Blood Administration Lisa Randall, RN, MSN, ACNS-BC RNSG 2432.
RNSG 1263 SYLLABUS SPRING 2010 - Panola CollegeOral Presentation, Silvestri’s, 15% Teaching plan,...
Transcript of RNSG 1263 SYLLABUS SPRING 2010 - Panola CollegeOral Presentation, Silvestri’s, 15% Teaching plan,...
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Course Syllabus
RNSG 1263 – Clinical to Complex Concepts of Adult Health
Revision Date: 5/28/2015
Catalog Description: A health-related work-based learning experience that enables the student to apply specialized occupational theory, skills, and concepts. Direct supervision is provided by the clinical professional. Lecture hours = 0, Lab hours = 2
Prerequisites: RNSG 1205, 1309, 1362, 1441, 1262
Semester Credit Hours: 2
Lecture Hours per Week: 0
Lab Hours per Week: 9
Contact Hours per Semester: 128
State Approval Code: 51.3801
Instructional Goals and Purposes: Students will use the nursing process in providing preventive, restorative, and maintenance/supportive care for adult patients and their families. Nursing care will be provided for specific adult health disorders working from the framework of the nurse as member of the profession, provider of patient-centered care, patient safety advocate, and member of the health care team. Students will also apply concepts of nursing, environment, person and health throughout the course.
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TABLE OF CONTENTS Core Competencies: …………………………………………………………………… 3
Course Outcomes…………………………………………………………………… 3
Teaching Learning Strategies/ Dress Code/ Medication Administration exam Grading ………………………………………………
4
Grading/Nursing Care Plan Guidelines ………………………………………………………..
5
Bedside Assessment Guidelines …………………………………… Assignment………………………………….
6
Silvestri’s/ Oral Presentation Project/Textbook/References………………………………
7 Teaching Plan/ Health Fair Assignment
Objectives……………………………………………………………………. 8
Textbook/ References/ Learning Objectives SCANS………………………………………………………………………………..
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Student Acknowledgement…………………………………………………………… 15
Appendices:
A. Patient Care Plan Grading Criteria…………………………………………….. 16
B. Bedside Assessment Grading Criteria…………………………………………. 17
C. Client information sheet template……………………………………………… 18
D. Alternative CIS………………………………………………………………… 22
E. Medication List Template……………………………………………………… 23
F. Log for Clinical Nursing Experience………………………………………….. 24
G. Care Plan Guidelines ………………………………………………………….. 25 H. Care Plan Template……………………………………………………………. 26
I. Patient Assessment Form (Teaching Plan)……….……………………………. 27
J. Teaching Plan Grading Criteria ………………………………………………. 28
K. Teaching Plan Form…………………………………………………………… 29
L. Sample Teaching Plan…………………………………………………………. 30
M. Oral Presentation Grading Criteria ……………………………………………. 32
N. Clinical Evaluation Grading Sheet…………………………………………….. 33
O. Midterm Evaluation……………………………………………………………. 38
P. Clinical evaluation tool Summary…………………………………………….. 39
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Panola College
Associate Degree Nursing Program Core Competencies: Students are expected to demonstrate basic competency in reading,
writing, oral communication, math, and computer skills. Students are expected to be an active
learning participant by assuming accountability in preparing for each clinical day by
completing required readings and/or other learning activities as listed in the syllabus.
Proficiency will be measured by clinical participation, skills assessment, documentation, and
interaction as a team member.
Course Requirements:
1. Regular clinical attendance within current attendance policies.
2. Acceptable documentation of current immunization status 3. A minimum score of 75% on the clinical evaluation tool.
4. A minimum average score of 75% on nursing care plans is required.
5. Preparation and active participation in clinical conferences
6. Outside individualized readings and assignments
7. Compliance with all rules and regulations as outlined in the current Department of Nursing
Student Handbook and Panola College Catalog.
8. Current Basic Life Support (BLS) certification.
9. Demonstration of college-level skills following American Psychological Association (APA)
guidelines.
COURSE OUTCOMES with Clinical Activities
MEMBER OF THE PROFESSION: At the end of the course the student will be able to:
1. Assume responsibility and accountability for the practice of
professional nursing within the scope of nursing (Scans I B,C II B,C)
PO# 1
DEC# IA,B,D
2. Participate in activities that promote the development of
Professional nursing practice (Scans I C II B)
PO# 2
DEC# IC
PROVIDER OF PATIENT-CENTERED CARE: At the end of the course the student will be able to:
3. Assimilate knowledge from the humanities and sciences in
developing and providing safe and holistic care within the
legal and ethical scope of practice (Scans I A,B II B,C)
PO# 3
DEC# II A,B,C,D
4. Plan and implement teaching plans for complex patients
through the innovative use of multimedia (Scans I B,C II B,C,E)
PO# 4
DEC# II A,G,H
5. Initiate the plan of care using clinical reasoning and evidence- PO# 5
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based literature for clinical judgment and decision making (Scans I B,C II B,C)
DEC# II A,B,C,E,F
THE NURSE AS PATIENT SAFETY ADVOCATE At the end of the course the student will be able to:
6. Advocate for complex patients and their families by reporting
pertinent information to members of the interdisciplinary care
team (Scans I A, B,C; II B,C)
PO# 6
DEC# III A,B,C,D,E
7. Obtain instruction, supervision, or training as needed when
implementing nursing procedures or practices(Scans I A,B,C; II B,C,E)
PO#7
DEC#III A,B,C,D
THE NURSE AS MEMBER OF THE HEALTH CARE TEAM At the end of the course the student will be able to:
8. Demonstrate collaboration with peers, patients, families, and
health care teams in the process of planning, delegating,
implementing, and evaluating patient-centered care (Scans I B,C IIC)
PO# 8
DEC# IV A,B,D
9. Advocate for patients and families to ensure access to quality
health care (Scans I B,C; II A, B,C,E)
PO# 9
DEC# IV B,C
10. Communicate and utilize electronic data and technology to
support decision making in patient care (Scans I B,C II B,C,E)
PO# 10
DEC#IV B,C,D,E
11. Employ clinical reasoning and evidence based findings to make
decisions about task that may be delegated appropriately (Scans I B,C
II A,B,C,E)
PO# 11
DEC# IV F,G
TEACHING/LEARNING STRATEGIES: Clinical assignments Student-Teacher
conferences Patient care assignment
Computer Assisted Instruction Observation Group discussion Return demonstration
Clinical conferences, pre/post Simulation lab
PERSONAL APPEARANCE AND DRESS CODE Please review your Student Handbook policy for proper dress code. You will be sent home
if you do not meet these criteria.
MEDICATION ADMINISTRATION EXAM Students are required to demonstrate calculating dosages and solutions by achieving a score of 100% on a Medication Administration Exam given before the first clinical day. The student
will have three opportunities to achieve a score of 100%. If the student does not achieve
100%, he/she must withdraw from the course with a grade of an “F”.
CONCURRENT ENROLLMENT Concurrent enrollment in RNSG 1343 is required. Successful completion of both theory and
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clinical courses is required for progression. If a student is not successful in either course
(RNSG 1343 or 1263), the student MUST repeat BOTH courses.
GRADING Each student will be evaluated in a clinical conference at the mid and endpoint of this clinical
course. The evaluation will be based on observation of the student’s performance and
behaviors in the clinical setting and all required written assignments (see pg 39).
The Associate Degree Nursing Program, in accordance with policy, uses the following
numerical scale in computing final course grades: (see Policy 5.1)
A = 90-100
B = 80-89
C = 75-79
F = 74.99 and below
Final grades will consist of the following:
Clinical evaluation 85% (using the attached grading tool)
Oral Presentation, Silvestri’s, 15%
Teaching plan, Bedside assessment,
and 3 care plans
NURSING CARE PLANS
GUIDELINES:
1. A client information sheet and care plan is required for three (3) patient care situations.
2. The student will use the assessment tool and care plan tool provided in the syllabus. The
grading criteria are provided in the syllabus.
3. All nursing assessments and care plans will be typed according to APA format to include a
cover page and a reference page. Please include the date you were assigned to the patient and
NOT the date that you submit the care plan for a grade.
4. All care plans must be typed and consist of the following:
a. Minimum – Two (2) Nursing Diagnosis are required, (one psychosocial and one physical)
b. Maximum – One (1) goal per each diagnosis. (Must be measurable)
c. Minimum- Three (3) interventions per related to or AEB statement.
d. Rationale for each intervention- Include citations using proper APA format
include copies of articles used with referred sections highlighted.
e. Evaluation of each goal. (Must be measurable)
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5. Care plans must include a CIS. All pertinent diagnostic reports and rationales for
abnormal results as it relates to the patient’s nursing and medical diagnoses should be
included.
6. Include medications in the care plans (see medication list for formatting).
7. Care Plans will NOT be accepted if they are:
a. Submitted late.
b. Handwritten.
c. Not in APA format. 8. Care plans are due as assigned. SIM lab care plan will be the only care plan done by hand
and turned in by the end of the day. All other care plans will be submitted on line.
9. Alternative critical thinking tools (Alternative CIS) will be required on all patients unless
care plan to be done (see #5 above). All CIS and alternative CIS must be typed and have a
medication sheet turned in with them.
NURSING BEDSIDE ASSESSMENT
1. Each student will perform one (1) graded bedside assessment. The bedside
assessment will be scheduled and posted under announcements on the canvas
course. It is the students’ responsibility to notify the instructor prior to the
graded assessment if they need individualized help or instruction on bedside
assessment.
2. The bedside assessment criterion is to be followed for each assessment. The student
is expected to be able to perform the assessment from memory. No books, charts or
grading criteria will be allowed in the room for student use during the observed
examination.
3. The assessment will then be charted in a narrative format on a form provided by the
instructor. Please review narrative charting before this assignment.
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Silvestri Assignment
Units to be covered in Silvestri from CD are:
Renal
Nervous
Musculoskeletal
GI
Endocrine
1. Four quizzes and one exam must be done. A score sheet showing a minimum grade of 90%
must be turned in through Canvas to get credit for the assignment. Each unit must be done
but the student can choose which 4 to do as quizzes and which one to do as an exam. One
subject per quiz or exam, no mix and match.
2. The student’s name and date must be printed on the results sheet. If not printed on
the sheet the assignment will not be accepted.
Oral Presentation
1. Present a 15 – 20 minute Oral presentation identifying a disease process, clinical issue or
trend, or problem that is critical to nursing, health, or healthcare delivery.
2. Select topics from the units of med-surg covered in RNSG 1343 or other current issues or
trends.
3. Presentation should include the reason topic was chosen, role of nursing in addressing
the issue, trend, or problem, the topic is described and a description of what was
learned. (See grading criteria).
4. You must cite at least three articles from current literature (no older than 5 years). Attach
a reference sheet and cover sheet with the grading sheet.
5. A visual aid developed by the student is required for this assignment included but not
limited to a poster, skit, handouts, or power point.
6. The presentation will be recorded.
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Teaching Plan
1. Select an individual/family or group who demonstrates a knowledge deficit
2. Complete a brief nursing history to validate the need for intervention. (see page 26)
3. Identify the clients’ strengths and limitations in meeting the need.
4. Develop a teaching plan
5. Implement the teaching plan. Teaching plan must be used to instruct a real patient no SIM
patients or make believe.
6. Develop a PowerPoint to accompany the teaching plan. Patient is the audience for the
PowerPoint. Do not include the powerpoint as a teaching strategy in the teaching plan.
7. Evaluate the effectiveness of the teaching plan in meeting its learning objectives and
the evaluation strategies used.
8. Attach a copy of the PowerPoint, assessment sheet (pg 26), and teaching plan (pg 28), and
any references used with the grading sheet (pg 27).
Health Fair Assignment 1. This is a group assignment
2. Each Clinical section will be divided into groups.
3. Select a topic from the list provided by the instructor and create a community focused
poster display.
4. Each student is responsible for a section on the poster and must identify the section done.
5. You must cite at least three articles from current literature (no older than 5 years)
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TEXTBOOK/REFERENCES: The textbooks listed for RNSG 1343 will be used for this clinical course.
Learning Objectives:
1. Assume responsibility and accountability for the practice of
professional nursing within the scope of nursing.
a. Act responsibly within the limits of nursing knowledge.
i. Solicits supervision from the instructor when needed.
ii. States own limitations
iii. Provides interventions with respect for human dignity and
rights unrestricted by considerations of social or economic
status, personal attributes, or the nature of health problems.
CO# 1
b. Apply principles inherent in the laws and standards governing
the nursing practice to the care of patients in diverse settings.
i. Adheres to Panola College student handbook policies and
clinical agency policies when providing care for culturally
diverse patients.
ii. Arrives at the clinical setting on time.
iii. Perform within legal and ethical guidelines of the nursing
practice act.
CO# 1
c. Demonstrates the principles of the “Code of Ethics” for nurses
i. Maintains patient confidentiality.
ii. Provides patient privacy.
iii. Seeks help from others when needed.
CO#1
2. Participate in activities that promote the development of professional
nursing practice .
a. Participates in clinical self evaluation.
i. Documents skills and relevant behaviors on e-value.
ii. Complete self-evaluation
iii. Identifies areas of needed improvement
CO# 2
b. Participates in self directed learning.
i. Demonstrates the initiative to seek new learning experiences.
ii. Seeks opportunities to learn new skills or to practice skills.
iii. Accepts responsibility for clinical assignments without excuse.
iv. Participates in Health Fair
CO#2
c. Participate in or discuss the benefits of the available professional
organizations.
CO# 2
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3. Assimilate knowledge from the humanities and sciences in
developing
and providing safe and holistic care within the legal and ethical scope
of
practice.
a. Perform comprehensive assessment to identify health needs and
obtain patient and family history to determine patient needs in
areas of physical, spiritual, cultural, and psychological.
CO# 3
b. Apply information from evidenced based literature and nursing
science to assist in planning and providing safe and holistic
patient
care.
CO# 3
c. Interpret and analyze health data using knowledge of anatomy
and
physiology, pathophysiology, and signs and symptoms of disease
processes to assist in planning safe holistic care for the adult with
complex health issues.
CO# 3
4. Formulate teaching plans for complex patients through the innovative
use of multimedia.
a. Assess learning needs of adult patients with complex health
issues and their families.
CO# 4
b. Develop and implement teaching plan with the use of multimedia
and best practice standards and include consideration of age,
culture, educational level and other areas of diversity.
CO# 4
c. Evaluate learning outcomes of adult patients and their families. CO# 4
d. Revise teaching plan if needed. CO# 4
5. Initiate the plan of care using clinical reasoning and evidenced-based
literature for clinical judgment and decision making.
a. Relate clinical reasoning to adult patient needs in planning care. CO# 5
b. Prioritize nursing diagnoses and develop goals for adult patients
with complex health issues.
CO# 5
c. Devise interventions with cultural aspects taken into
consideration derived from evidence based information for adult
patients.
CO# 5
d. Evaluate interventions for effectiveness and modify plan of care
for adult patients with complex health issues.
CO# 5
e. Evaluate patients’ responses to medication, treatment, or
procedures and be able to prioritize problems and respond
appropriately.
CO# 5
6. Advocate for complex patients and families by reporting pertinent
information to members of the interdisciplinary care team.
a. Consult with interdisciplinary care team members when planning CO# 6
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and providing care to adult patients with complex health issues.
b. Report and document pertinent information to appropriate
interdisciplinary care team members.
CO# 6
c. Document and report any adverse reactions to medications,
procedures, or treatment that may occur in adult patients with
complex health issues.
CO# 6
d. Evaluate care administered to adults with complex health issues
by
members of the interdisciplinary care team.
CO# 6
7. Obtain instruction, supervision, or training as needed when
implementing procedures or practice.
a. Arrange instruction, supervision, and education associated with
the
implementation of a new or previously observed nursing
procedure.
CO#7
b. Identify potential safety risk for adult patients with complex
health issues.
CO# 7
c. Formulate a plan to decrease safety risks by using guidelines in
the Texas Nursing Practice Act.
CO# 7
d. Apply standards of nursing practice and evidenced based
information to provide and evaluate nursing care of adults with
complex health issues.
CO# 7
8. Demonstrate collaboration with peers, patients, families, and health
care teams in the process of planning, delegating, implementing, and
evaluating patient centered care.
a. Utilize patient and family input when planning care for the adult
patient with complex health issues.
CO# 8
b. Construct plan to include care provided to adult patients by
other
members of the interdisciplinary team.
CO# 8
c. Maintain timely communication and collaboration with
members
of the interdisciplinary care team for optimal patient health
status.
CO# 8
d. Evaluate patient care through collaboration with
interdisciplinary
care team by using evidence based information and patient
evaluation data.
CO# 8
9. Advocate for patients and families to ensure access to quality health
care.
a. Coordinate resources available in the health care setting to
optimize patient centered care.
CO# 9
b. Serve as a patient advocate in promoting quality care and access
to resources for adult patients and their families.
CO# 9
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c. Teach patients and families about access to reliable and valid
resources including health information.
CO# 9
d. Refer adult patients to appropriate outpatient services in the
community to provide them with access to quality health care.
CO# 9
10. Communicate and utilize electronic data and technology to support
decision making in patient care.
a. Employ technology as a means of communication and
management of patient information to improve delivery of care.
CO# 10
b. Participate in simulation lab using electronic data to improve
patient care.
CO# 10
11. Employ clinical reasoning and evidenced based findings to make
decisions about tasks that may be delegated appropriately.
a. Compare the needs of the patient with the knowledge, skills, and
abilities of the assistive personnel prior to delegating task.
CO# 11
b. Participate in decision making related to delegation to improve
clinical reasoning.
CO# 11
c. Evaluate nursing care provided by unlicensed personnel by using
evidenced-based nursing information
CO# 11
Secretary of Labor’s Commission on Achieving Necessary Skills (SCANS)
1) Foundation skills are defined in three areas: basic skills, thinking skills, and personal qualities.
a) Basic Skills: A worker must read, write, perform arithmetic and mathematical operations, listen, and speak effectively. These skills include: i) Reading: locate, understand, and interpret written information in prose and in documents
such as manuals, graphs, and schedules. ii) Writing: communicate thoughts, ideas, information, and messages in writing, and create
documents such as letters, directions, manuals, reports, graphs, and flow charts. iii) Arithmetic and Mathematical Operations: perform basic computations and approach practical
problems by choosing appropriately from a variety of mathematical techniques. iv) Listening: receive, attend to, interpret, and respond to verbal messages and other cues. v) Speaking: Organize ideas and communicate orally.
b) Thinking Skills: A worker must think creatively, make decisions, solve problems, visualize, know how to learn, and reason effectively. These skills include: i) Creative Thinking: generate new ideas. ii) Decision Making: specify goals and constraints generate alternatives, consider risks, and
evaluate and choose the best alternative. iii) Problem Solving: recognize problems and devise and implement plan of action. iv) Visualize ("Seeing Things in the Mind's Eye"): organize and process symbols, pictures,
graphs, objects, and other information. v) Knowing How to Learn: use efficient learning techniques to acquire and apply new knowledge
and skills. vi) Reasoning: discover a rule or principle underlying the relationship between two or more
objects and apply it when solving a problem.
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c) Personal Qualities: A worker must display responsibility, self-esteem, sociability, self-management, integrity, and honesty. i) Responsibility: exert a high level of effort and persevere toward goal attainment. ii) Self-Esteem: believe in one's own self-worth and maintain a positive view of one-self. iii) Sociability: demonstrate understanding, friendliness, adaptability, empathy, and politeness in
group settings. iv) Self-Management: assess oneself accurately, set personal goals, monitor progress, and
exhibit self-control. v) Integrity and Honesty: choose ethical courses of action.
2) Workplace competencies are defined in five areas: resources, interpersonal skills, information, systems, and technology.
a) Resources: A worker must identify, organize, plan, and allocate resources effectively. i) Time: select goal-relevant activities, rank them, allocate time, and prepare and follow
schedules. ii) Money: Use or prepare budgets, make forecasts, keep records, and make adjustments to
meet objectives. iii) Material and Facilities: Acquire, store, allocate, and use materials or space efficiently. Examples: construct a decision time line chart; use computer software to plan a project; prepare a
budget; conduct a cost/benefits analysis; design an RFP process; write a job description; develop
a staffing plan.
b) Interpersonal Skills: A worker must work with others effectively. i) Participate as a Member of a Team: contribute to group effort. ii) Teach Others New Skills. iii) Serve Clients/Customers: work to satisfy customer's expectations. iv) Exercise Leadership: communicate ideas to justify position, persuade and convince others,
responsibly challenge existing procedures and policies. v) Negotiate: work toward agreements involving exchange of resources, resolve divergent
interests. vi) Work with Diversity: work well with men and women from diverse backgrounds. Examples: collaborate with a group member to solve a problem; work through a group conflict
situation, train a colleague; deal with a dissatisfied customer in person; select and use
appropriate leadership styles; use effective delegation techniques; conduct an individual or team
negotiation; demonstrate an understanding of how people from different cultural backgrounds
might behave in various situations.
c) Information: A worker must be able to acquire and use information. i) Acquire and Evaluate Information. ii) Organize and Maintain Information. iii) Interpret and Communicate Information. iv) Use Computers to Process Information. Examples: research and collect data from various sources; develop a form to collect data;
develop an inventory record-keeping system; produce a report using graphics; make an oral
presentation using various media; use on-line computer data bases to research a report; use a
computer spreadsheet to develop a budget.
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d) Systems: A worker must understand complex interrelationships. i) Understand Systems: know how social, organizational, and technological systems work and
operate effectively with them. ii) Monitor and Correct Performance: distinguish trends, predict impacts on system operations,
diagnose deviations in systems' performance and correct malfunctions. iii) Improve or Design Systems: suggest modifications to existing systems and develop new or
alternative systems to improve performance. Examples: draw and interpret an organizational chart; develop a monitoring process; choose a
situation needing improvement, break it down, examine it, propose an improvement, and
implement it.
e) Technology: A worker must be able to work with a variety of technologies. i) Select Technology: choose procedures, tools or equipment including computers and related
technologies. ii) Apply Technologies to Task: understand overall intent and proper procedures for setup and
operation of equipment. iii) Maintain and Troubleshoot Equipment: Prevent, identify, or solve problems with equipment,
including computers and other technologies. Examples: read equipment descriptions and technical specifications to select equipment to meet
needs; set up and assemble appropriate equipment from instructions; read and follow directions
for troubleshooting and repairing equipment.
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Panola College
Associate Degree Nursing
Student Acknowledgment
I have read the Panola College Associated Degree Nursing program syllabus for
RNSG 1263 Clinical Nursing and I understand the policies as discussed.
I will comply with the requirements as delineated. It is my understanding that this form will
become part of my permanent file.
Student Name (Printed)
Student Signature Date
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Patient Care Plan Grading Criteria
Points
Possible
Points
Earned Assessment Pertinent history and physical assessment finding related to
Admission. (Including, but not limited to, allergies,
medications, diet, statement of presenting problem,
physical assessment findings which support the nursing
diagnosis.)
20
Nursing Diagnoses Identify two (2) high priority nursing diagnoses supported
by the assessment data. (1physical and 1 psychosocial)
20
Patient
Objectives
(Goals)
directly related
to the nursing
diagnoses
Patient centered Observable
Measurable and Specific
Time limited
20
Nursing
Interventions
Individualized/Comprehensive Appropriate/
Specific
Feasible/Realistic
Time related
20
Rationale State rationale behind each nursing intervention. Literature must be used to support each
intervention. At least one journal article must be
used per care plan.
*If no journal article is used, you will receive a 0 in
this category.
5
Evaluation State if the patient outcome was met or not met.
State how you evaluated each patient goal.
10
APA Cover page, citations, and bibliography follow the APA guidelines
5
Total
Comments:
Student Name:
Instructor:
Date of Patient Care
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Bedside Assessment Grading Criteria
The bedside assessment will be observed by the instructor and charted by the student.
Both components will be graded. Provide the grading criteria to the instructor during
the observed assessment. Assessment will be charted and turned end before the end of
the clinical day.
Assessment Criteria Possible
Points
Points
Earned
Comments
Vital Statistics: *Height, *Weight, *Temperature, *Pulse, *Respirations, *Blood
Pressure, *Pain, *Allergies
5
Neurological *Level of consciousness, *orientation, *Affect, pupils, speech
characteristics,
*Hand grips and leg strength,
follows commands
10
Respiratory Quality of respirations, depth of respirations, respiratory rate
*Breath sounds in all areas (anterior
and posterior) , O2 use, *O2
saturation, presence of secretions
5
Cardiovascular Heart sounds, rate and rhythm, *carotid, radial, and pedal pulses,
clubbing , *capillary refill,
*Peripheral edema, JVD
5
Abdomen Scars, nausea/vomiting, *Bowel sounds, tenderness, drains,
NGT location, descriptions &
amount of drainage, drains
*Last BM & characteristics
5
Skin *Temperature, moisture level, *turgor, *color, *Characteristics of
oral mucosa, lesions, dressings
5
Musculoskeletal Ability to sit up, turn gait *ROM 5
Urinary *Foley, voiding, *color and amount of urine
5
Misc. *IV’s, site assessment, Feedings,
dressings
5
Charting 50
Total
* Critical Assessment data
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Pt. Initials:
Date of Adm: Chief complaint/
Admitting Medical Diagnosis:
Current
Vital
Signs
T P Surgery type and Post-Op
day:
(if applicable)
R BP
Age/
Sex:
Allergies and type of reaction
(all types):
Pertinent Past Medical
History:
O2
Sat
O2
Use
Respiratory Therapy
Treatments
Height: Weight: IV Therapy/
SL:
Solution and
rate
Ethnicity: Dentures: Upper Lower Fluid Restriction:
Hearing Loss: Right Left Diet:
Marital Status:
Impaired vision Code Status:
Advance
Directive?
Safety
Considerations:
Activity: Reason:
Hx
tobacco
use: pack
year
history
Hx. Alcohol or
substance
abuse:
Fall Risk:
Aspiration
Risk:
Other:
Panola College ASSOCIATE
DEGREE NURSING RNSG 1263
Student: Clinical Date: Instructor:
CLIENT INFORMATION SHEET (CIS)
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*Treatment and Special Orders: (include all such as TCDB, incentive spirometer, Resp.
therapy, nursing interventions, etc.)
Treatment/Procedure Frequency Rationale for Treatment/Procedure
Date Diagnostic Test Results Rationale for test Nursing implications
Chief Complaint and Brief History of Present Illness:
Past Medical History, Including Home Meds:
Pathophysiology of current illness or major medical diagnosis:
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*Lab Data: ( Not and all inclusive list)
Lab Test Result (s) & Date (s) Normal
Range
Brief Rationale for
Abnormalities (Be sure to
explain all grossly abnormal
labs)
CBC Date Date Date
WBC 4.6 – 10.2
RBC 4.0 – 5.5
Hgb 12.2 – 16.2
HCT 37.7 – 47.9
Platelets 140 - 440
Coagulation
PT 10-12 sec
PTT 30-45 sec
INR 2-3( target)
Electrolytes
Na+ 136 – 145
K+ 3.50 – 5.10
Cl- 98 – 107
CO2 22.0 – 29.0
Magnesium 1.5-2.0
BUN 6.0 – 20.0
Glucose 60 – 105
Creatinine 0.70 – 1.30
Cardiac
Enzymes
CKMB < 7.1U/L
Troponin <1ng/mL
Chemistry
Albumin 3.5-5.0
Protein 6-8.4
Amylase 4-25
UA
Color straw - yellow
Appearance clear - hazy
Specific
Gravity
1.003 – 1.030
pH 5.00 – 9.00
Protein negative
Glucose negative
Ketone negative
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Lab test Date Date Date Normal Rationale for abnormal
ABG
PH 7.35-7.45
PO2 70-100 mm Hg
PCO2 35-45 mm Hg
HCO3 22-26 mm Hg
B.E. +1 to -2
O2 Sat. 96%-100%
Additional labs
RNSG1263
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Alternative CIS
Name____________________________ Date_____________________
For each patient answer these questions:
1. What are you on alert for today with this patient?
2. What are the important assessments to make?
3. What complications may occur? What could go wrong?
4. What interventions will prevent complications?
5. Add any abnormal or normal lab pertinent to patient’s condition. Any lab listed on medication sheet must
be listed here.
Lab Test Value Indications specific to patient
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Brand Name Generic Name Class &
Actions
Applicable
Indication
why pt is using this
drug
Dosage Route Frequency Possible
Side-Effects
Patient Specific
Nursing
Implications
and Actions
MEDICATION LIST
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PANOLA COLLEGE ASSOCIATE DEGREE NURSING
Log for Clinical Nursing Experience
Student Name: Clinical Area:
Instructor:
Date Pt
Initials
Nursing Diagnosis Skills Performed Student Comments
Reflections on experience:
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Assessment Nursing Diagnosis Client Objectives Nursing
Intervention Rationale for
Nursing
Interven
tions
Evaluation
Assessment requires:
1. Communication
with the client via
the client interview
and nursing history.
2. Data: Physical
Intellectual
Emotional
Social
Spiritual (Subjective data:)
What the client
says. (Objective data:)
Observable,
measurable data i.e.,
laboratory reports,
nursing
observations, review
of the chart 3. Medical Diagnosis
Nursing Diagnosis *(NANDA approved)
followed by “related
to” phrase followed by
“as evidenced by” …
Contributing factors:
Environmental,
Sociological
Psychological,
Spiritual,
Physiological, or
any other factors
involving health
problems
Must be:
-related to the
nursing diagnosis.
(stem) -client centered
-action oriented
-mutually exclusive
-realistic
-measurable
-behaviorally stated Need to include
condition, projected
time, and date for client
to achieve goal. Need to include short
term or long term
objectives.
i.e., Ms. Doe will walk
to the end of the hall &
back QID with the
Assistance of a walker
by 10/12.
Nurse Directed
contain action verb
stated clearly should
include:
-What is to be done
or given?
-How the behavior is to
be performed.
-Frequency & specific
time for order to be
done.
-Should include:
comfort measures,
treatments,
medications,
observations, and
teaching. -Directed towards the
“related to” or “as
evidenced by”
statements.
Must be specific to
patient
Give scientific rationale
for each nursing
intervention.
State why nursing
intervention was
developed or selected.
List citations (Authors
last name, year, and
page number)
i.e.(Smith, 2004,
pp125)
Full reference on
reference page
1 journal article per
care plan
Show data that
supports evaluation
of client objectives.
State whether or
not each objective
was met (met,
partially met, or not
met.)
State Patients
response.
State reason(s) why
objectives were met
or not met.
State any needed
revisions in
objectives or nursing
orders.
Do not include
interventions
NURSING 1263 - CLIENT CARE PLAN GUIDELINES
Student Name: ___________ Pt. Initials
Date of Care Plan: ___ Pt Sex/Age:
Clinical Section: Date of Admission/Surgery Health Agency Unit: Diagnosis/Surgery
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PATIENT CARE PLAN
Assessment
Nursing
Diagnosis
Client Objectives
Nursing
Interventions
Rationale for
Nursing
Interventions
Evaluation
Student Name:
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PANOLA COLLEGE ASSOCIATE DEGREE NURSING
PATIENT ASSESSMENT
(to accompany teaching plan)
Students’
Name:
Date:
Client Initials: Age/Sex:
Assessment/Data Collection
Pertinent Client Data/ Brief Nursing History
Subjective
Objective:
Assessment
Nursing diagnosis (knowledge deficit: specify (ex: IS) related to…)
Client Assets and Limitations (relative to knowledge deficit)
ASSETS LIMITATIONS
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Grading Criteria Teaching Plan
Points
Possible Points Given
Comments
Identifies Learning Need
a. Communicates learning need/ knowledge deficit to instructor
b. Select an individual, family, or group who
demonstrates a knowledge deficit
5
c. Complete a brief nursing history to substantiate the clients need for educative intervention
10
d. The student followed all directions given 5
Constructs a Teaching Plan
a. Develops a written plan for teaching based on an identified learning need of the
patient/family
b. Develops a topical outline of content material
15
c. Utilizes the nursing process to develop the teaching plan
d. Uses a holistic approach in teaching plan
10
e. Includes preventive measures in teaching plan 5
f. Identifies appropriate resources available 2
g. Develops specific client focused learning objectives
5
h. Identify planned teaching learning activities and time frame for planned activities
5
Presentation
a. Develop a power point presentation to accompany the teaching plan
25
Evaluation
a. Evaluate the effectiveness of the teaching
plan in achieving the learning objectives
5
Conventions/Usage/Sentence Structure
a. The sentences are well constructed, vary in form, and show no major examples of non-
standard sentence formation.
2
b. The grammar, spelling and punctuation are
basically free of error except minor infractions.
2
Format
a. APA format was used throughout paper. 2
b. Reference page is correct 2
c. Cover page in APA
Total 100
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PANOLA COLLEGE ASSOCIATE DEGREE NURSING
HEALTH TEACHING PLAN FORM
Patient Learning Objectives
C - (Cognitive)
P - (Psychomotor)
A - (Affective)
Content Teaching Learning Activities Time Allotment Evaluation of Patient Learning Objectives and evaluation strategies.
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Patient Learning Objectives
C - (Cognitive)
P - (Psychomotor)
A - (Affective)
Content Teaching Learning Activities Time Allotment Evaluation of Patient Learning Objectives and evaluation strategies.
By the end of this lesson
the client will be able
to: Select from a list three
benefits of relaxation
(cognitive) Agree to experiment
with walking and
various relaxation
techniques (affective) Count his pulse within
three beats of what the
nurse counts
(psychomotor)
Introductions
Relaxation
Definitions
Balance with
exercise
Benefits
Reduce blood
pressure
Reduce tension
Increase efficiency
Medication
Fears Side effects
Life-style change
Costs
Benefits
Techniques for
Pulse taking
Location of artery
Finger placement
Discussion Question “What
does relaxation mean to you?”
Discuss the relationship
between stress and blood
pressure. Give the patient the
pamphlet: Balancing Relaxation
and Exercise
Discussion fears and mixed
feelings
“Who else in your family has
been diagnosed with
hypertension? What did it do to
control it, and what were the
results?” Demonstrate pulse taking. Have
the client return demonstration
of pulse taking. Develop a
record keeping system
monitoring pulse rate. Read
directions for deep breathing,
10min
10min
10min
PANOLA COLLEGE ASSOCIATE DEGREE NURSING
SAMPLE TEACHING PLAN FORM
them? What have they done to
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Counting Multiplying
Recording method
Technique for
Relaxation
Deep breathing
Yoga
Medication
Imagery
Prayer
Wrap up
yoga, meditation, and imagery.
Obtain a clock with a second
hand. Develop a chart for recordkeeping at home. Obtain
an audio cassette for recording
directions for deep breathing,
yoga, meditation, and imagery.
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Grading Criteria Oral Presentation
Points
Possible Points Given
Comments
Introduction
A. Identify the reason the diagnosis or nursing issue, trend, or problem was chosen
10
B. The student followed all directions given 5
Overview of the Content
A. The work addresses effectively the topic B. The main ideas are stated clearly, thoroughly
supported, and developed
C. Description of what was learned
25
A. Describe the perceived impact of the topic on client care or in clinical situations
10
A. Present information in a professional manner
a. Rapport with audience (eye contact)
b. Speaking voice (volume and diction)
c. Confidence (enthusiasm, speaks without
reading every word)
d. Material supporting oral presentation:
skits, power point, handouts, posters,
pamphlets, etc.
10
B. Present information on resources available to
patients and health care providers regarding the
topic
10
C. Interacts with the audience. Discussion generated
by the presentation, stays within the time frame
(15 – 20 minutes)
10
Format
A. Presented on assigned date (10 points deducted if not presented on assigned day)
5
B. The presentation is well constructed.
5
C. The grammar, spelling and punctuation are basically free of error except minor infractions
5
D. Correct APA format: cover and reference page 5
Total: 100
Note : Required 3 references, Must be Peer reviewed and publication within the last 5 years.
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CLINICAL EVALUATION GRADING SHEET
CRITERIA POINTS
Possible Points Student
Evaluation
Faculty
Evaluation
MEMBER OF THE PROFESSION
1. Act responsibly within the limits of
nursing knowledge
a. Solicits supervision from the
instructor when needed.
4
b. States own limitations
4
c. Provides interventions with
respect for human dignity and
rights unrestricted by
considerations of social or
economic status, personal
attributes, or the nature of health
problems.
4
2. Apply principles inherent in the
laws and standards governing the
nursing practice to the care of
patients in diverse settings.
a. Adheres to Panola College student
handbook policies and clinical
agency policies when providing
care for culturally diverse patients.
4
b. Arrives at the clinical setting on
time.
4
c. Perform within legal and ethical
guidelines of the nursing practice
act
4
3. Demonstrates the principles of the
“Code of Ethics” for nurses
a. Maintains patient confidentiality 4
b. Provides patient privacy. 4
c. Seeks help from others when
needed.
4
4. Participates in clinical self-
evaluation.
a. Documents skills and relevant
behaviors on e-value.
4
b. Complete self-evaluation 4
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c. Identifies areas of needed
improvement
4
d. Participates in health fair. 4
5. Participates in self-directed
learning.
a. Demonstrates the initiative to seek
new learning experiences.
4
b. Seeks opportunities to learn new
skills or to practice skills.
4
c. Accepts responsibility for clinical
assignments without excuse.
4
6. Participate in or discuss benefits of
the available professional
organizations.
4
PROVIDER OF PATIENT-
CENTERED CARE:
7. Perform comprehensive assessment
to identify health needs and obtain
patient and family history to
determine patient needs in areas of
physical, spiritual, cultural, and
psychological.
4
8. Apply information from evidenced
based literature and nursing science
to assist in planning and providing
safe and holistic patient care.
4
9. Interpret and analyze health data
using knowledge of anatomy and
physiology, pathophysiology, and
signs and symptoms of disease
processes to assist in planning safe
holistic care for the adult with
complex health issues.
4
10. Assess learning needs of adult
patients with complex health issues
and their families.
4
11. Develop and implement teaching
plan with the use of multimedia
and best practice standards and
include consideration of age,
culture, educational level and other
areas of diversity
4
12. Evaluate learning outcomes of
adult patients and their families.
4
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13. Revise teaching plan if needed. 4
14. Relate clinical reasoning to adult
patient needs in planning care.
4
15. Prioritize nursing diagnoses and
develop goals for adult patients
with complex health issues.
4
16. Devise interventions with cultural
aspects taken into consideration
derived from evidence based
information for adult patients.
4
17. Evaluate interventions for
effectiveness and modify plan of
care for adult patients with
complex health issues.
4
18. Evaluate patients’ responses to
medication, treatment, or
procedures and be able to prioritize
problems and respond
appropriately
4
THE NURSE AS PATIENT SAFETY
ADVOCATE
19. Consult with interdisciplinary care
team members when planning and
providing care to adult patients
with complex health issues.
4
20. Report and document pertinent
information to appropriate
interdisciplinary care team
members.
4
21. Evaluate care administered to
adults with complex health issues
by members of the interdisciplinary
care team.
4
22. Document and report any adverse
reactions to medications,
procedures, or treatment that may
occur in adult patients with
complex health issues.
4
23. Arrange instruction, supervision,
and education associated with the
implementation of a new or
previously observed nursing
procedure.
4
24. Identify potential safety risk for
adult patients with complex health
issues.
4
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25. Formulate a plan to decrease safety
risks by using guidelines in the
Texas Nursing Practice Act.
4
26. Apply standards of nursing practice
and evidenced based information to
provide and evaluate nursing care
of adults with complex health
issues.
4
MEMBER OF THE HEALTH CARE
TEAM
27. Utilize patient and family input
when planning care for the adult
patient with complex health issues.
4
28. Construct plan to include care
provided to adult patients by other
members of the interdisciplinary
team.
4
29. Maintain timely communication
and collaboration with members of
the interdisciplinary care team for
optimal patient health status.
4
30. Evaluate patient care through
collaboration with interdisciplinary
care team by using evidence based
information and patient evaluation
data.
4
31. Coordinate resources available in
the health care setting to optimize
patient centered care.
4
32. Serve as a patient advocate in
promoting quality care and access
to resources for adult patients and
their families.
4
33. Teach patients and families about
access to reliable and valid
resources including health
information.
4
34. Refer adult patients to appropriate
outpatient services in the
community to provide them with
access to quality health care.
4
35. Employ technology as a means of
communication and management
of patient information to improve
delivery of care.
4
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36. Participate in simulation lab using
electronic data to improve patient
care.
4
37. Compare the needs of the patient
with the knowledge, skills, and
abilities of the assistive personnel
prior to delegating task.
4
38. Participate in decision making
related to delegation to improve
clinical reasoning.
4
39. Evaluate nursing care provided by
unlicensed personnel by using
evidenced-based nursing
information.
4
CIS and Medication Sheet or
Alternative CIS and Medication Sheet
1.
2.
3.
4.
5.
6.
7.
8.
(4 points each)
32
SUBTOTAL 232
85% of subtotal
+
Silvestri’s, care plans, teaching plan,
bedside assessment, and oral
presentation 15%
Total
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Mid-Term Evaluation
Student is to fill out the top portion of the evaluation and email to instructor by due date
Student strengths, as identified by student:
Student areas for improvement, as identified by student:
Student strengths, as identified by instructor:
Student areas for improvement, as identified by instructor:
Student Signature Date Instructor Signature Date:
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RNSG 1263 CLINICAL EVALUATION TOOL SUMMARY
The clinical evaluation tool is structured along the five major areas of nursing function:
Assessment, Nursing Diagnoses, Planning, Implementation, and Evaluations. The organization
of the objectives/outcomes uses the four major roles of the practicing nurse: Member of the
Profession, Provider of Patient-centered Care, Patient Safety Advocate, and Member of the
Healthcare Team. Grades for RNSG 1263 are derived by observing the student’s performance,
evaluating required assignments and the student in the role of Member of the Profession,
Provider of Patient-centered Care, Patient Safety Advocate, and Member of the Healthcare
Team.
Points will be assigned to each objective/outcome reflecting the level of competence as follows:
4 -- Consistently performs at an independent level. Meets the described objectives with self-
direction. 90-100% on assignments =4 points
3 — Demonstrates consistent performance and improvement. Needs minimal guidance to meet
described objectives. 80-89% = 3points
2 — Satisfactory/safe level of performance. Meets objectives with consistent guidance. 75-79%
on assignments = 2 points
<2 — Unsatisfactory/Unsafe. Level of performance does not meet standards. Unable to meet
objectives without frequent, direct, intensive guidance and instruction to avoid errors. This
includes submitting late assignments, substandard assignments, failure to submit assignments
and inconsistent performances from week to week.
The points for each course outcome are derived from a combination of Nursing Care Plans
(NCP), Assignments (A), and/or Faculty Observations (FO). If a student receives a grade of zero
(0) on any assignment or nursing care plans, the student will also receive a zero (0) on this
clinical evaluation tool for the corresponding assignment.
85% of course grade = Clinical Evaluation
15% of course grade = Care Plans/Bedside Assessment/Teaching Plan/ Oral Presentation
/Silvestri’s