make, precautions, teaching) PATIENT NAME: DIAGNOSIS MEDICATION TIME/DOSE/ RATIONALE FOR SIDE EFFECTS ROUTE THIS PATIENT TRADE CLASSIFICATION GENERIC TRADE CLASSIFICATION GENERIC TRADE CLASSIFICATION GENERIC TRADE CLASSIFICATION GENERIC TRADE CLASSIFICATION GENERIC ALLERGIES: NURSING INTERVENTIONS __________________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ __________________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ __________________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ __________________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ __________________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ DISCHARGE PLANNING GUIDE At or shortly after admission of the patient (during the assessment phase), it is the nurse’s responsibility to begin a discharge plan. These plans are based upon information obtained on admission and can be revised as necessary as the patient’s condition changes. Include appropriate plan for patient diagnosis and condition. Choose a date for discharge. At a very minimum, these plans should include: A ACTIVITY M MEDICATIONS: The patient is (or will be) taking. Does the patient know what the medication is for; when to take it; how long to keep taking it; what the expected actions of the medications are; and what kind of side effects to watch for? Should the patient request an easy-open container or can he manipulate a “child-proof” one? Written at level of patient understanding, i.e. 3 times a day with medication. E EQUIPMENT: Will the patient require special equipment (i.e., walker, bedside commode, etc.)? Will he need special instructions on how to use it? EXERCISES: Are there any special exercises to be done at home? T TREATMENTS: Does the patient know how to take care of the wound? Will special instruction need to be given to family members? Can the patient return-demonstration any procedure that will be required at home? H HELP: Will the patient need special help at home or can family manage care? If family cannot manage care, should alternative home arrangements (i.e., nursing home, home health) be made? O ORGANIZATIONS: Are community resources needed? If so, have referrals been made to proper person(s)? D S OFFICE VISIT: Does patient know when next office appointment is? Does he have transportation to get there? Does he understand if he needs to have lab or x–rays done before the visit? DIET: Are these any diet modifications needed? Does patient understand diet restrictions? Is consult needed? SAFETY: SEXUAL ACTIVITY: STRESS MANAGEMENT: DISCHARGE PLANNING PT: _________ADMISSION DATE: _________PREDICTED DISCHARGE DATE: ________ Discharged to Home________ Nursing Home_______ SNF:________ Other____________ ACTIVITY: MEDICATIONS: EQUIPMENT: EXERCISES: THERAPIES: HELP: ORGANIZATIONS: OFFICE VISITS: DIET: SAFETY: SEXUAL ACTIVITY: STRESS MANAGEMENT: PATIENT TEACHING: (INCLUDE FAMILY) RANGER COLLEGE BROWN COUNTY CENTER CLINICAL EVALUATION TOOL FOR RN PROGRAM RNSG 2562: CLINICAL IV CLINICAL NURSING – REGISTERED NURSE TRAINING DATE: STUDENT: Upon completion of the clinical experience the learner must have demonstrated mastery of the following competencies. A cumulative score (total of midterm and final scores) of no less than 54 points is required to continue in the nursing program. ALL ITEMS ON THIS COMPETENCY LIST ARE CONSIDERED CRITICAL INDICATORS AND MUST BE MARKED AT LEAST A 2 IN ORDER TO PASS THIS CLINICAL. GRADING SCALE SCALE KEY A = 67 - 80 points 3 = performed independently/minimal assistance and correctly B = 54 – 66 points 2* = required moderate/minimum guidance to perform and minimum correction C = 40 – 53 points 1* = required intensive guidance and/or was unable to perform D =27 – 39 points * = must be accompanied by supporting comments in evaluation tool or through Student Action Plan forms F = Below 26 A. ROLE: PROVIDER OF CARE Mid-term Final Date/Inst Initial Date/Inst Initial Expected Clinical Behavior Circle Number Score 1. Respond to signs/symptoms and adaptive behaviors to clients in the acute care settings 2. With minimal supervision safely administer care to a minimum of clients in the acute care settings, including: pediatric, maternal, psychiatric, and adult medical/surgical. 3. Formulate a specific care plan according to relevant nursing diagnosis with outcomes for the clients in the acute care settings. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 B. Mid-term Final Date/Inst Initial Date/Inst Initial ROLE: COORDINATOR OF CARE Expected Clinical Behavior Circle Number Score 1. Explore the structure, function and interdisciplinary relationships within the clinical facility. 2. Identify cultural and spiritual needs of the clients and families in the acute care settings. 3. Identify appropriate resources to assist the clients in the acute care settings. 4. Demonstrate the ability to effectively communicate, as a member of the interdisciplinary team, verbally and in writing. 5. Identify specific problems involving professional issues and discuss ways to alleviate, cope or seek help with legal and ethical concerns. 6. Review ethical/legal process related to the care of clients with complex healthcare needs. 7. Examine issues and trends in delivery of care for clients/families with complex healthcare needs and available community resources C. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Mid-term Final Date/Inst Initial Date/Inst Initial ROLE: MEMBER OF A PROFESSION Expected Clinical Behavior Circle Number Score 1. Demonstrate professional behavior in nursing practice. 1 2 3 1 2 3 2. Recognize behaviors that support advocacy for clients with complex health care needs. 3. Explore peer review and quality improvement processes in acute care facilities. 1 2 3 1 2 3 1 2 3 1 2 3 Total points for each rotation Mid-term Clinical Grade_________________ Final Clinical Grade____________________ MID-TERM Instructor Comments: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Student Comments: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________ _________________________________ Student Signature Instructor Signature Date Date FINAL Instructor Comments: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Student Comments: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________ _________________________________ Student Signature Instructor Signature Date Date